Academic journal article German Policy Studies

The Private Health Insurance: Demarketization of a Welfare Market?

Academic journal article German Policy Studies

The Private Health Insurance: Demarketization of a Welfare Market?

Article excerpt

1 Introduction

The German health care system with its coexistence of statutory and private health insurance (SHI/PHI) is characterized by a peculiarity, which differs substantially from other European health care systems. However, this peculiarity results less from the general existence of private health insurances, but rather from its substitutive character. Therefore, the PHI is not only suitable as supplementary insurance but also as a substitute full-cover of SHI. In spite of this substitutive function, many fundamental differences exist between these systems. The past years have witnessed a tendency of convergence of PHI and SHI systems. In the SHI, a development of marketization took place, whereas the PHI faced a growing influence of regulatory state intervention. While changes in the SHI--due to their relevance for a predominant part of the population--are often analyzed in detail, reforms of PHI normally play a subordinate role. This article will focus on recent developments of Germany's private health insurance and tries to analyze, if this process can be described as "demarketization" of a welfare market.

In Chapter 1, some general considerations of health insurance and the role of welfare markets are outlined. Chapter 2 gives a brief overview of historical path dependencies and the exceptional position of the German PHI in Europe, where the Third Non-Life Insurance Directive (Dritte Richtlinie Nichtlebensversicherung) of the European Union exerts a relevant influence on national state interventions. The most important regulations are represented and analyzed in the following sections: the introduction of the standard tariff in 1994 and its replacement by the basic tariff in 2009 (Chapter 3), the implementation of consumer protection concepts (Chapter 4), as well as fixing the funding principle as a sociopolitical adjustment to protect older private insured (Chapter 5). Against the background of these developments, Chapter 6 analyses the modified relationship of PHI and SHI regarding the principles of solidarity and competition. Finally, the results are summarized and alternatives for the future organization of health insurance are proposed.

2 Health insurance and the role of welfare markets

The past decades have witnessed a tendency towards marketization in many fields of social policy. Looking at the German welfare state and especially health care policies, it seems that these changes run counter to its constitutive characteristics, which were often identified as conservative or corporatist (Esping-Anderson 1990; Pierson 2001). Even if many of these comparative studies focused on pension systems as well as labor market and family policies, for a long time, most notably the self-government of "Bismarckian" statutory health insurance was one of the central pillars of the German health care system. Self-administration became predominantly a field for corporatist representatives with relatively little transparency and democratic rights for SHI-insured. Political discourses of the 1980s and early 1990s have tended to focus on "reform blockades", "structural constancies", and "institutional stickiness" of corporatist decision-making and mutual self-government institutions (Mayntz 1990; Rosewitz/Webber 1990; Alber 1992; Pierson 2001). Yet the German health care system was much more market-based than was highlighted in welfare state research (e.g. the double-role of office-based physicians as associated doctors and freelancers with strong economic interests; the existence of private health insurances, to a certain extent hospitals in private ownership, a mainly market-based pharmaceutical sector etc.).

Since the early 1990s, however, the role of markets has grown in social policy. Issues of health policy have been analyzed under a variety of headings over the last 20 years. A range of health policy dichotomies like "State vs. Market" or "Regulation vs. Competition" have been discussed. …

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