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Healthcare financing in OECD countries beyond the public-private split


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  • Götze, Ralf
  • Schmid, Achim
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    Background: Studies of long-term trends in the healthcare financing mix generally focus on a dichotomous concept discerning public from private funding sources. More detailed analyses of the funding mix tend to be restricted to a small number of cases or do rarely examine time trends. Aim: This paper enhances the existing body of literature by developing and applying a trichotomous concept for healthcare funding, distinguishing taxes, contributions, and private sources. This includes a new aggregated indicator for the mix of three financing sources and its graphical representation. Methods: The study mainly builds upon OECD Health Data 2011. We measure changes in the funding mix since 1972 as its distance from a funding mix that equally draws upon taxes, contributions and private sources. Results: Up to 1980, the OECD healthcare systems move toward ideal-typical financing schemes. Between 1980 and 2000, the funding mix hybridizes mainly driven by privatization processes in NHS and social insurance countries and ongoing switch-over-processes between these two healthcare system types. Since 2000, OECD countries again tend toward ideal-typical funding schemes. Discussion: We use the framework for institutional change developed by Streeck and Thelen. The quantitative approach highlights changes in terms of displacement, layering, and drift but fails to fully reveal conversion processes. Therefore, further qualitative research is needed to capture not only shifts between the funding sources but also more gradual changes within them. Conclusion: The back-and-forth development of the trichotomous funding mix challenges assumptions of a universal trend toward hybrid financing structures. -- Rahmen: Arbeiten, die langfristige Trends des Finanzierungsmix von Gesundheitsausga-ben untersuchen, basieren in der Regel auf einem dichotomen Konzept, das öffentliche und private Quellen unterscheidet. Detailliertere Studien zum disaggregierten Finanzierungsmix sind zumeist auf kleine Fallzahlen beschränkt oder betrachten keine Entwicklungen über Zeit. Ziel: Das Arbeitspapier entwickelt ein trichotomes Finanzierungskonzept, das zwischen Steuern, Beiträgen und privaten Quellen unterscheidet und wendet dieses auf OECD-Gesundheitssysteme an. Hierfür wird ein neuer Hybriditätsindex gebildet, der den Finanzierungsmix eines Landes beschreibt und graphisch verortet. Methoden: Wir messen die Veränderungen im Finanzierungsmix seit 1972 als Distanz von einem hypothetischen Finanzierungsmix, der sich jeweils zu einem Drittel auf Steuern, Beiträge und privaten Ausgaben stützt. Als Quelle dienen die OECD Health Data 2011 und ergänzende nationale Statistiken. Ergebnisse: Bis etwa 1980 steuern die OECD-Gesundheitssysteme auf unterschiedliche idealtypische Finanzierungsmodelle zu. Zwischen 1980 und 2000 beobachten wir eine Hybridisierung der Finanzierung von Gesundheitsausgaben, die vorwiegend auf Privatisierungsprozesse in den NHS- und Sozialversicherungsländern zurückgeführt werden kann. Überdies tragen einzelne Länder durch einen inkrementellen Übergang vom Sozialversicherungssystem zum NHS zunächst zur Hybridisierung bei. Seit 2000 neigen die OECD-Länder wieder idealtypischen Finanzierungsstrukturen zu. Diskussion: Wir analysieren die Befunde anhand der von Streeck und Thelen entwickelten Formen institutionellen Wandels. Der Hybridisierungsindex verdeutlicht Wandel in Form von Displacement, Layering und Drift, während Conversion-Prozesse nicht vollständig abgebildet werden können. Hierfür bedarf es qualitativer Analysen, die nicht nur Verschiebungen zwischen Finanzierungsarten sondern graduelle Veränderungen innerhalb einer Finanzierungsart erfassen. Fazit: Der Wandel zwischen Hybridisierungsphasen und Phasen der Stärkung idealtypischer Finanzierung deutet darauf hin, dass funktionale Annahmen eines langfristigen Trends zu hybriden Finanzierungsstrukturen zu kurz greifen.

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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 160.

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    Date of creation: 2012
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    Handle: RePEc:zbw:sfb597:160

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    1. Bärnighausen, Till & Sauerborn, Rainer, 2002. "One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low-income countries?," Social Science & Medicine, Elsevier, vol. 54(10), pages 1559-1587, May.
    2. Adam Wagstaff, 2010. "Social health insurance reexamined," Health Economics, John Wiley & Sons, Ltd., vol. 19(5), pages 503-517.
    3. Gerdtham, Ulf-G. & Jonsson, Bengt, 2000. "International comparisons of health expenditure: Theory, data and econometric analysis," Handbook of Health Economics, in: A. J. Culyer & J. P. Newhouse (ed.), Handbook of Health Economics, edition 1, volume 1, chapter 1, pages 11-53 Elsevier.
    4. Castles, Francis G., 2004. "The Future of the Welfare State: Crisis Myths and Crisis Realities," OUP Catalogue, Oxford University Press, number 9780199273928.
    5. Pedro Pita Barros, 2007. "The slow and unnoticed changes in the funding mix," Health Economics, John Wiley & Sons, Ltd., vol. 16(5), pages 437-440.
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    Cited by:
    1. Fan, Victoria Y. & Savedoff, William D., 2014. "The health financing transition: A conceptual framework and empirical evidence," Social Science & Medicine, Elsevier, vol. 105(C), pages 112-121.


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