The impact of German health insurance reforms on redistribution and the culture of solidarity

Embedding Attitudes Toward Immigrants in Solidarity Contexts: A Cross-European Study

This article aims to retrospectively investigate the embeddedness of attitudes toward immigrants (ATI) in cultures of solidarity seen as general orientations toward solidarity measured at a country level. We predict individual-level ATI with country-level aggregated indicators of solidarity that were observed decades earlier. The latter measure local, social, and global solidarity and are explained by a general, overall orientation toward solidarity. For computing the indicators, we combine aggregate data from the European Values Study (EVS) 1999 and 2008 and individual-level data from the spring 2015 Eurobarometer to show that the effect of country-level solidarity on individual-level ATI is strong and stable. The findings reveal that cultures of solidarity have a long-term effect and are the strongest contextual determinant for individual-level ATI. Both 1999 and 2008 data proved to be related to 2015 individual-level attitudes, having a positive effect. In particular, local solidarity positively affects attitudes toward both European Union (EU) and (to a smaller extent) non-EU immigrants. General solidarity remains the most relevant, and it should be used for boosting positive views about immigrants.

Development of the Kisiizi hospital health insurance scheme: lessons learned and implications for universal health coverage

BACKGROUND

Kisiizi Hospital Health Insurance scheme started in 1996 to; improve access to health services, and provide a stable source of funding and reduce bad debts to Kisiizi hospital. Objectives of this study were; to describe Kisiizi Hospital Health Insurance scheme and to document lessons learned and implications for universal health coverage.

METHODS

This was a descriptive cross-sectional study. Data from different sources were triangulated and thematically analysed.

RESULTS

Most households (96%) were organized in Engozi societies (e-Societies), met monthly, and made financial contributions. Cultural solidarity in e-Societies provided a platform for the Kisiizi hospital health insurance scheme establishment, operation and made it compulsory for members. e-Societies disciplinary measures and fear of high out-of-pocket payment for health care enforced enrolment, retention and increased membership. Community sensitisation and community participation in setting premiums and co-payments provided for better understanding of health insurance and rendered them acceptable, affordable and equitable. Membership increased from 330 in 1996 to 38,400 families in 2017. Kisiizi hospital health insurance scheme covered only health services obtained from Kisiizi hospital. Kisiizi hospital health insurance scheme offered no exemption, credit and referral facilities. e-Societies sometimes paid premiums for members from savings and offered them loans to. Kisiizi hospital provided good quality health services, which were easily accessed by insured members. Kisiizi hospital got a stable source of funding and reduced debt burden.

CONCLUSIONS

Kisiizi hospital health insurance scheme improved access to health services, provided a stable source of funding and reduced bad debts to the hospital. Internal and external factors to e-Society enforced enrolment and retention of members in Kisiizi hospital health insurance scheme. Good quality health services at Kisiizi hospital demonstrated value for money and offered incentives for enrolment and retention, and coverage expansion. Community sensitization and participation in setting premiums and co-payments rendered Kisiizi hospital health insurance scheme acceptable, affordable and catered for equity. Insured members enjoyed benefits; protection against catastrophic health spending, impoverishment, and easy access to quality health care.

A Longitudinal Investigation of Willingness to Pay for Health Insurance in Germany

OBJECTIVE

To investigate factors affecting willingness to pay (WTP) for health insurance of older adults in a longitudinal setting in Germany.

DATA SOURCES

Survey data from a cohort study in Saarland, Germany, from 2008-2010 and 2011-2014 (n₁  = 3,124; n₂  = 2,761) were used.

STUDY DESIGN

Panel data were taken at two points from an observational, prospective cohort study.

DATA COLLECTION

WTP estimates were derived using a contingent valuation method with a payment card. Participants provided data on sociodemographics, lifestyle factors, morbidity, and health care utilization.

PRINCIPAL FINDINGS

Fixed effects regression models showed higher individual health care costs to increase WTP, which in particular could be found for members of private health insurance. Changes in income and morbidity did not affect WTP among members of social health insurance, whereas these predictors affected WTP among members of private health insurance.

CONCLUSIONS

The fact that individual health care costs affected WTP positively might indicate that demanding (expensive) health care services raises the awareness of the benefits of health insurance. Thus, measures to increase WTP in old age should target at improving transparency of the value of health insurances at the moment when individual health care utilization and corresponding costs are still relatively low.

Your genes in insurance: from genetic discrimination to genomic solidarity

Advances in genomics and postgenomics have renewed interest in the impact of genomic health information on private life insurance across Europe. These developments reopen the issue of how genes - apart from being the object of discrimination (exclusion) - also operate as generators of solidarity (inclusion). This article traces several developments in regulating genetics and life insurance and its social implications in the European context. At first, genes were viewed as a source of differentiation, which led to fears of 'genetic discrimination' in life insurance. In response, genetic nondiscrimination regulations were enacted across Europe. Current debates on the use of genomic health information in life insurance have actually opened up possibilities for a form of genomic solidarity between 'all of us'. The introduction of genes and genomes appears to turn private life insurance practices of actuarial risk discrimination increasingly into 'discriminatory' practices by challenging the larger fundamental 'right to underwrite'.

Disease management and health care reforms in Germany—Does more competition lead to less solidarity?

Up to the 1990s German health care legislation was dominated by measures regulating the supply side. Measures, such as budgets, aimed at volume control and sought to confine the increase of health care spending to the growth of the national income. To curb costs more effectively, competitive elements were introduced in the 1990s with free choice of sickness funds (open enrollment). To balance competition and solidarity, a risk compensation scheme (RCS) was implemented two years prior to open enrollment. Since then, balancing competition and solidarity has been a key feature of all consecutive health care reforms. The implementation of disease management programs in the statutory health insurance (SHI) served the dual purpose to promote quality of care and to foster competition. Preliminary experiences suggest, that the aligning of disease management programs with a RCS can greatly aid its implementation and benefit solidarity and competition.

Managing the behavior of the medically insured in Germany: the acceptance of cost-sharing and risk premiums by members of the statutory health insurance

In the course of the conflicts over the reform of statutory health insurance in Germany complaints about moral hazard-behavior on the part of the insured were repeatedly raised and linked to the demand for expanding managerial incentives aimed at reducing the consumption of health care benefits (copayments). However, critics and supporters of managerial incentives mostly neglect the perceptions and dispositions of the insured. In contrast, the article examines how members of the statutory health insurance scheme assess managerial intervention, namely cost-sharing and risk premiums.

One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low-income countries?

A number of low and middle income countries (LMICs) are considering social health insurance (SHI) for adoption into their social and economic environment or striving to sustain and improve already existing SHI schemes. SHI was first introduced in Germany in 1883. An analysis of the German system from its inception up to today may yield lessons relevant to other countries. Such an analysis, however, is largely lacking, especially with regard to LMICs. This paper attempts to fill this gap. For each of the following lessons, it considers if and under which conditions they may be of relevance to LMICs. First, small, informal, voluntary health insurance schemes may serve as learning models for fund administration and solidarity, but in order to achieve universal coverage government action is needed to formalise these schemes and to introduce a principle of compulsion. Once compulsory health insurance exists for some people, incremental expansion of coverage to other regions and social groups may be feasible to achieve universality. Second, in order to ensure sustainability of SHI, the mandated benefit package should be adapted incrementally in accordance with changing needs, values and economic circumstances. Third. in a pluralistic SHI system equity, as well as risk pooling and spreading, can be enhanced if funds merge. The optimal number of funds, however, will depend on the stage of development of the SHI system as well as on other objectives of the system, including choice and competition. A risk equalisation scheme may prevent the adverse effects of risk selection, if competition between insurance funds is introduced into the system. Fourth, as an alternative to both state and market regulation, self-governance may serve as a source of stability and sustainability as well as a means of decentralising and democratising a health care system. Finally, costs can be successfully contained in a fee-for-service system, if cost-escalating provider behaviour is constrained by either political pressure or technical means.

Is German long-term care insurance a model for the United States?

German long-term care insurance, implemented in 1995, significantly extends the coverage of care-related risks. Given the similarities of German and U.S. institutional features, the German social insurance approach has been put forward as a possible model for long-term care in the United States. Using a political economy framework, the authors conducted a policy analysis that compares the main shortfalls of long-term care (LTC) provision in the United States and Germany, examines the responses provided by LTC insurance in Germany, and relates them to broader trends and proposals for change in welfare policy in both countries. German LTC insurance includes a high degree of consumer direction and compensation and protection for informal caregivers; it supports the extension of community-based services. Its shortfalls include the continued split between health and LTC insurance. In both countries, decentralization and institutional and financial fragmentation are some of the characteristics responsible for the failure to promote egalitarian social policy and substantially expand social protection to family- and care-related risks. The German LTC program is a good model for the United States. With a social insurance approach to LTC, costs are spread across the largest possible risk pool. Major goals that can be reached with such a program include establishment of universal entitlements to LTC benefits, consumer choice, and equitability and uniformity.

Risk equalization, competition, and choice: a preliminary assessment of the 1993 German health reforms

Risk adjustment and/or equalization has become a central issue in the health care reform initiatives of many countries, including Germany, Switzerland, the Netherlands, Israel, the U.K. and the U.S. Risk adjustment is widely seen as essential to prevent cream skimming and to promote fair competition. In this vein, the 1993 German health reforms require implementation of a risk-based contribution rate equalization scheme by 1996. This paper provides a preliminary assessment of the risk equalization methodology currently proposed for Germany. Recent research in the U.S. and the Netherlands is used to examine whether the sociodemographic factors being used in Germany are likely to be effective. Research findings from both countries indicate that risk formulas based only on socio-demographic factors predict only one-tenth to one-fourth of the maximum possible explainable variance. If the current formula is used, sickness funds with higher concentrations of high risk groups are likely to be substantially under compensated, and to face serious enrollment and financial problems. The authors conclude that improvements in the formula through measures based on diagnosis and prior hospitalization, disability status, and regional variations in utilization and cost are urgently needed before the system is implemented. The German experience is also relevant to other countries that have relied to date on socio-demographic measures for risk adjustment.