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The changing role of the state in the Dutch healthcare system


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  • Götze, Ralf
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    This paper deals with the changing role of the state in the Dutch healthcare system. At the eve of the first oil crisis the Netherlands had a relatively compound healthcare system combining several characteristics of the three Western healthcare system types: National Health Service, social health insurance system, and private health insurance system. Comparative case-studies on OECD countries indicate a hybridization trend from relatively pure to mixed healthcare systems during the era of 'permanent austerity'. The adequate question is therefore, how and why the role of the state has changed in the relatively mixed Dutch social health insurance system. In order to approach this research question in a systematic way, we distinguish between three dimensions of the healthcare system: regulation, financing, and service provision. In the regulation dimension we observe an increasing state influence on coverage by an incremental socialization of the private sector. This progress culminated in 2006 in the merger of sickness funds and private health insurances into a functional social health insurance under private law. Since the early 1980s the state also directly intervened in the corporatist bargaining of providers and insurers in order to contain costs and regain global competiveness. At the beginning of the new millennium tight budgets resulting in long waiting lists were no longer accepted against the background of a booming economy. Instead, the role of competition increased through new opportunities and incentives for selective contracting between insurers and providers. Therefore, we observe a shift from corporatist self-regulation towards state-regulated market competition within the institutional framework of a social health insurance system. This ongoing reform process towards a welfare market for medical goods was supported by the main political parties on the left and right in order to enhance efficiency and safeguard solidarity. -- Gegenstand dieses Papiers ist die veränderte Rolle des Staates im niederländischen Gesundheitssystem. Vor der ersten Ölkrise zeichneten sich die Niederlande durch ein vergleichsweise gemischtes Gesundheitssystem aus, das einzelne Elemente der drei westlichen Gesundheitssystemtypen beinhaltete: Nationaler Gesundheitsdienst, Sozialversicherungssystem und Privatversicherungssystem. Vergleichende politikwissenschaftliche Studien zeigen einen Hybridisierungstrend in der OECD-Welt von eher idealtypischen zu hybriden Gesundheitssystemen seit dem Ende des Goldenen Zeitalters der Wohlfahrtstaaten in den 1970er Jahren. Daraus ergibt sich die Frage, wie sich die Rolle des Staates im bereits zum Ausgangspunkt vergleichsweise gemischten niederländischen Sozialversicherungssystem entwickelt. Zur systematischen Beantwortung dieser Frage wird in diesem Papier zwischen drei Dimensionen eines Gesundheitssystems unterschieden: Regulierung, Finanzierung und Leistungserbringung. In der Regulierung zeigt sich ein deutlicher Anstieg des Staatseinflusses bei der Absicherung durch eine inkrementelle Sozialisierung der Privatversicherung. Dieser Prozess fand 2006 mit der Verschmelzung der gesetzlichen und privaten Krankenversicherung zu einer funktionalen Sozialversicherung auf privater Basis seinen vorläufigen Höhepunkt. Auch in der Interaktion zwischen Versicherern und Leistungserbringern baute der Staat seit Anfang der 1980er Jahre stetig seinen direkten Einfluss aus, um mit einer strikten Kostendämpfung die internationale Wettbewerbsfähigkeit der Niederlande zu verbessern. Zur Jahrtausendwende war die restriktive staatliche Budgetplanung allerdings angesichts steigender Wartezeiten nicht mehr vermittelbar, wodurch verstärkt Möglichkeiten und Anreize für mehr Vertragswettbewerb geschaffen wurden. Damit wurde die für Sozialversicherungssysteme typische korporatistische Selbstverwaltung schrittweise unterhöhlt und durch Elemente eines staatlich regulierten Wettbewerbs ersetzt. Diese sich weiterhin im Prozess befindliche Hinwendung zu einem Wohlfahrtsmarkt für Gesundheitsgüter wurde von den relevanten linken und bürgerlichen Parteien in unterschiedlichen Koalitionen in der Überzeugung mitgetragen, Effizienzpotenziale zu heben und die Solidarität nicht zu gefährden.

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    Paper provided by University of Bremen, Collaborative Research Center 597: Transformations of the State in its series TranState Working Papers with number 141.

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    Date of creation: 2010
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    Handle: RePEc:zbw:sfb597:141

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    1. Krugman, Paul, 1987. "The narrow moving band, the Dutch disease, and the competitive consequences of Mrs. Thatcher : Notes on trade in the presence of dynamic scale economies," Journal of Development Economics, Elsevier, vol. 27(1-2), pages 41-55, October.
    2. Patricia M. Danzon & Jonathan D. Ketcham, 2004. "Reference Pricing of Pharmaceuticals for Medicare: Evidence from Germany, the Netherlands, and New Zealand," NBER Chapters, in: Frontiers in Health Policy Research, Volume 7, pages 1-54 National Bureau of Economic Research, Inc.
    3. Brouwer, Werner & van Exel, Job & Hermans, Bert & Stoop, Arjen, 2003. "Should I stay or should I go? Waiting lists and cross-border care in the Netherlands," Health Policy, Elsevier, vol. 63(3), pages 289-298, March.
    4. Brouwer, Werner B. F. & Hermans, Herbert E. G. M., 1999. "Private clinics for employees as a Dutch solution for waiting lists: economic and legal arguments," Health Policy, Elsevier, vol. 47(1), pages 1-17, April.
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