Mirella Cacace

9 The changing role of the state in healthcare systems

This article focuses on two major questions concerning the changing role of the state in the healthcare systems of OECD countries. First, we ask whether major changes in the level of state involvement (in healthcare systems) have occurred in the past 30 years. Given the fact that three types of healthcare system, each of which is characterized by a distinct role of the state, evolved during the ‘Golden Age’, we 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 provision and regulation. As far as financing is concerned, we observe a small shift from the public to the private sphere, with a tendency towards convergence in this dimension. The few data available on service provision, in contrast, show neither signs of retreat of the state nor of convergence. In the regulatory dimension – which we analyse by focusing on 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 healthcare system. Putting these findings together we find a tendency of convergence from distinct types towards mixed types of healthcare systems.

Assessing quality in cross-country comparisons of health systems and policies: Towards a set of generic quality criteria

There is a growing body of cross-country comparisons in health systems and policy research. However, there is little consensus as to how to assess its quality. This is partly due to the fact that cross-country comparison constitutes a diverse inter-disciplinary field of study, with much variation in the motives for research, foci and levels of analyses, and methodological approaches. Inspired by the views of subject area experts and using the distinction between variable-based and case-based research, we briefly review the main different types of cross-country comparisons in health systems and policy research to identify pertinent quality issues. From this, we identify the following generic quality criteria for cross-country comparisons: (1) appropriate use of theory, (2) explicit selection of comparator countries, (3) rigour of the comparative design, (4) attention to the complexity of cross-national comparison, (5) rigour of the research methods, and (6) contribution to knowledge. This list may not be exclusive though publication and discussion of the list of criteria should help raise awareness in this field of what constitutes high quality research. In turn, this should be helpful for those planning, undertaking, or commissioning cross-country comparative research.

Von der Risiko- zur Anbieterselektion

Zusammenfassung Seit den 1990er Jahren lässt sich in mehreren OECD-Gesundheitssystemen des Sozialversicherungstyps die Implementation wettbewerblicher Reformen beobachten. Ein Vergleich von Deutschland und den Niederlanden als zwei Vertretern dieses Typs zeigt, dass diese Reformen eine Eigendynamik entwickeln: Einmal in einem Teilsegment eingeführter Wettbewerb erfordert „mehr“ Wettbewerb und Re-Regulierung. Von der freien Kassenwahl gingen in beiden Staaten zunächst steigende Anreise zur Risikoselektion aus. Um dieser Fehlentwicklung Einhalt gebieten, verbesserte der Gesetzgeber die Risikoadjustierung und eröffnete Möglichkeiten zur Anbieterselektion. Als Konsequenz wird das korporatistische Steuerungsmodell sukzessive durch Marktwettbewerb und staatliche Hierarchie ergänzt oder sogar substituiert.

The Changing Public-Private Mix in OECD Health-care Systems

The economic recession following the oil price shocks of the 1970s triggered a broad range of cost containment measures in social polices throughout the OECD world. Health care was no exception. Globalization, demographic change and advancements in medical technology have strengthened the need for reforms that assure both the quality and efficiency of health-care systems while at the same time guaranteeing equal access to services (OECD, 1994). The pertinent question to be dealt with in this contribution is how the role of the state and the market in attaining these challenging and somewhat contradictory objectives, has changed over time. Evidence suggests that although common challenges are experienced, the responses to various socio-economic pressures have differed considerably across healthcare systems (Tuohy, 1999; Rothgang et al., 2006). Starting in the 1990s, for example, we observe that in many predominately publicly financed health-care systems market-oriented health-care reforms have been implemented or proposed (van de Ven, 1996; Freeman and Schmid, forthcoming), whereas in countries with private insurance systems access to health care and the introduction of universal health insurance have gained political salience (Skocpol, 1994; Zweifel, 2000). This contribution focuses particularly on the ‘hybridization’ of health-care systems induced by the changing public–private mix. In order to capture these developments systematically, we differentiate between dimensions of health-care systems: financing, service provision and regulation.

Beyond Path Dependency: Explaining Health Care System Change

In July 2008 Lorraine Frisina sent me a note describing a conference she and others were organizing in Bremen, Germany. The conference would bring together political scientists, economists, and other social scientists in an effort to examine and explain the deep changes that were taking place in health care systems around the industrialized world. She asked whether JHPPL might be interested in publishing a set of the papers that emerged from the conference. We were. The conference, held in early December 2008, brought together an extraordinary collection of health policy experts who together considered a range of theoretical approaches applied to an even larger range of health care systems. Following the conference, Lorraine and her colleague Mirella Cacace worked with Lawrence D. Brown and me to coedit this issue. Mirella and Lorraine then wrote the note below, which summarizes some of the themes presented and the papers written. It is an impressive collection. We even added a bonus highlight: an extremely engaging backandforth between David Wilsford and Larry Brown on the utility of pathdependence theory in explaining health system change. Enjoy.

The Changing Role of the State in Healthcare Financing

Institutional legacies are one broad explanation for considerable and persisting differences in the ways nations finance their healthcare systems (Pierson 2004; Taylor-Gooby 1996; Wilsford 1994). Yet it is clear that although all countries throughout the world rely on their own, specific funding-mix in healthcare, this mixture is also subject to readjustment and change (Huber 1998: 63; Scott 2001: 3). Changes in the funding mix may be caused by political interventions such as the inclusion of new groups in a public health1 insurance scheme, changes in co-payment rules or the scope of the benefit package covered by the public system (Maarse 2004b). Different growth trends of healthcare sectors which are predominantly financed by rather private or public funds may also alter the funding-mix substantially (Tuohy et al. 2004). Neither the financing structure nor funding levels have therefore been static during the past decades. While the development of total health expenditure and its determinants have been analyzed extensively, the evolution of public healthcare spending and of differences in the funding-mix across countries have attracted less attention (Barros 2007; for notable exceptions see Castles 2004; Comas-Herrera 1999; Mossialos and Dixon 2002; Starke et al. 2008). In this chapter we scrutinize the role of the state as a financer versus other sources of financing since the early 1970s in 23 OECD countries (see Chapter 1).

Small- and Medium-Sized Enterprises’ Preferences for Occupational Health Services and Willingness to Pay

Small and medium-sized enterprises (SMEs) in particular benefit from occupational health services because these may help to reduce the potential costs of accidents or illnesses at work, support staff retention and recruitment, and decrease wage costs. Nevertheless, SMEs, especially microenterprises (<10 persons employed), rarely offer these services to their employees. The innovation incubator’s project “Healthy at Work” offers research-based advice to private service units to support SMEs to provide occupational health services in the region of Luneburg. This chapter describes how we use an Adaptive Choice-Based Conjoint Analysis combined with a short willingness to pay (WTP) questionnaire to elicit SMEs’ preferences regarding occupational health services. We found that the optimal approach is to offer a comprehensive service package tailored to the needs of the individual company on a pay-per-use basis. The private supplier benefits from cooperation with a social insurance provider: either a health insurance fund or occupational accident insurer. Further, we found that employers are willing to pay for services. Within the group that is willing to pay, WTP increases with company size. It is therefore particularly important to offer appealing and affordable occupational health services to microenterprises, preferably in cooperation with social insurance providers.

Promoting Workers’ Health in Small- and Medium-Sized Enterprises: Designing and Evaluating a Concept for Preventing Occupational Skin Diseases

This chapter describes the development and evaluation of a concept for trainings in skin-care tailored to the specific needs of small and medium-sized enterprises (SMEs) in rural regions. It covers SME in industries in which employees work in wet or damp environments or are exposed to strong chemical or allergenic substances or both; these risk factors frequently lead to work-related skin problems. Florists, outpatient and inpatient care providers, hairdressers, bakers, and metalworkers were recruited to our study. Overall, 72 SMEs participated. The first research step was to explore company owners’ expectations of the training and the requirements particular to their organizations. Trainings on skin-care were developed and tailored to the specific needs of the SMEs and surveyed industries. For evaluation purposes a randomized controlled trial was conducted in which the effectiveness of the trainings was quantitatively assessed by employees of the participating SMEs completing three waves of written surveys. A significant reduction in skin-related symptoms, a positive effect on skin-care and cleaning, and a significant positive effect on participants’ knowledge in the area of occupational skin protection were found. However, the dermatological training did not have a positive effect on the participants’ satisfaction with their work. The average cost of the intervention per participant was approximately 63.50 €; foregone working time not included.

The Hybridization of Healthcare Regulation: An Explanation in Cross-national Perspective

It has been the principal challenge for OECD healthcare systems over the past four decades to reconcile the public demand for access to state-of-the-art healthcare with the need to control increasing healthcare expenditure. The oil crises of the 1970s heralded the end of a period of continual benefit expansion, while cost containment policies came to dominate the political agenda and efforts to improve the efficiency of healthcare systems gained in importance. This has fundamentally challenged the established regulatory structures of healthcare systems and provoked various adjustment processes.