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Abstract
The article concentrates on a single theoretical model, the Bismarckian social health insurance system, and examines its functioning in the two major cases of application, France and Germany. The comparative results demonstrate that the “same” institutional model can differ substantially. They reveal the weakness of classification principles that ignore the differences in the system of actors and in the political context. The first section provides an account of basic similarities and differences between the two cases. The second section shows how the national architecture shapes reform trajectories in cost containment, emphasizing finance, access, and the implication of the medical profession. The third section concentrates on the key element of the model, the management capacity of social health insurance that sharply differentiates the two cases. The fourth section interprets the comparative results. It argues that both systems are hybrid, and that hybridization should be considered as a normal and unavoidable process. Finally, it characterizes the German case as “renewed social risk management”, and the French case as “liberal universalism”. The latter concept, although seen as contradictory in welfare state theory, not only explains the French system; it may also provide a perspective for theorizing new types of public/private arrangement developing in advanced healthcare systems.
Notes
1. Giaimo (Citation2001) provides a precise application to the health sector, comparing its structure and reforms in the USA (liberal), the UK (Beveridgian) and Germany (Bismarckian).
2. On average, national expenditures on healthcare account for 9 per cent of the GDP in OECD countries, nearly 12 per cent for France and Germany.
3. Public opinion in European welfare states is strongly attached to universal healthcare provision. French opinion polls reveal a high level of stability of opinions, with a strong preference for safeguarding, above all, the “public” character of the health system (83 per cent of respondents), followed in second position only by the pension scheme (73 per cent), and far behind by protection in case of unemployment (57 per cent). Sources: DRESS, 2000–2006 (French Ministry of Health), CREDOC and EUROBAROMÈTRES (European Commission).
4. Examples of this are the upgrading of the financing of the National Health Service under the last Blair government in the UK, as well as the Anti-Cancer Plans in Great Britain and in France, the new universal schemes to cover expenditure for long-term care, such as the statuary insurance for “dependency” in long-term care in Germany.
5. The risk, when these implications are ignored and all branches of the social security system are considered as equivalent, is concept stretching, illustrated by over-arching formulations, such as “Neo-Bismarkian Regulatory Health Care State” (Hassenteufel and Palier Citation2007).
6. Compare Freeman's contribution in this issue.
7. The public/private ratio, however, should not be taken as an isolated factor that would be comparable between these two countries. There are institutional differences relating to the respective role of compulsory and voluntary health insurance. See discussion below.
8. In terms of imposed tariffs, contracts or even employment.
9. In 1885, 4.3 million Germans were already covered by the Bismarckian social insurance, and in 1910, 13.9 million. In France only 4.2 million people were covered by the voluntary system in 1910.
10. Kay (Citation2005: 553) concludes his critical analysis of the use of “path dependency” in the following terms: “path dependency, despite being theoretically inchoate and difficult to operationalize empirically, is a valid and useful concept for policy studies. However, its proper application demands sensitivity from scholars to other temporal dynamics that operate in policy development”.
11. With the exception of some authors however: Wilsford 1991, Kervasdouéet al. 2003, Ferrera Citation2005, Catrice-Lorey and Steffen Citation2006, Steffen 2007.
12. Following reforms geared to more global efficiency, the number shrank from 2,028 in 1960 and 1,221 in 1993 to 292 in 2004 and 254 in 2005. Further concentration is under way.
13. La Pflichtversicherungsgrenze, was equivalent to 1.6 percent of the average income in 2003, which was the same level as in 1925. This ratio was lowest in 1987 (1.1) and highest in the early stages of the German system: 3.1 in 1885 and 2.1 in 1913. Various sources, quoted by Busse and Riesberg Citation2005: 19.
14. On the base of an exchange rate of $1.40 for [euro]1.
15. The remaining 2.7 per cent represents two main groups: those directly insured by the state (police, armed forces), and people depending on local social assistance.
16. In the official French vocabulary, these private health insurance funds, mostly mutual benefit funds, are labeled as “complementary health schemes” (Complémentaire-Santé).
17. Actually, Juppé had written a book 15 years earlier, which received little attention, but in which he described the main lines of the future reform (Juppé 1983).
18. This section will not retrace the reforms, but focus on selected points. For an account of the reforms in the English literature, see: Altenstetter and Busse Citation2005, Rochaix and Wilsford 2005, Catrice-Lorey and Steffen Citation2006, Steffen 2007.
19. A French civil servant earning [euro]4,000 a month (gross salary), who contributes to the complementary mutual benefit scheme for his or her occupation, to which the contribution is also based on salary, pays at least [euro]460 per month to the health insurance, the compulsory and the “complementary” funds together, as well as [euro]25 for RDS (“reimbursement of the social debt”), in addition to a [euro]400 contribution paid by his or her employer. This amounts to a total contribution of [euro]880 per month, that is 22 per cent of the gross salary. Further compulsory contributions have to be paid on income from invested capital and rented property. But the contribution remains the same irrespective of the number of insured family members and of the person's health and age.
20. The Beitragsbemessungsgrenze amounted to [euro]3,525 gross income per month (2006).
21. The unsolved question in Germany concerns the upper income class: the new “Health Fund” does not include private health insurance, as the political Left had wanted. However, the 2007 reform makes it more difficult for people to switch over to private insurance: in the future, a person's income will have to have been above the Pflichtversicherungsgrenze for at least three years before being allowed to opt out of the public system.
22. According to the report of the General Inspectorate for Health and Social Affairs (IGASS) published in May 2007, “the practice of exceeding set rates is general among specialists in private practice and is spreading more and more to general practitioners”. In the last 15 years “the global amount of fees charged over the set rate has doubled”.
23. One for employees, one for self-employed individuals, and one for farmers.
24. Judging the reforms of the Kohl governments, Giaimo (Citation2001: 357) considers German cost containment schemes as a “programmatic success”.
25. The opinion polls of the FORSA Institute, general media coverage as well as the publications of the various stakeholders, all attest to strong opposition.