Welfare Regimes and Out-of-Pocket Healthcare Spending in the Last Year of Life Among Cancer Decedents in Europe and Israel

Background/Objectives: Out-of-pocket (OOP) healthcare spending can remain substantial near the end of life even in countries with broad health coverage, yet less is known about whether these expenditures follow broader welfare-regime patterns. This study examined OOP healthcare expenditure among cancer decedents and assessed whether welfare-regime differences persisted after adjustment for individual demographic and socioeconomic characteristics. Methods: We analyzed Survey of Health, Ageing and Retirement in Europe (SHARE) End-of-Life data for 1950 cancer decedents aged 50 years and older from 14 countries including Israel, classified into Continental, Social Democratic, Mediterranean, and East European welfare regimes. Logistic regression examined the likelihood of OOP expenditure, and linear regression examined expenditure magnitude, adjusting for gender, age, education, household economic capacity, and supplemental health insurance. Results: Overall, 58.0% of cancer decedents incurred OOP healthcare expenditure during their final year of life. Compared with the Continental regime, adjusted odds were higher in the Social Democratic regime (OR = 1.841) and lower in the Mediterranean (OR = 0.480) and East European (OR = 0.731) regimes. Social Democratic and East European regimes were also associated with lower expenditure levels than the Continental regime, whereas the Mediterranean regime did not differ significantly. Supplemental health insurance was associated with lower odds of OOP expenditure, while education was inversely associated with expenditure magnitude. Conclusions: OOP healthcare spending among cancer decedents varies systematically across welfare-regime contexts. Macro-institutional arrangements governing healthcare financing and social protection appear to be associated with household exposure to healthcare costs beyond individual socioeconomic characteristics.