Out-of-pocket health expenditure differences in Chile: Insurance performance or selection?

Chile has a mixed health system with public and private actors engaged in provision and insurance. This dual system generates important differences in health expenditure between private and public insurances. Selection is a preeminent feature of the Chilean insurance system. In order to explain the role of the insurance in out-of-pocket expenditures between households for different insurance schemes, decomposition methods are applied to disentangle the effect of household 'composition and insurance' degree of financial protection on health expenditures. Health expenditure patterns have not changed in the last 10 years with drugs, outpatient care, and dental health representing 60% of the health expenditure. Health expenditure/income is similar for different income groups in the public insurance, but decreases with income in households with private coverage, reflecting regressivity in health expenditure. On the other hand, health expenditure as share of expenditure increases with income for both groups. Per capita health expenditure in households with private coverage is four times the expenditure of households with public insurance; this gap is mostly explained by differences in households' expenditure and demographics. Roughly 80% of the difference in expenditure is explained by the model, showing the role of selection in understanding the expenditure gap between insurance schemes.