Towards Neo‐Bismarckian Health Care States? Comparing Health Insurance Reforms in Bismarckian Welfare Systems

Abstract

Germany, France and the Netherlands all have specific 'Bismarckian' health insurance systems, which encounter different and specific problems (and solutions) from those of national health systems. Following a relatively similar trajectory, the three systems have gone through important changes: they now combine universalization through the state and marketization based on regulated competition; they associate more state control (directly or through agencies) and more competition and market mechanisms. Competition between insurers has gained importance in Germany and the Netherlands and the state is reinforcing its controlling capacities in France and Germany. Up to now, continental health insurance systems have remained, however, Bismarckian (they are still mainly financed by social contribution, managed by health insurance funds, they deliver public and private health care, and freedom is still higher than in national health systems), but a new 'regulatory health care state' is emerging. Those changes are embedded in the existing institutions since the aim of the reforms is more to change the logic of institutions than to change the institutions themselves. Hence, structural changes occur without revolution in the system.

Healthcare policies over the last 20 years: Reforms and counter-reforms

“…The Social Democrats sought instead to improve the co-ordination among the various components of the healthcare system. The most notable result of the 1993 Strukturreform, passed by the Kohl government, was the marked reduction in the number of health insurance funds functioning nationwide-from more than 1200 to 250 in just a few years [11]. The system of funding thus became more competitive, but at the same time less pluralistic.…”

“…Furthermore, in 1997 the carnet de santé (a booklet in which doctors would have all relevant information concerning the diagnosis and treatment of individual patients) was introduced with the intention of avoiding contradictory or redundant prescriptions. Finally, in 1998 began the experiment of the médecins traitants, that is family doctors entrusted with the role of gatekeeping for secondary care [11]. The reform was meant to discourage direct access to specialists.…”

“…In 1990-1991 the German government faced a growing fiscal crisis due primarily to the costs of German unification [11]. There were also significant differences among the various sickness funds, in terms of both contribution rates and benefits granted to their members [12].…”

Translating Dutch: challenges and opportunities in reforming health financing in Ireland

“…A Consumer Quality index that measures consumers' experiences with health insurers and providers can be viewed on a government-sponsored website [16]. As of January 2006, all Dutch citizens were permitted to change their insurer; an estimated 21% of the population did so immediately [8], which was heralded as success of the reform. However, switching rates fell sharply to 4.5% in 2007 and 3.5% in 2008 [7] and fears have been expressed that consumers are not cooperating with market logic [17].…”

“…Most inpatient services are paid prospectively using a detailed Diagnostic Treatment Combinations system [8], based on both the patient's diagnosis and subsequent treatment rather than length of stay. Primary care providers are paid using a combination of capitation and fee for service.…”