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Bismarck’s Unfinished Business in Western Europe

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  • 313
    CHAPTER 12
    Bismarck’s Unfi nished Business in
    Western Europe
    Hans Maarse, Alexander S. Preker, Marianne E. Lindner,
    and Onno P. Schellekens
    o extract valuable lessons for scaling up health insurance, some main trends
    in the historical development and the current state of national health insur-
    ance in Europe are reviewed in this chapter. Special attention is given to
    Belgium, France, Germany, the Netherlands, and Switzerland,
    ve countries
    that have a national health insurance model in common to protect their citi-
    zens against the costs of sickness and ensure their access to basic health care. The
    main characteristics of this model are: mandatory membership, broad coverage in
    terms of persons and health services, contributions related to income instead of
    medical risk, no integration of health care fi nancing and provision of medical ser-
    vices, and strong government involvement (Saltman, Busse, and Figueras 2004).
    Neither a detailed description of the historical developments in each of the
    ve countries nor extensive comparison of their current health insurance sys-
    tem is intended.
    Instead, from the historical paths that emerge from this study,
    policy lessons are sought. What are the opportunities and threats for scaling up
    health insurance in low-income countries that have as yet had little experience
    with it (Bärnighausen and Sauerborn 2002)?
    Modern national health insurance arrangements are highly complex systems.
    They rest upon some fundamental notions with not always well-understood
    implications: joint action, normative-affection, instrumentality, good gover-
    nance and accepted authority, and selectivity. They imply some important pol-
    icy lessons for the introduction of health insurance arrangements and share a
    common theoretical basis: social capital.
    National health insurance (or any health insurance arrangement) is based on
    the principle of joint action. The participants pool their risks to protect them-
    selves against the costs of disease. Usually, they cannot afford to pay privately
    for expensive medical treatments. What people essentially buy when they join a
    common arrangement is the certainty that, once they are sick, the costs of their
    medical treatment will be covered by a third party. Joint action also functions
    as an effi cient instrument to collect resources for medical care in a community.
  • 314 Hans Maarse, Alexander S. Preker, Marianne E. Lindner, and Onno P. Schellekens
    Health insurance arrangements rest to some extent upon a “moral infrastruc-
    ture” (Hinrichs 1995) that can be described as a shared notion that members
    of the community are mutually dependent and must take care of their fellow
    members who are sick and need medical care. It is regarded as a moral obligation
    to remove fi nancial barriers to health care. This cultural or normative-affective
    dimension of health insurance provides a moral basis for pooling each other’s
    risks. On the European Continent, the normative-affective dimension of health
    insurance is often referred to as the solidarity dimension (Ter Meulen, Arts, and
    Muffels 2001).
    Health insurance and solidarity also have an instrumental dimension. People
    join a scheme not only for moral reasons, but also to protect themselves against
    nancial risks. Thus, they are motivated by self-interest as well as altruism.
    The notion of self-interest corresponds to the Anglo-Saxon concept of fairness,
    which, much stronger than the concept of solidarity, refers to mutual obliga-
    tions and rights (Van Oorschot 1999). Fairness is a matter of shared utility based
    upon contracts (“contractual solidarity”) rather than shared identity.
    Most normative-affective and instrumental considerations are not strong
    enough to support solidarity relationships in modern society. Support is neither
    necessarily spontaneous nor completely voluntary. Furthermore, there may be
    a problem of free-ridership. To resolve these problems, control and coercion of
    contributions will be necessary. Hence, health insurance is shaped as a man-
    datory arrangement. This may be called the dimension of accepted authority of
    health insurance (Van Oorschot 1999).
    The notion of accepted authority is closely related to the concept of good
    governance. In fact, good governance functions as a precondition for effective
    health insurance. The gradual extension of state intervention in health insur-
    ance required the state to be politically capable of not only enacting health leg-
    islation but also building up an effective administrative organization and fi scal
    capacity to put the legislation into practice. Kaufmann, Kraay, and Mastruzzi
    (2004, 2005) defi ne good governance as a multidimensional concept with three
    main dimensions: the process by which governments are selected, monitored,
    and replaced; the capacity of the government to formulate and implement poli-
    cies effectively; and the respect of citizens and the state for the institutions that
    govern economic and social relations (annex 12C).
    The notion of selectivity has always played a signifi cant role in national health
    insurance. Who is covered, and who is excluded? This question leads to the
    more fundamental question of the structure of society and its criteria for draw-
    ing social boundary lines. Bayertz (1999: 26) rightly points out that the concrete
    meaning of “solidarity is relative to the community.” The selection criteria used
    to draw the dividing line in the fi ve countries studied are seen later in this chap-
    ter. Here, it is suffi cient to note that over time, health insurance became ever
    more inclusive in terms of membership. Diminishing selectivity was intimately
    linked to the expanding state role in health insurance and the transition from
    voluntary to mandatory arrangements.
  • Bismarck’s Unfi nished Business in Western Europe 315
    So far, fi ve fundamental notions on health insurance have been briefl y elabo-
    rated. They have a common basis, social capital, which in the view of Putnam
    (1993: 167) “refers to features of social organization, such as trust, norms and
    networks that can improve the effi ciency of society by facilitating coordinated
    actions.” Putnam sees social capital as a public good that functions as a prerequi-
    site for institutional performance and democratic institutions. It creates a socio-
    cultural basis for joint action and accepted authority. Social capital presumes a
    minimum level of reciprocity, trust, or mutual confi dence in society, based upon
    notions of normative-affection and instrumentality (Rothstein 2001). Social
    capital is selective, too, because it is bound to a certain (sub)community. The
    relationship between social capital and good governance can best be seen as
    reciprocal. Social capital stimulates good governance (Putnam’s claim), and good
    governance is a precondition for the development of social capital (Levi 1996).
    Health insurance started as a model of voluntary and informal risk sharing. It
    was a product of self-organizing activity in social life during the 17th and 18th
    centuries. In Belgium and the Netherlands, guilds initially played a leading role.
    Because of increasing political problems due to the French Revolution, guilds
    were either converted to mutual societies or terminated in the 19th century.
    In the 20th century, many nonguild-related voluntary mutual societies, associa-
    tions, and nonprofi t and commercial companies were also developed as a collec-
    tive arrangement for covering the costs of medical care and loss of income due
    to illness, physical ailment, or death (Veraghtert and Widdershoven 2002).
    The advent of health insurance arrangements cannot be divorced from the
    progressive industrialization of economic life in the 17th and 18th centuries.
    Sickness deprived workers of their income. Therefore, most schemes started as
    a sick pay arrangement for workers during sick leave. Only later did covering
    medical care costs become the main function of health insurance.
    The shifting
    focus is nicely illustrated by the fact that in Germany social health insurance at
    its inception provided 1.7 more cash benefi ts than benefi ts in-kind. By 1955 this
    ratio had reversed to 1:4, by 1977 to 1:10, and by 1984 to 1:16 (Bärnighausen
    and Sauerborn 2002: 1569).
    Although local governments in Belgium and the Netherlands did not directly
    participate in the creation of sickness funds, they soon became indirectly
    involved. Local governments mostly welcomed the private initiative of the
    guilds or other social organizations because it lessened the need for public pov-
    erty programs. For this reason, they conferred on the funds the right to intro-
    duce compulsory membership.
    Health insurance in France and Switzerland was also a bottom-up initiative
    rather than a state-orchestrated process. Only Germany followed a more cen-
    tralistic path. Some states, in particular Prussia and Bavaria, passed legislation

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Bismarck’s Unfinished Business in Western Europe

Bismarck’s Unfinished Business in Western Europe. Chronicles the historical development of national health insurance in Europe, emphasizing that it took many continental European countries more than a hundred years of gradual, incremental reforms in economic, political, and social policy to reach universal coverage for their populations, and that resulting health systems are diverse, and the funding mechanisms are varied. The five countries of Belgium, France, Germany, the Netherlands, and Switzerland have a national health insurance model in common to protect their citizens against the costs of sickness and ensure their access to basic health care. The main characteristics of this model are: mandatory membership, broad coverage in terms of persons and health services, contributions related to income instead of medical risk, no integration of health care financing and provision of medical services, and strong government involvement. Important policy lessons include understanding that national health insurance arrangements must be embedded in each country’s wider social, economic, political, and cultural contexts.

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