**4. Discussion**

In Europe, health systems tend to be mandatory and offer universal coverage. Despite this major trend, there is a market for voluntary private health insurance. Portugal is characterized by having a National Health Service of universal coverage with distinctive features of mandatory occupation-based insurance. Because the health insurance market suffers from asymmetric information, insurance companies adopt cream-skimming strategies to minimize adverse selection and moral hazards. One such strategy is to set the eligibility requirement for buying an insurance health policy is having to be under 65. In this way, most older people are unable to buy a health insurance policy. However, there is a small market and about 5% of Portuguese older people report having voluntary private health insurance of some kind.

Our aim in this work was to find the main determinants of the demand for private health insurance by older people in Portugal and contribute to the literature on voluntary health insurance schemes in different European countries, as there is no study for Portugal. We used data collected by the 2014 National Health Survey and estimated a probit for people over 65 having private health insurance.

The main results are aligned with previous studies concerning the importance of income and education [11, 16–19]. The higher the income and the better educated the individuals, the greater the probability of having private health insurance.

Concerning age and health insurance, we found that as they get older, they are less likely to have private voluntary health insurance [23, 35, 36]. The results show that only a minority of individuals, about 332 people, have a voluntary private health insurance policy. These people tend to have a high income and a high level of education, which is uncommon among people older than 65. Most older people in Portugal receive small pensions and have a low level of formal education, which deters them from taking out health insurance. The lack of schooling is the origin of illiteracy, both financial and health-related, which precludes people from making wiser choices on how to make better use of their savings and reduce future out-of-pocket expenditures. One major concern relates to dental care and the (high) associated cost. This aspect of health care is usually neglected by older people because it is not covered by the NHS and because they do not have a complementary private health insurance policy to cover it [37, 38].

Regarding the role of health status and behavior in explaining the demand for private health insurance, our results are mixed. On the one hand, there is some evidence of advantageous selection because better health status and no smoking are


*Note: \* Significant at less than 5%.*

**Table 4.** *Probit results.*


*Voluntary Private Health Insurance Demand by Older People in a National Health Service… DOI: http://dx.doi.org/10.5772/intechopen.105100*
