Multi-layer health insurance coverage, medical services use and health in a Universal National Health System, the case of Portugal


The Portuguese health system has the peculiar characteristic of being a Beveridge–Bismarck type aiming at universal coverage. On top of the national health system coverage, there is a second coverage provided to some professionals, plus a third layer of coverage that can be acquired by taking out voluntary private health insurance. The aim of this work is to ascertain whether people benefiting from supplemental multi-layer health coverage (on top of the existing National Health System) have more consultations, either with general practitioners or with specialists, and enjoy better health status. We used data from the National Health Survey from 2014 to estimate a recursive system of ordered probits. The main results confirm that multi-layer health coverage is correlated with the use of more specialist consultations, but not with more GP consultations. It is also correlated with better health status. These results may indicate the existence of moral hazard, induced demand and/or 'access effect'. Regarding policy matters, the measures aimed to reduce waiting times, improve patient choice, and increase access could counteract such results and mitigate the potential inequity of access and health status, and also excessive use of medical services that can happen under double health coverage.

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We would like to thank Pedro Pita Barros and the participants in the 16thCNES conference (2019) for their valuable comments on earlier version of this work.


The author of this research received no specific grant from any funding agency in the public, commercial, or not-for profit sectors.

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Correspondence to Aida Isabel Tavares.

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Tavares, A.I., Marques, I. Multi-layer health insurance coverage, medical services use and health in a Universal National Health System, the case of Portugal. Eur J Health Econ 22, 141–153 (2021).

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  • Health insurance
  • Coverage
  • Utilization
  • Health

JEL Classification

  • I11
  • I13