Access to healthcare refers to the timely use of services to achieve the best possible health outcomes [1]. It is an important topic that has long attracted the attention of epidemiologists, physicians, patients and politicians [2–4]. Indeed, timely access to care has been shown to be crucial in preventing disease and disease complication [5, 6]. Additionally, medical needs of patients should be met by allowing them to access care without having to consider forgoing healthcare, especially for financial reasons. While there could be a discourse in choosing whether one should undergo elective procedures or not, access to healthcare should not depend on socioeconomic factors, tending towards a more equitable approach.

Several models have been studied to allow for optimal health coverage. Health coverage takes into account access to care, payments and reimbursements. Premiums and deductibles are considered as payments and are usually tied. When deductibles become too high, an opportunity cost will eventually be calculated by the consumer or patient, and individuals might choose to forgo healthcare to avoid paying the high deductible [7]. Additionally, countries that do not impose mandatory health insurance will tend to attract higher risk individuals to be covered, with potentially average higher costs [8]. On the other hand, individuals with insurance might tend to consume more resources and thus negatively impact costs of healthcare in general [9].

Universal health coverage (UHC) has been presented as one of the solutions to increase insurance coverage and access to care [10]. UHC refers to a system in which all individuals who are eligible have access to a defined set of essential health services without facing financial hardship. However, even in a model like UHC, access to healthcare can still be inequitable and patients might choose to forgo healthcare for financial reasons. In a study evaluating forgoing healthcare in the OECD countries, socioeconomic disparities were evident via especially an income gradient and a difference of over 6 percentage points of forgoing healthcare between the lowest and highest income quintiles [11]. In the United States, 12.1% of adults between 18 and 64 delayed or did not receive needed medical care due to financial reasons [12]. In this same report, forgoing healthcare for financial reasons was associated with socioeconomic disparities.

Switzerland has compulsory health insurance for all its citizens. The model used in Switzerland is consumer-driven with universal health coverage [13]. Health insurance covers the cost of medical treatment including prevention, medication, emergency care services and hospitalizations. The Swiss system combines individual choice with strong public regulation as residents are required to purchase a basic insurance plan from private insurers within a strictly regulated market. Federal law defines a uniform basic benefits package that all insurers must provide. The Federal Office of Public Health (FOPH) supervises insurers, approves annual premium levels. However, as of this date, no public insurance option exists in Switzerland for healthcare coverage.

In Switzerland, a population-based study in 2012 showed that one out of 7 individuals reported forgoing healthcare for economic reasons [14]. Forgoing healthcare was associated with socioeconomic disparities including lower income, female sex, higher deductibles and being a single parent. More recent results on the same study population showed that high deductibles were associated with forgoing healthcare [7] for financial reasons and that dental care was one of the first services to be forgone by patients [15], especially that dental insurance and direct dental care are not subsidized. A recent federal report showed trends in forgoing healthcare in Switzerland [16], however this report only included data up until 2019 (pre-COVID19 pandemic).

The present population-based study relies on data from the canton of Geneva. Geneva represents a highly urbanized region with a diverse population and consistently ranks among the highest cantons in healthcare expenditure per capita and mandatory health insurance premiums. To date, no study has evaluated the long-term trends in forgoing healthcare for financial reasons in Switzerland. Given the rise in the costs of healthcare and insurance premiums in Switzerland, and potentially changing behaviors due to the COVID-19 pandemic, it would be essential to assess whether forgoing healthcare for financial reasons has increased with time.

The objective of this study is to look at the trends in forgoing healthcare for financial reasons in the population-based Bus Sante study in Geneva, Switzerland between 2011 and 2025. The study also evaluates associations of forgoing healthcare with socioeconomic or health determinants, as well as the association between forgoing healthcare for financial reasons and health outcomes.

The Bus Sante study is a yearly transversal study of about 1’000 participants each year distributed by age and sex representative of the distribution in the general population in Geneva. Participants are randomly selected through lists from the state registry cantonal office of population and migration. Subjects are first contacted via a mailed invitation letter, followed by up to seven phone calls and two more letters. Those who are not reached after these attempts are replaced using the same procedure. Initially, the age range for participants was 35–74 years, but this was expanded to 20–74 years in 2011. The Bus Sante study was briefly interrupted between 2020 and 2023 due to the COVID-19 pandemic and a digitalized version of the questionnaires was introduced in 2024. All participants are French speaking residents of the Geneva canton and have given written informed consent. The study was approved by the Geneva Ethics Committee for Research [IRB00003116].

Overall, n = 10,169 participants were included in this study with an average participation rate of 61%. Participants completed five questionnaires that assessed sociodemographic characteristics, nutrition, physical activity and health outcomes. Participants also underwent a physical examination measuring height, weight and vital signs. Fasting blood samples for a glycemic and lipid profiles were also collected during the visit.

Forgoing healthcare for financial reasons was measured by asking individuals if they had forgone any type of healthcare in the past 12 months for financial reasons, with options “yes” and “no.”

Socioeconomic measures included sex (male, female), age later grouped into age groups (20–34; 35–49; 50–64; 65 and above), education (primary, secondary or tertiary). Civil status was defined as single, married or living in couple, divorced and living alone, divorced and living in couple, widowed and living alone, widowed and living in couple. Nationality was grouped into Swiss and Non-Swiss. Income was measured based on the average monthly income divided into 6 categories in Swiss Francs CHF ≈1.24 USD (<3,000; 3,000–4,999; 5,000–6,999; 7,000–9,499; 9,500–13000; >13,000), individuals could also choose “don’t know”, or “don’t wish to answer”. Healthcare insurance subsidy was measured by asking participants if they receive any subsidy for healthcare insurance with options “yes,” “no,” “don’t know” and “don’t wish to answer.” Individuals reported their health insurance deductibles with options in CHF (None, 300, 500, 1,000, 1,500, 2,000, 2,500, don’t know, and don’t wish to answer). Individuals also reported whether they had a complementary insurance (yes, no).

Health measures included BMI (kg/m2) that was calculated based on measured height and weight and later categorized (underweight, healthy, overweight, obesity), smoking status (yes, no), and self-rated health (very good, good, average, poor, very poor). Diabetes was defined as fasting blood glucose level ≥ 7 mmol/L, self-reported diabetes diagnosis, or self-reported intake of antidiabetic treatment. Diabetes unawareness was defined as blood glucose level ≥ 7 mmol/L, with no reported diagnosis or treatment. Dyslipidemia was defined as fasting cholesterol level ≥6.2 mmol/L, self-reported dyslipidemia diagnosis, or self-reported intake of dyslipidemia treatment. Dyslipidemia unawareness was defined as fasting cholesterol level ≥6.2 mmol/L with no reported diagnosis or treatment. Hypertension was defined as mean systolic and/or diastolic blood pressure ≥140/90 mmHg, self-reported hypertension diagnosis, or self-reported use of anti-hypertensive treatment. Hypertension unawareness was defined as mean systolic and/or diastolic blood pressure ≥140/90 mmHg, with no reported diagnosis or treatment.

Overall trends in insurance premiums (simple market averages) between 2011 and 2025 were collected from the Federal Office of Public Health data [17, 18].

In 2025, one out of four individuals in a population-based study in Geneva, Switzerland reported forgoing healthcare for financial reasons. Trends between 2011 and 2025 show an increase in forgoing healthcare along increasing insurance premiums, with a 2% increase in forgoing healthcare for financial reasons for every 10 CHF (12.6 USD) increase in insurance premiums. Forgoing healthcare for financial reasons increased in higher income categories, with increasingly more higher income individuals forgoing healthcare for financial reasons (+9.5%). Results revealed a strong and positive correlation between the increase in health insurance premiums and the rise in forgoing healthcare, with nearly 61% of the variance explained by premium increases alone. Results showed that women and young adults were disproportionately burdened by rising healthcare costs. Young adults could perceive themselves as healthier and have more risk tolerance in forgoing healthcare for financial reasons. Women, individuals with a lower income, divorced individuals living alone, as well as smokers, individuals suffering from obesity or underweight, and individuals with poorer self-rated health were more likely to forgo healthcare for financial reasons.

Forgoing healthcare for financial reasons is an important determinant in access to care in a timely manner. When individuals delay or forgo care due to cost, they become at increased risk of finding disease later in its progression, with higher severity, more complications and an increase in avoidable hospitalizations. A pooled study in 2020 showed that 17.9% of households had forgone healthcare and 10.3% in 2021 [20]. However, these results were evaluated during the COVID-19 pandemic and it is important to look beyond the pandemic years, especially with half of the world’s population lacking access to essential health services in 2024 [21], despite the push towards universal healthcare coverage, results shows that even within this model, disparities persist and 25% of individuals forgo healthcare for financial reasons. With an increasing prevalence of forgoing healthcare for financial reasons in Geneva, Switzerland, the population and healthcare system are at risk of incurring increased costs, and deteriorating healthcare. A projected further rise in forgoing healthcare highlights the need to reevaluate the healthcare system based on increasing health insurance premiums.

Results showed that lower income was significantly associated with forgoing healthcare for financial reasons. However, more detailed results also showed that individuals with a higher income were forgoing healthcare for financial reasons differentially more than individuals with a lower income, between 2011 and 2025. This phenomenon could be explained by increasing premiums, but also by an increase in the subsidies for healthcare insurance in lower income groups. Indeed, in Geneva recent years have shown an increase in subsidies for health insurance for lower income groups [22].

The observed increase in forgoing healthcare and correlation with rising insurance premiums shows that affording healthcare insurance is a growing concern across the income spectrum, despite subsidies being allocated to those with lower income. With increasing premiums and financial considerations from a household perspective for several family members, individuals might be more likely to choose high-deductible plans for their household. High deductibles, one of the options to decrease an individual’s insurance premiums, could be a significant factor in forgoing healthcare for financial reasons due to out-of-pocket expenses [7], and a potential target for policymakers. Results in this study showed that the association between an increase in deductibles and forgoing healthcare for financial reasons remained significant even after adjusting for all other socioeconomic factors including age, sex, education and income.

Associations showed that younger adults and women were more likely to forgo healthcare for financial reasons. A positive strong correlation was seen between forgoing healthcare and the increase in health insurance premiums especially in women and young adults with respectively 66% and 65% of the variance explained by premium increases alone. After adjusting for income, health insurance premiums, and subsidies, younger age was still independently associated with higher odds ratios of forgoing healthcare for financial reasons. It is possible that younger adults perceive themselves as generally healthier and allow themselves more margins to forgo healthcare for different reasons including financial reasons. The strong correlation between the increase in forgoing healthcare and the increase in premiums in this population group warrants a more targeted approach and potentially more attractive premiums for this population. Women were also consistently more likely to forgo healthcare for financial reasons after multivariable adjustments for other socioeconomic and health determinants, and that was especially true in the subgroup of women with high deductibles. This could be due to a socioeconomic disparity between men and women, but also to caregiving responsibilities falling largely on women and delaying access to care [23]. Divorced individuals living alone were also more likely to forgo healthcare for financial reasons, the financial burden of being a single parent or being divorced and living alone, without shared household resources could accelerate forgoing healthcare. Interestingly, this association was seen in women and not in men, further highlighting sex-based socioeconomic disparity.

Health variables such as smoking and being in poor health were associated with forgoing healthcare for financial reasons. Smokers are potentially individuals that put less emphasis on their health by engaging in deleterious behaviors and potentially forgoing healthcare. This would create a double burden of high-risk behavior and poorer access to care, leading to undiagnosed chronic conditions and long-term complications. Similarly, individuals with poor or very poor health were more likely to forgo healthcare for financial reasons, suggesting that those who need healthcare the most might not be accessing it. This phenomenon has been described in the literature as inverse care law [24–26], creating a differentially higher burden for individuals with poor health. Some of the protective associations seen with dyslipidemia and hypertension, where individuals who suffered from these conditions seemed to be less likely to forgo healthcare for financial reasons, could reflect higher contact with the healthcare system for individuals with chronic conditions, especially for those who are being managed. While this model could indicate that healthcare access is met when needed (pre-existing conditions), reducing potential overconsumption, it is important to note that individuals with poor self-rated health still had increased levels of forgoing healthcare for financial reasons, potentially worsening their health. Self-rated health has been shown in the literature to be associated with mortality [27].

The study has several limitations including self-reported data that could be subject to recall bias and social desirability bias. However, this is partly mitigated by the large sample size. Second, while the population-based recruitment allows for a sample that is representative of the general population, non-respondents could have different health behaviors including access to care. This study included French speaking residents of the canton of Geneva, thus potentially excluding non-francophone migrant groups. Adjusting for age, sex, education and income partly addressed this limitation. Third, data were missing between 2020 and 2023, and more long-term data over the next few years are needed to evaluate whether trends are fluctuating or more linear. While this is important to keep in mind, the increase between 2011 and 2025 was already evident, and calls for close monitoring.