Health Governance in the Aftermath of Traditional Corporatism: One Small Step for the Legislator, One Giant Leap for the Subsystem?

Summary

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There is much change happening within outpatient care in Germany. What will be the out-come of these changes? This article analyzes changes in the legal framework and policy impacts concerning the system of organized interests. Subsequently the manifold changes in German regions are analyzed to develop ideal-typical scenarios of the possible future of hierarchy, market, and cooperation in outpatient care governance. It is argued that minor reform compromises are about to lead to major changes of the subsystem.

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Health Governance in the Aftermath of Traditional Corporatism: One Small Step for the Legislator, One Giant Leap for the Subsystem?

1 Introduction1

Until the late 1980s outpatient care in Germany was an "ideal-type" of sectoral corporatism (Rosenbrock/Gerlinger 2006: 280). Self-governance and the dominance of large provider associations were the main characteristics of the German outpatient health care governance (Lehmbruch 1988). Public corporations in particular were able to insure privileges for their members by being involved in every decision concerning the range of benefits and prices of outpatient care.

This system has come under increasing political pressure since the first oil crisis in the mid 1970s (Hegelich/Meyer 2008: 130-131). Governments led by both the CDU/CSU and the SPD have argued for sustainable solutions to contain the rising health costs. More than 20 attempts to introduce structural reforms have been undertaken, though most of these only lead to incremental change. The German consensus democracy, the patterns of semi-sovereignty and the powerful associations worked as efficient veto points in preventing a significant change in the German health system (Altenstetter/Busse 2005).

If the supporters of major reform policy look at the policy outcome there will be little cause for optimism: The proportion of the GDP on health expenditure has risen continuously. The most recent Statutory Health Insurance (SHI) Competition Strengthening Act of 2007 (CSA, GKV-Wettbe-werbsstärkungsgesetz), concurred with a further rise of contributions to the SHI (Green/Paterson 2009). Considering the financial and economic crisis that started in 2008 even larger problems in the German health system can be expected.

But there is another side to the German health policy that is revealed when investigating policy output instead of outcome: Despite the failure of sustainable cost containment there have been some considerable changes in the institutional structures. The first major changes were introduced by the Health Structure Act (HAS, Gesundheitsstrukturgesetz) of 1992. The HSA did not overcome the self-governance of the SHI but changed the legal framework of the negotiations significantly (Bandelow 1998: 206-208).

The subsequent attempts of both the former Kohl and Schröder governments hardly continued the structural conversion started by the HSA. So it was up to the grand coalition that came into po...

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