"This study investigates the outcomes out-of-pocket payments (OOPP) produce in terms of income-related disparities in unmet health needs (UHN) due to inability to pay and highlights the commodifying effect of OOPP in European healthcare systems. It merges micro data from the European Union Statistics on Income and Living Conditions survey (EU-SILC) for 2005–2012, with macro data from the World Bank, Organisation for Economic Co-operation and Development (OECD) and World Health Organization (WHO). Our results show that, first, across all European countries and years under study, income determines whether a person reports an occasion within the last year where she needed medical treatment or examination but did not receive it due to inability to pay. Second, the more a country relies on OOPP as a means of healthcare financing, the higher the proportion of respondents who report UHN. Third, the share of OOPP amplifies the effect of income considerably. While the poorest decile has a 2 percentage points higher predicted probability of suffering from financially determined UHN than the richest decile in a country with relatively low OOPP (11% of total health expenditure), this difference soars up to 10 percentage points in a country with relatively high OOPP (25%)."

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