Organization and financing of social health insurance systems

This chapter probes more deeply into the complex technical commonalities and variations among the seven social health insurance (SHI) countries in western Europe, and Israel.

Reflecting the four-level pyramid model introduced in Chapter 1 (Figure 1.2), this chapter details the structural characteristics, respectively from its top, of the funding, organization and (to a lesser degree) state levels of SHI systems as well as recent developments.

Since the funding flows are inextricably linked to the institutions that organize SHI systems, these top two tiers will be reviewed simultaneously, followed by the role of the state.

As the four-level pyramid model highlights, these financial and organizational relationships are embedded within, and heavily steered by, the two lower levels of the pyramid (e.g. the state and, below that, the broader society in which the state sits).

The chapter is organized into three main sections. In the first, the eight SHI systems, as they are currently configured, are described in relation to ten key structural dimensions. This is followed by a brief review of the role of the state in these systems.

In the third section, the main trends of recent policy developments in the eight studied SHI systems are categorized and assessed.

The current organizational make-up

One useful way to explore the key organizational and financial components in the eight studied SHI health care systems is a modified version of the classic triangle composed of ‘insured/patients’, ‘third-party payers’ and ‘providers’ (Figure 3.1).

These three main actors – or rather four as the collector of the revenue is considered separately since it is not the same as the actual payer in many countries – are linked by a correlating set of relationships. Using this triangle as a basis, this first section of the chapter explores the following dimensions of these eight SHI systems (the numbers are used to place each dimension in the figure):

number, governance and accountability of sickness funds
the extent to which the population is insured
relationship between insurees and sickness funds, especially degree of choice for the insurees
by whom the contributions are collected
how contributions/premiums are calculated or based
mechanisms and extent of pooling and (re-)allocation of contributions to/ among sickness funds
benefits available under SHI, especially regarding the non-acute sectors of public health/health promotion and long-term care
forms and organizational set-up of providers
contractual relationships between sickness funds and providers about types of services, reimbursement and quality; and
patient access to, as well as gatekeeping by, providers.

Issues 1 to 6 concern the sickness funds as well as organizational and financial aspects of the relationships between funds and the insured. Important information and data regarding the issues 1 to 6 are summarized for the eight countries in Table 3.1.

Issues 7 to 10, presented subsequently, concern the covered benefits, the providers and the structure of relationships between providers, the sickness funds and patients. The sickness funds The number of funds, their size and their structure vary widely.

Austria, France and Luxembourg have a comparatively small and stable number of funds (Table 3.2) defined on the basis of occupational status or, in the case of Austria, by occupational group and/or by region of residence, with no insuree choice among them. In the French system, sickness funds have to be differentiated from the various ‘regimes’.

Most notably, the largest sickness fund (Caisse Nationale de l’Assurance Maladie des Travailleurs Salariés, CNAMTS, or: Régime Générale), operates the General Regime of Social Security covering employees, industrial workers, pensioners, unemployed and their dependants.

Eighty-four per cent of the population are covered by this fund (2000 data) which has a pyramidal structure, with a national office, 16 regional coordinating funds (Caisses Régionales d’Assurance-Maladie) and 129 local ‘caisses’ (Caisses Primaires d’Assurance-Maladie).

Luxembourg has nine sickness funds – one each for manual workers (CMO, the largest), white-collar workers in the private sector, selfemployed, the agricultural sector, civil servants of the state, civil servants of local authorities, manual workers at ARBED, white-collar workers at ARBED, and the Luxembourg railways (Kerr 1999).

The other five countries have competing funds with greatly varying numbers. Israel has, with four, the smallest number of competing funds. The Netherlands has 22 funds (January 2003) with several of them forming part of the same holding company.

Just after World War II there were about 250 sickness funds in the Netherlands (Veraghtert and Widdershoven 2002), thus in the Netherlands as well as in Germany and Switzerland, there has been a substantial decrease in the number of separate funds.

Each Dutch fund still has a regional stronghold, although these links are weakening (see Chapter 4, Table 4.12). The introduction of limited competition in the mid-1990s led to both mergers and new funds.

Another Dutch phenomenon is the fact that many sickness funds have merged with private health insurers to form holding companies with both a statutory and a private arm (Den Exter et al. 2002). In Belgium, there are some 100 funds, organized according to religious and/or political affiliation.

All are governed by public law, and all but two groups (the Auxiliary Association and the Railway Association) are members of one of the five sickness fund associations (i.e. Christian, Neutral, Socialist, Liberal, Free and Professional).

The association of Auxiliary funds is not organized as a mutual society but is rather state-organized. In addition to those individuals who choose this fund, persons who fail to affiliate themselves with any fund are by law insured by it (Kerr 2000).

In Germany, as a result of competition and the professionalization of fund management (the latter was made mandatory by law from 1993 onwards), the number of funds has been radically reduced from more than 1000 in the early 1990s to 355 in 2002.

These have been historically organized on the basis of geographical areas, occupation or employer and are legally classified into seven groups which reflect their origin: 17 general regional funds; 12 substitute funds; 287 company-based funds; 24 guild funds; 13 farmers’ funds; 1 miners’ fund; and 1 sailors’ fund.

In Germany (as in Austria, Belgium, France and Luxembourg), all sickness funds are not-for-profit entities under public law.

Besides that legal status, they share a management structure with, as a general rule, equal representation of employers and employees – with differences both between countries (e.g. in France, the ratio between employers and employees in boards is 1:2) and within countries (e.g. in the case of the German substitute funds which are managed by the employees only).

Both the composition of the management and supervision boards as well as the decision-making powers of those boards are defined by law; for example, whether they include the right/obligation to determine the contribution rate (see ‘The role of the state’, p. 58).

They are also subject to control either directly by the government or by an agency charged with that responsibility; i.e. the relationship between the state and the sickness funds in these countries is a classic example of ‘enforced self-regulation’ (cf. Saltman and Busse 2002).

Since the 1990s, the decision-making powers of these SHI decision-making bodies have, as a general rule, decreased. In France, the national parliament now passes a budget for all sickness funds, which is subdivided into ‘envelopes’ (i.e. sectoral sub-budgets).

In Germany, the governmental aim to exercise more control over the types of services included in the benefit catalogue as well as the way they are delivered has paradoxically led to the creation of new selfgovernmental committees charged with the implementation and actual running of those legal stipulations.

Whether the current government’s proposal to create a National Institute for Quality in Medicine marks the end of that development in favour of more direct governmental control, remains to be seen. In Switzerland, the number of insurers offering compulsory health insurance has declined from almost 1000 in 1965 (Beck et al. 2003) to less than 100 in 2001.

Compulsory health insurance is offered both by sickness funds and by private insurance companies (which may only make profits from the provision of supplementary insurance). Sickness funds can be incorporated under public or private law in various legal forms (e.g. association, foundation, mutuality or not-for-profit stock company).

In all countries except Germany, the sickness funds are supplemented by a national umbrella organization. In the Netherlands, there is a difference between the voluntary association which also includes the private insurers (Zorgverzekeraars Nederland) and the statutory Health Care Insurance Board (College voor zorgverzekeringen) charged, among others, with the management of the collective resources (Den Exter et al. 2002).

Insured persons

The eight countries use different frameworks to define the group of persons insured. France, Israel, the Netherlands (for their long-term care insurance [AWBZ]) and Switzerland have by law universal coverage for their SHI system.

Belgium also has universal coverage but as a two-tier system for the 88 per cent in the ‘general regime’ (with a comprehensive benefits package) and the 12 per cent in the ‘regime for self-employed’ (for whom the benefits package covers ‘major’ risks only) (Nonneman and Van Doorslaer 1994).

Austria and Luxembourg have de facto universal coverage though some persons remain uninsured. In Germany, a large proportion of the population (c. 74 per cent) has mandatory insurance and a small portion is legally excluded (6 per cent)2 – leaving a third group (mainly employed people with income above a relatively high threshold) with a choice between statutory and private health insurance (PHI).

Of the approximately 18 per cent eligible for voluntary SHI membership, about 14 per cent are insured with the sickness funds and 4 per cent privately (Busse and Riesberg 2003). The percentage of voluntary members differs between 2.3 per cent and 37.9 per cent among the 35 largest sickness funds (MedWell Gesundheits-AG 2002).

In the Netherlands, there is a strict legal separation based on an income limit between the mandatory ZFW (statutory health insurance) system and private health insurance (PHI), allowing insured persons no choice between the two systems (Den Exter et al. 2002). As the income limit is lower than in Germany, the share of the population insured under ZFW is smaller than in Germany.

Location: Indonesia