Up to 120,000 working-age residents of Estonia have no health insurance over the long term, according to an analysis by the Praxis Centre for Policy Studies, which explored a switch to a universal healthcare system as one option available to Estonia.

While the number of people without health insurance in Estonia is currently the lowest it has been in a decade, it still remains high compared to the average for OECD member states and the EU, the Ministry of Social Affairs said on Tuesday.

The overwhelming majority of residents lacking health insurance in the long term have intermittent coverage. The analysis also revealed that the absence of health insurance was unevenly distributed among population groups.

"Inadequate coverage is the most widespread among men, people of prime working age, people whose native language is something other than Estonian, and people with a lower education level," said Tarmo Jüristo, chairman of the management board at Praxis. "Also vulnerable are mothers of children who have recently turned three whose entry or return to the labour market is not smooth."

Jüristo noted that the intermittency of health insurance coverage for women was significantly more often linked to parenthood than was the case with men.

Current insurance system obsolete

Reasons for disruptions in insurance coverage or absence thereof lie in both the labour market and the social system, the study finds.

"Looking at the labour market, we can see thousands of people who have no health insurance as a result of irregular income or the nature of their work," Jüristo highlighted. "Currently, many individuals in free professions and people doing non-traditional work, who have no contract with a specific employer, are in an uncertain situation. The current system isn't flexible in allowing different forms of employment and is becoming increasingly obsolete."

Among other things, the analysis recommends changing the criteria for employment and payments in health insurance. Under the current system, social tax paid for the previous calendar month is counted in assigning health insurance coverage; according to Praxis, this period should be extended to 12 months.

"A change like this would allow for increasing the flexibility of the labour market, reducing the structural labour shortage and help ensure equal treatment to people who pay the same amount of social tax over the year, regardless of the nature of their employment relationship," Jüristo added.

Many unaware of options available to them

The analysis also points out that people who are entitled to health insurance coverage via the social system are often not informed or motivated enough to take advantage of the various opportunities available for seeking health insurance.

"For instance, a large portion of the newly unemployed do not register with the Estonian Unemployment Insurance Fund (Töötukassa) as they do not qualify for benefits and allowances, and are thus deprived of health insurance as well," Jüristo said, adding that coverage can only be slightly increased via raising awareness and influencing people's behaviour.

Currently, there are altogether some 50 different bases for qualifying for health insurance in Estonia, which are difficult for the state to manage and citizens to be aware of. In light of this, the analysis by Praxis highlights the possibility of moving toward a system of universal healthcare coverage valid for all residents of Estonia.

"By fine-tuning the current system, health insurance coverage could be increased by one percent," Jüristo said. "Universal health insurance would be a large-scale reform requiring a fundamental change in the financing of healthcare and the tax system. Which of the scenarios would be manageable for Estonia and take into account the population and labour market changes with which we are faced will require a more in-depth analysis and societal debate."

A universal healthcare system would provide everyone with health insurance by untying it from the payment of social tax.