Private Health Insurance and the Risk of Frailty in Older Europeans: Evidence from SHARE

Abstract Background Frailty, a state of physiological decline and impaired homeostasis, raises the risk of adverse outcomes in older adults. With an ageing population and cuts to public health spending, private health insurance (PHI) is becoming more common, offering faster access and reduced out-of-pocket expenses. However, PHI may also widen health inequalities, as lower-income groups face greater barriers, delayed or missed care, and prevention, increasing their frailty risk. This study aimed to assess the impact of PHI on frailty risk among Europeans aged 50+ in follow-up since 2013. Methods Data was retrieved from waves 5 to 9 of SHARE dataset, a longitudinal panel study of adults aged 50+. Frailty was assessed using the SHARE Frailty Instrument. Cox proportional hazards regression was performed to examine determinants of frailty, the model was adjusted for demographic, socioeconomic, behavioural, and health-related variables. Results The analysis included 53,873 individuals from 17 countries. The mean age at baseline was 64.87 years, with 54.19% of participants being female. A total of 27.10% belonged to the highest socioeconomic status group. At study entry, 15.48% (n = 8,337) of individuals were classified as pre-frail. The follow-up period ranged from 0 to 9 years, yielding a cumulative observation time of 311,695 person-years, during which 4,645 incident frailty cases were recorded. PHI was associated with a 13% reduced risk of developing frailty (HR = 0.87; 95% CI: 0.79-0.96; p < 0.01). In the second lowest income quartile the effect was even stronger (Q2: HR = 0.80; 95% CI: 0.67-0.95; p < 0.01). In Spain, PHI was associated with a 37% reduced frailty risk (HR = 0.63; 95% CI: 0.40-0.99; p = 0.04). Conclusions PHI offer protection against the development of frailty. Whilst encouraging PHI enrolment as part of the retirement strategy could mitigate frailty risk, it might increase inequalities by weakening the Public Health System if not fully integrated into a wider strategy. Key messages • Private health insurance was linked to a 13% lower risk of frailty in Europeans aged 50+, with even stronger protection in lower-income groups, based on data from 53,873 individuals. • PHI may help mitigate frailty risk in ageing populations, but if not integrated within public health systems, it risks deepening health inequalities and weakening universal healthcare access.