Social Determinants of Out-of-Pocket Health Expenditures for the Older Adults in Turkey: An Econometric Analysis Using TURKSTAT 2023 Data

The rise in the older-aged population due to the demographic transition increases healthcare needs, creating a
substantial Out-of-Pocket expenditure burden that is structurally determined not just by medical necessity but also by critical social and socioeconomic factors. This study aimed to analyze the social and socioeconomic determinants affecting the decision to make out-of-pocket (OOP) health expenditures and the expenditure amount among older adults individuals aged 65 and over in Turkey, utilizing the Turkish Statistical Institute 2023 Household Budget Survey data. Due to the high rate of zero expenditure observations, a two-stage econometric model strategy was adopted, employing Logistic Regression to examine the expenditure decision and Linear Regression to examine the positive expenditure amount. The analysis revealed that core disability statuses (working disability: OR=1,959) and health insurance ownership (OR=2,777) strongly increase the probability of making an expenditure. This is consistent with descriptive findings showing that expenditure tendency increases as income and education levels rise. However, a paradoxical situation was detected: while the probability of making OOP expenditure decreases for lower socioeconomic groups (low-income, low education), the amount they spend increases once they decide to make an expenditure (low-income: B=0,092; low-education: B=0,042). The largest share of the expenditure burden stems from items where SGK/GSS coverage is insufficient, such as dental care, inpatient treatment, and pharmaceuticals, indicating that financial inequalities structurally shape OOP behavior. Consequently, it is recommended that the scope of SGK/GSS be expanded in high-burden areas and that the costs of preventive services be completely zeroed out to protect lowincome older adults and prevent delayed care.