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Towards sustainable health care systems – strategies in health insurance schemes in France, Germany, Japan and the Netherlands

Henke K.-D, Schreyögg J
Geneva: International Social Security Association, 2. revised edition. 1. edition 2004





In all four countries health care expenditures grow while revenues remain at the same level or even shrink in many cases. Due to medical progress, aging and many other factors, the gap is widening over time. The pay-as-you-go approach is encountering limits, either with rising employer and employee contribution rates, as is the case in the so-called Bismarck-Systems, or with higher taxes in the so-called Bever idge-systems. Neither of the two systems is able to regulate them selves quasi automatically. The number of political interventions increases, and patch work repair is the reality everywhere. Major reforms are either too difficult in an increasingly overcomplex area or are politically unmanageable in a highly sensitive area such as health care. This describes in brief why the public is calling for more substantial and longer-lasting reforms in Europe and Japan.
The overall answer to resolve this situation is relatively easy and consists of three approaches. Nations facing financial gaps may first cut back expenditures through budgets and/or exclusion of benefits and services. Secondly, they can increase revenue by either higher contribution rates, by using a broader base for financing and/or through higher co-payments and out-of-pocket-expenditures. Thirdly, major structural reforms could be the answer to close the financial gap. These reforms can be accomplished on the basis of the ability-to-pay-principle or with the help of the benefit or insurance principle. These theoretical approaches may be employed by all nations at any time. They offer not much more than a simple restructuring of the problem that virtually all nations face. But there are differences regarding the solutions used by each country to respond to this challenge, and they might be able to learn from each other if they are compared. 

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