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Abstract Background Lower-middle-income countries (LMICs) have a common goal to achieve universal health coverage (UHC) through voluntary health insurance schemes. This is important to improve access to healthcare services and ensure financial protection for all by reducing out-of-pocket expenditures. This study aimed to examine the role of risk preferences on enrollment status (currently insured, previously insured, and never insured) into a Tanzanian voluntary health insurance scheme targeted at the informal sector. Methods Data were collected from households in a random sample of 722 respondents. The risk preference measure was based on a hypothetical lottery game which applies the BJKS instrument. This instrument measures income risk where the respondents are to choose between a certain income and a lottery. Both multinomial and simple logistic regression models have been used to analyze the relationship between risk aversion and enrollment status. Results On average, the respondents have a high degree of risk aversion, and the insured are more risk averse than the uninsured (previously insured and never insured). There is a weak tendency for the wealthiest, measured by household income or total household expenditure, to be somewhat more risk averse than the less wealthy. Logistic and multinomial logistic regressions show that risk aversion is strongly associated with enrollment status. A higher degree of risk aversion significantly increases the probability of being insured, relative to being previously insured, and relative to being never insured. Conclusion Risk aversion matters in a decision to enroll into the iCHF scheme. Strengthening the benefit package for the scheme, might increase the enrollment rate and hence improve access to healthcare services for people in rural areas and those employed in the informal sector.