Paths to Health Reform

public-sector coverage. At the beginning,
of the decade, the social-insurance
systems in Spain and the Netherlands
excluded part of the population — mainly
high-income groups and the self-
employed—but both countries announced
during the 1980s that they were extending
compulsory, comprehensive coverage to
their entire populations.

Public finance remained the preferred
way of funding access to health for the
vast majority of citizens in all seven
countries. The United Kingdom retained
universal access to its tax-funded

National Health Service after a major
review in 1988/89. Voluntary insurance
had either become, or was about to
become, supplementary in most
countries. Cost-sharing by consumers in
the public systems also remained modest
in all these countries.

In spite of success in attaining many of
the objectives, intractable and persistent
differentials in health status still occur
across socio-economic groups in all seven
countries. Health-care systems on their
own cannot remove these. The most that
can be said is that the differentials are
much smaller than they would be under
voluntary systems.

In all seven countries the costs of
medical care grew rapidly during the
1970s, because, to some extent, of the
extension of the coverage of public
insurance. Yet these rising costs were
caused also by generous insurance cover
and by relatively open-ended payment
systems. Furthermore, the suspicion
existed in some countries that demand
had been induced by suppliers — that is,
by health professionals who, in view of
patients' lack of information and
cost-consciousness alike, may easily
succeed in-generating a growth in ser­
vices. Increasingly, governments came
to take the view that the opportunity
costs — and political repercussions — of
further increases in the taxes necessary
to finance health care were too high.

In general, policy-makers resisted calls
to shift a substantial part of the burden of

It is in hospitals that the most important reforms
have been introduced.

paying for services onto patients. Instead,
they concentrated reforms on the supply
side: by strengthening the hands of
insurers, and by imposing direct, central
controls on payments ...