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Competing Appeals: the Rise of Mixed Welfare Economies in Europe, 1850-1945
... Apart from the United States, there are only a few countries that can provide a well-documented longitudinal case study for the dynamics of public-private interaction in health insurance (Hacker, 2002;Lengwiler, 2010). The Dutch case is one of them (Schut, 1995;Vonk, 2013). ...
For almost a century, the Netherlands was marked by a large market for voluntary private health insurance alongside state-regulated social health insurance. Throughout this period, private health insurers tried to safeguard their position within an expanding welfare state. From an institutional logics perspective, we analyze how private health insurers tried to reconcile the tension between a competitive insurance market pressuring for selective underwriting and actuarially fair premiums (the insurance logic), and an upcoming welfare state pressuring for universal access and socially fair premiums (the welfare state logic). Based on primary sources and the extant historiography, we distinguish six periods in which the balance between both logics changed significantly. We identify various strategies employed by private insurers to reconcile the competing logics. Some of these were temporarily successful, but required measures that were incompatible with the idea of free entrepreneurship and consumer choice. We conclude that universal access can only be achieved in a competitive individual private health insurance market if this market is effectively regulated and mandatory cross-subsidies are effectively enforced. The Dutch case demonstrates that achieving universal access in a competitive private health insurance market is institutionally complex and requires broad political and societal support.
Context
History helps us to better understand the particulars of the form and functions of institutions. In this paper we present the case study of the evolution of health care financing in the Netherlands over the past 150 years, through the lens of incremental institutional change.
Methods
Our historical and political analysis is based on a review of secondary literature as well as relevant policy documents, parliamentary debates and archival material. We use the conceptual framework of incremental institutional change (i.e. layering, conversion, drift and displacement) for our analysis.
Findings
The constitutional program of the mid-nineteenth century laid down the foundations of a ‘private initiative first, government last’-approach to health care financing in the Netherlands. Over the course of 150 years this led to the evolution of a complex layered system of financial arrangements consisting of direct public funding, national, social and private health insurance with complex interdependencies. This was not a conscious strategy, but a result of the fact that the central government in the Netherlands preferred to tackle specific problems in health care financing with very specific measures, so as not to intrude on the trade of civil society and commercial business in health care.
Conclusions
Regulatory authority and statist power in and over health care financing is not something that was created through dramatic reform in the Netherlands, but came about through many decades of small, incremental, yet accumulating changes. This provides a case study for further analysis of incremental versus rapid change in health care systems internationally.
In the Western world we have forgotten how to be insured without state or commercial insurers. Yet mutual or micro-insurance has a long and venerable history. In the non-Western world, mutual insurance is becoming increasingly important. This book traces the track record of mutual insurance from 1550 to the present, examining provisions for burial, illness, unemployment, old age, and widowhood insurance. In this chapter we set out our guiding questions: How and why did it work? and Can it still work today?
Since the end of the eighteenth century, the insurance industry has cast a safety net around the world, first in the British Isles and then further afield, irrespective of cultural, political, and ideological divides. This book focuses on the creation of networks across borders from the end of the eighteenth century to the present day. The chapters draw upon examples from twenty countries across the continents to demonstrate how what was called the 'British system' of risk management spread out in waves, and describes the forces that made this possible - first among them migration from Europe and international trade. The book explores the economic, political, religious, and cultural obstacles that blocked the path of this European invention - not only religious law and traditional practices, but above all protectionism, inflation, and political ideologies. It examines the process of transformation through which modern insurance supplanted traditional forms of protection against perils and risks and was able to keep on offering new ways of dealing with the risks of modern life. As well as discussing primary insurance, it also considers the role played by reinsurance, without which the losses arising out of today's natural and man-made disasters would be immeasurably greater. Finally, taking modern-day disaster scenarios as examples, the book shows just what the limits of insurability are and what risks worldwide networks entail.
Using new statistical data on financing, coverage and economic and health care provisions, this article analyses how sickness
insurance was introduced, managed and extended in Spain, under the Franco dictatorship, between 1939 and 1962. This article
highlights how the dictatorship accelerated its implementation for political motives and this resulted in a failure of the
system due to the lack of public financing and the high pharmaceutical, medical and infrastructure costs.
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