The changing public/private mix in the American Health Care System

This paper discusses the fundamental changes in the American health care system during the past four decades. By applying a multidimensional framework, the changing role of the state in financing, service provision, and in the regulation of the health care system are scrutinized. The results suggest a considerable blurring of the private, market based health care system of the United States. While the state constantly retreats from service provision, it substantially intensifies its engagement in financing and also in the regulation of the system. The most path-breaking changes in regulation, however, are observed through the introduction of managed care, which, from a private market side, brought new elements of hierarchical coordination into the system. --

Fair financing in Germany's public health insurance: income-related contributions or flat premiums

Social justice in health care insurance relates to both, the utilisation of services and the financing of the system. With respect to the latter, in its World Health Report 2000 the WHO promoted a concept of fair financing that asks for contributions to health care financing that are proportional to households' capacity to pay. This claim contains three dimensions: the rejection of risk-related premiums, the claim that all households with equal income should pay equal premiums (horizontal justice), and the suggestion that higher income should lead to proportionally higher premiums (vertical justice). In this paper we first discuss the normative dimension of fair financing and develop a slightly modified version of the WHO's normative framework. Second, empirical findings based on WHO data and on data from the ECuity project are presented for selected countries. While the WHO concept does not allow drawing unambiguous conclusions, the latter shows, that Germany's system is regressive. With respect to the normative framework developed we can therefore conclude that future reforms should make the system more progressive. Against this background, two recent alternative strategies for reforming health financing, the Bürgerversicherung and the Gesundheitsprämie, are discussed. While both reform options are to be judged as more or less equivalent regarding horizontal justice and the rejection of risk-related premiums, some evidence is given towards the inferiority of the Gesundheitsprämie model with respect to vertical justice. --

Fair financing in Germany\u27s public health insurance : income-related contributions or flat premiums

Social justice in health care insurance relates to both, the utilisation of services and the financing of the system. With respect to the latter, in its World Health Report 2000 the WHO promoted a concept of fair financing that asks for contributions to health care financing that are proportional to households’ capacity to pay. This claim contains three dimensions: the rejection of risk-related premiums, the claim that all households with equal income should pay equal premiums (horizontal justice), and the suggestion that higher income should lead to proportionally higher premiums (vertical justice). In this paper we first discuss the normative dimension of fair financing and develop a slightly modified version of the WHO’s normative framework. Second, empirical findings based on WHO data and on data from the ECuity project are presented for selected countries. While the WHO concept does not allow drawing unambiguous conclusions, the latter shows, that Germany’s system is regressive. With respect to the normative framework developed we can therefore conclude that future reforms should make the system more progressive. Against this background, two recent alternative strategies for reforming health financing, the Bürgerversicherung and the Gesundheitsprämie, are discussed. While both reform options are to be judged as more or less equivalent regarding horizontal justice and the rejection of risk-related premiums, some evidence is given towards the inferiority of the Gesundheitsprämie model with respect to vertical justice

Small scale-Reform oder Erdrutsch? Eine Stellungnahme zur Gesundheitsreform in den USA

"(Die Autorin) behandelt eine gesundheitspolitische Reform, die, wenn man die Schärfe der nationalen Debatte und die große Aufmerksamkeit der Medien als Maßstab nimmt, unbedingt zu einer der bedeutendsten in den letzten Jahrzehnten zu zählen ist. Doch wie weit reicht das Reformprojekt Obamas? Wird es seiner Administration tatsächlich gelingen, bei 32 Millionen bisher unversicherten Menschen eine Absicherung für den Krankheitsfall zu erreichen? Die Autorin leuchtet die Hintergründe aus und bezieht Stellung." (Autorenreferat

Convergence of divergence of OECD health care systems

This article focuses on two major questions concerning the changing role of the state in the health care systems of OECD countries. Firstly, we ask whether major changes in the level of state involvement (in health care systems) have occurred in the past thirty years. Given the fact that three types of health care systems - which are characterized by a distinct role of the state - evolved during the golden age, we secondly discuss how this distinctiveness - or more technically: variance - has changed in the period under scrutiny. While many authors analysing health policy changes exclusively concentrate on finance and expenditure data, we simultaneously consider financing, service provi-sion, and regulation. As far as financing is concerned, we observe a small shift from the public to the pri-vate sphere with a tendency towards convergence in this dimension. Expanding Peter Flora´s `growth to limits´ theses, due to the ongoing increase of total financing and the melting off of the public share `private growth and public limits´ might be a future trend in the financing dimension of health care systems. The few data available on ser-vice provision, in contrast, show neither signs of retreat of the state nor of convergence. In the regulation dimension - which we analyse by picking major health system reforms in Germany, the United Kingdom and the United States - we see the introduction or strengthening of those coordination mechanisms (hierarchy, markets and self-regulation) which were traditionally weak in the respective type of health care system. `Gate-keeping´ and DRG models are remarkable examples to show that health policy might increasingly be oriented at `best practices´ even when the respective solutions are beyond the traditional path of reforms. Putting these findings together we find a ten-dency of convergence from distinct types towards mixed types of health care systems. - --

And fairness for all? Wie gerecht ist die Finanzierung im deutschen Gesundheitssystem? Eine Berechnung des Kakwani-Index auf Basis der EVS

Unser Beitrag thematisiert soziale Gerechtigkeit in der Finanzierung des deutschen Gesundheitssystems. Obgleich in öffentlichen Debatten häufig mit sozialer Gerechtigkeit argumentiert wird, fehlt ein entsprechendes Konzept und demzufolge auch die empirische Fundierung. Wir greifen dieses Defizit auf indem wir (1) einen theoretischen Referenzrahmen ableiten und (2) die empirischen Ergebnisse zu sozialer Gerechtigkeit im Status Quo des deutschen Gesundheitssystems aktualisieren. Als theoretischen Referenzrahmen wählen wir das WHO Konzept zur fairen Finanzierung in Gesundheitssystemen. Nach einer Zusammenfassung der Kritik an der WHO Studie benennen wir als Postulate: (1) keine risikogebundenen Prämien (2) Haushalte mit gleichem Einkommen sollen gleiche Prämien bezahlen (horizontal justice) (3) höhere Einkommen führen zu entsprechend höheren Prämien (vertical justice). Zur Messung fairer Finanzierung berechnen wir die Gesamt- und Teilwerte des Kakwani-Index auf Basis aktueller Daten der Einkommens- und Verbrauchsstichprobe 2003 (EVS 2003). Im Vergleich zeigen unsere Ergebnisse für den Gesamtindex, dass die Finanzierung der Gesundheitsausgaben innerhalb der vergangenen 15 Jahre geringfügig weniger regressiv geworden ist (von -0.045 auf -0.041). Bei einer differenzierten Betrachtung der einzelnen Finanzierungskomponenten zeigen sich Verschiebungen. Wir schließen unsere Betrachtung mit einem methodischen Hinweis zur Anwendung des Kakwani-Index für das deutsche Gesundheitssystem. -- This contribution deals with social justice in healthcare financing in Germany. It starts from the observation that social justice - although often referred to in the public debate - is neither explicitly conceptualized nor empirically measured. Our paper provides (1) a theoretical framework and (2) a timely empirical basis, reflecting fairness in financing in the status quo of the German healthcare system. With regards to the first point, we recur to the normative concept underpinning the WHO Report 2000. After summing up the critique the WHO study provoked, we extract that (1) healthcare premiums should not be risk-dependent, (2) all households with equal disposable income should make equal contributions (horizontal justice), and (3) higher income should lead to higher contributions (vertical justice). For the measurement of fair financing in the German healthcare system, we calculate the Kakwani-Index (overall index and partial indices) based on most recent available empirical data set of the Sample Survey of Income and Expenditure 2003 (EVS 2003). Our results for the overall Kakwani-Index show that healthcare financing in Germany has become slightly less regressive (from -0.045 to-0.041) within the past 15 years. Furthermore, we find some interesting changes in the partial indices. Finally, we point at the limits the Kakwani-Index imposes on the measurement of fair financing in the German healthcare system from a methodological perspective.

How is well-being in the information society introduced?

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