Private Health Insurance in Sweden : Implications for the legitimacy of the public health care system

Abstract: The market for private health insurance (PHI) is growing in many countries with public, tax-funded health care systems. In Sweden, this development has generated an at times intense and polarised debate, exposing that the principles on which the public health care system rests in many aspects collide with the construction of PHI. Two dimensions have been suggested as being important for maintaining the legitimacy of public health care systems. The first is that citizens support the normative principles underpinning the system, including solidaristic funding through general taxation. With this comes the willingness of the population, and in particular the middle classes as net contributors, to pay tax to support the system. The second dimension is related to how the population perceives the performance of public services, as it has been suggested that public services need to be of sufficiently high quality for private alternative to be considered redundant. The growing market for PHI, where people can duplicate the public health care coverage with private health care services, raises concerns regarding the legitimacy of public health care. The aim of this thesis was, therefore, to investigate how PHI affects the legitimacy of the public health care system in Sweden. Three research questions were raised, addressing the prevalence and scope of PHI in Sweden, whether the experience of having PHI affects willingness to pay tax towards public health care, and satisfaction with public services. Four studies consisting of two quantitative cross-sectional studies and two qualitative interview-based studies were conducted to answer these questions. The results indicate that PHI in Sweden provides benefits foremost for the healthy and wealthy. The findings furthermore suggest that the first dimension of health care legitimacy (willingness to pay tax towards public health care) does not seem to be reduced by the experience of having PHI. Regarding the second dimension of legitimacy (satisfaction with the public services), the results are mixed. PHI-funded services were preferred over publicly funded services in terms of access and service quality within the primary care sector, while the medical quality of the public sector was considered high. In conclusion, the legitimacy of the public health care system in Sweden appears fairly resilient to the impact of PHI, although decreasing satisfaction might, in the long run, challenge the stability of the system.