Ralf Götze

Five types of OECD healthcare systems: Empirical results of a deductive classification

This article classifies 30 OECD healthcare systems according to a deductively generated typology by Rothgang and Wendt [1]. This typology distinguishes three core dimensions of the healthcare system: regulation, financing, and service provision, and three types of actors: state, societal, and private actors. We argue that there is a hierarchical relationship between the three dimensions, led by regulation, followed by financing and finally service provision, where the superior dimension restricts the nature of the subordinate dimensions. This hierarchy rule limits the number of theoretically plausible types to ten. To test our argument, we classify 30 OECD healthcare systems, mainly using OECD Health Data and WHO country reports. The classification results in five system types: the National Health Service, the National Health Insurance, the Social Health Insurance, the Etatist Social Health Insurance, and the Private Health System. All five types belong to the group of healthcare system types considered theoretically plausible. Merely Slovenia does not comply with our assumption of a hierarchy among dimensions and typical actors due to its singular transformation history.

Cross-National Policy Learning in Health System Reform: The Case of Diagnosis Related Groups

Observations of policy convergence and the cross-national diffusion of ideas, knowledge and policies have raised the question about the ways countries might learn from their peers. This article examines the role of cross-national learning with regard to Diagnosis Related Groups (DRGs). We review the spread of this policy instrument and analyse the implementation of DRGs in three late-adopting countries: Germany, Switzerland and the Netherlands. The three cases show that the implementation of this policy instrument required intense studies, cooperation with stakeholders and adjustment to country-specific needs. The countries learned from foreign experience, but it was only with the introduction of a regulatory framework for competition between sickness funds that DRGs came fully onto the political agenda. While Germany and Switzerland drew upon foreign DRG models, the Netherlands developed an alternative system to classify patients according to case-mix.

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.

Healthcare Financing in OECD Countries Beyond the Public-Private Split

Background: Studies of long-term trends in the healthcare financing mix generally focus on a dichotomous concept discerning public from private funding sources. More detailed analyses of the funding mix tend to be restricted to a small number of cases or do rarely examine time trends. Aim: This paper enhances the existing body of literature by developing and applying a trichotomous concept for healthcare funding, distinguishing taxes, contributions, and private sources. This includes a new aggregated indicator for the mix of three financing sources and its graphical representation. Methods: The study mainly builds upon OECD Health Data 2011. We measure changes in the funding mix since 1972 as its distance from a funding mix that equally draws upon taxes, contributions and private sources. Results: Up to 1980, the OECD healthcare systems move toward ideal-typical financing schemes. Between 1980 and 2000, the funding mix hybridizes mainly driven by privatization processes in NHS and social insurance countries and ongoing switch-over-processes between these two healthcare system types. Since 2000, OECD countries again tend toward ideal-typical funding schemes. Discussion: We use the framework for institutional change developed by Streeck and Thelen. The quantitative approach highlights changes in terms of displacement, layering, and drift but fails to fully reveal conversion processes. Therefore, further qualitative research is needed to capture not only shifts between the funding sources but also more gradual changes within them. Conclusion: The back-and-forth development of the trichotomous funding mix challenges assumptions of a universal trend toward hybrid financing structures.

The Changing Role of the State in the Italian Healthcare System

The present study describes and explains the changing role of the state in the Italian healthcare system since the beginning of the 1970s, with a particular focus on developments following 1978 when the healthcare system was transformed from a social insurance system into a national health service. In order to address these changes in a systematic way, we track healthcare system development along three dimensions: regulation, financing, and service provision. With regard to regulation, we observe a relative retreat of the state due to decentralization processes and internal market mechanisms. Quantitative measures for the financing and service provision dimension also indicate a modest relative retreat of the state. Taking regional data into account, we identify a clear North-South-divide in the public/private mix of financing and service provision. Although the focus of the paper is to describe the changing role of the state in the Italian healthcare system, we also offer preliminary explanations. We seek to identify the role of exogenous shocks such as economic crises versus endogenous stressors specific to the healthcare system itself (i.e. inherent inefficiencies) on healthcare system change. Therefore, the paper aims to provide a tentative, yet dynamic account of healthcare system change that is both descriptive and explanatory.

Fiscal and Social Policy: Financing Long-Term Care in Germany

This paper deals with the coverage of long-term care (LTC) in Germany since the post-war period. Until the 1990s, long-term care was mainly a task of the family with means-tested, tax-financed care assistance as a last resort. In 1994, after two decades of political debate, the German parliament approved the LTC Insurance Act. This path-breaking reform act introduced a two-tiered, mandatory long-term care insurance (LTCI) for virtually the entire German population. We will capture the genesis of the so-called fifth pillar of the social security system from the initial stage of problem recognition to the agenda-setting period and the decisive implementation phase. We also shed light on recent reforms of the original LTCI Act. We argue that the introduction of the LTCI can be explained as an interplay between fiscal and social policy. In order to mask their financial interests, municipalities and charities acted as advocates for the elderly in need of LTC and their families. Summarizing the effects of the LTCI and comparing them with the initial estimations and targets, we identify unresolved issues and further need for reform. Even today’s reform debates, however, can be understood as deriving from the tension between fiscal and social policy, but overshadowed by a revival of ideological debates over private vs. public provision.

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.

Keeping an Eye on IRIS: Risk and Income Solidarity in OECD Healthcare Systems

Healthcare financing involves varying distributive effects and builds on different concepts of solidarity. We suggest a set of indicators to explore equity issues in healthcare financing using aggregate spending and revenue data: the Index of Risk and Income Solidarity (IRIS). Contrary to established indicators, IRIS compares eleven OECD countries over four decades. In terms of risk solidarity we observe upward convergence. By contrast, the average and the variance of income solidarity remain fairly stable over time. The expected reform pattern of increasing risk solidarity and reduced income solidarity is only observed in the Netherlands and Switzerland. Yet, this reflects country-specific political compromises rather than assumptions about the effects of health spending growth and global competition on income solidarity.