Why are voluntary health insurance holders willing to pay tax towards public healthcare? A qualitative study from Sweden

Abstract Background Voluntary health insurance (VHI) is increasing in many European healthcare systems, including the tax-funded public healthcare systems found in Northern Europe. As private alternatives to publicly financed health services expand, there is a risk that the willingness to pay tax towards redistributive public healthcare systems will diminish. This study investigated how employer-funded VHI holders accounted for their continued willingness to pay income tax to suppor the public healthcare system and the motivation underlying their tax compliance. Methods A qualitative approach based on 19 semi-structured interviews with individuals holding an employer-funded VHI in Sweden was used. The interviews were analysed using thematic analysis. Results The findings suggest a continued willingness to pay tax towards the public healthcare system among Swedes with an employer-funded VHI. The support was motivated by a moral logic and belief in the principle of equal access to health for all citizens. Respondents also expressed ambivalence about gaining faster access to care than others. Conclusion These accounts suggest that the growth of employer-funded VHI does not by itself erode the willingness to fund public healthcare, and that the egalitarian principles underpinning a universal system can sustain a sense of obligation to contribute even among those who use private healthcare. The ambivalence respondents expressed indicates that contributing on egalitarian grounds and benefiting from privileged access are not easily reconciled.