Extract
Health care reform in Germany.
1 Introduction
The German health care system is undergoing a process of fundamental change affecting both its care structures and its financial and regulatory mechanisms. This transformation is an expression of a paradigm change in health policy initiated during the first half of the 1990s. At the heart of the transformation is the implementation of competition--centered structural reforms designed to establish a regulated market in the health service and help modernize structures of medical provision that had come to be regarded as inefficient. These reforms have been accompanied by a progressive privatization of treatment costs. This paradigm change in health policy increasingly favors the goal of adapting the health care system to the perceived requirements of a globalized economy at the expense of the aim of covering the social life--risk of "sickness". Since it began, health policy has proceeded down that chosen development path, generally by means of incremental reforms. In the following the content of this paradigm change will be brought out in more detail and differentiated from the preceding phase of cost-containment policy (Section 2). Sections 3-5 deal with the effects of this transformation on the care, financial and regulatory structures of the German health care system. Section 6 outlines to what extent the various coalitions that governed between 1992 and 2007 differed in their approach to health policy. Finally I take a look forward at future developments in health policy. 2 Paradigm Change in Health Policy 2.1 Structure-Conserving Cost-Containment Policy German health insurance is divided into two systems: statutory health insurance and private health insurance. About 90 percent of the population is covered by statutory insurance (generally under compulsory insurance cover), while private insurance--to which only civil servants, the self--employed and high--earning employees have access--covers about 10 percent of the population. Whereas private health insurance is governed by the principles of the insurance market, in the statutory health insurance system the state guarantees members almost universal access to health services, even if these days patients also have to carry considerable charges themselves. Health service financing is accomplished almost exclusively through contributions representing a fixed percentage of gross wages (on the principle of equivalence) and borne in (almost) equal parts by employers and employees. Health service provision is based on the special position of the practicing doctor, generally working in his or her own practice. In the ambulatory sector fund members have the right of free choice of doctor and can consult a specialist directly, but outpatient treatment in hospitals is possible only in exceptional cases. The almost 250 health insurance funds--between which the insured can choose freely--and their umbrella organizations are of primary importance for regulating the system. Within a given legal framework the insurance funds (and their umbrella organizations) conclude contracts with service providers (doctors, hospitals, pharmaceutical manufacturers, etc.). The regulatory system is strongly sectoral differentiated, with each individual sector characterized by its own complex mix of state, corporatist and market management elements. Corporatist elements are strongest in the ambulant sector, state management elements in the stationary sector and market management elements in the pharmaceuticals sector (Rosenbrock and Gerlinger 2006). Although the German health care system can (still) be relatively clearly classified as a health insurance system in the typology Thomas Gerlinger used in health system research, it turns out to be relatively resistant to simple classification in welfare state typologies, co...See the full content of this document
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