Academic journal article German Policy Studies

Economization and Marketization in the German Healthcare System: How Do Users Respond?

Academic journal article German Policy Studies

Economization and Marketization in the German Healthcare System: How Do Users Respond?

Article excerpt

1 Introduction

From an historical perspective, the German corporatist healthcare system appeared for a long time reluctant to proceed with any far-reaching reforms. However, since the 1990s the German healthcare system has been targeted by several modernization processes, characterized by pundits as an "incremental reform" (see Gerlinger/Schmucker in this volume). This article scrutinizes two of its key drivers, economization and marketization, arguing that the two approaches restructure the healthcare system differently and have different consequences for healthcare users' behavior. They share, however, common ground: economization and marketization processes aim at the expert patient as a focal figure. For instance, state-driven agendas of user activation as well as market-based healthcare services emphasize individual responsibility, as well as financial stakes and participation of healthcare users. Simultaneously, there is a differentiation of users' identities, especially against the backdrop of mixed healthcare provision and the establishment of a complementary healthcare market. Users act in different contexts as citizens, patients, co-producers, consumers or community members. In order to do so, there is an increasing need for a specific health knowledge and competence; that means the development of a context-related "health literacy" (Nutbeam 2000).

By analyzing the implementation of economic and market-based elements in the field of healthcare and the differentiation of users' identities--or rather the way they are culturally embedded--this article will give some evidence of opportunities as well as constraints of users' autonomy and self-determination. In the first part, a theoretical distinction between economization and marketization processes within the German healthcare system will be made. Both strategies, superficially viewed as assigned to market principles, stimulate very different users' identities as well as self-governance needs. While an economized healthcare system favors cost containment policies and compliant users above all, the emergence of a healthcare market with various tailored products and services forces users to act as experts on their own behalf, or rather as health consumers.

The second and the third part of the article portray current reforms in the German healthcare system. Illustrative examples of the economization of healthcare (e.g., Disease Management Programs and Diagnosis Related Groups) as well as the marketization of health (e.g., so-called Individual Healthcare Services) will be discussed with a special focus on their consequences for users. The main argument of the fourth part is that ambivalent, and to some extent contradictory, demands emanate from both processes. As it turns out, recent policies are characterized more by controlling users' be-havior and bringing them into the service system in order to contain costs than by positive effects such as more choice and user involvement in market-based healthcare arrangements. Finally, the conclusion outlines individual coping strategies for healthcare users in an economized and partly market-based healthcare system and calls for an appropriate supporting environment.

2 Economization and marketization: Two different approaches of a modern health policy

In the field of health policy, it would be a mistake to limit the process of modernization merely to the implementation of market principles. Instead, a variety of different, but related, changes and dynamics that are taking place at the same time have to be taken into account. From a broader perspective that is related not only to health policy but also to social policy in general, three lines of development are shaping the policy framework:

- First, the reinvention of legitimacy patterns for social policy interventions (Rothgang/Preuss 2008). Efficiency criteria emerging from the paradigm that all social investments must show returns into the future became decisive. …

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