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- W606738497 abstract "1 Introduction Germany's health insurance system represents the archetype of the health-care arrangement generally known as the model. In the decades following its establishment in 1883 it served as the model for numerous other states setting up and designing their own health systems. Nations in continental western and central Europe were first to follow the German example, later joined by countries in Asia and Latin America. Since the collapse of the communist bloc, elements of the German-style health insurance system have come to play an important role in many central and eastern European states. In international comparative research the Bismarck model is identified today as one of three or four classic types of health system (e.g. Wendt 2008). For all the differences of detail, health insurance systems are characterized by the following shared core elements: - Healthcare is managed by self-governing corporatist bodies, where a distinction must be drawn between self-government of the sickness funds by their members and employers and self-government of healthcare services in the sense of the state delegating to sickness funds and service providers (corporatist partners) the authority to flesh out the details of a broad policy framework (collective negotiations and collective agreements play a central role here). - Healthcare is funded primarily by income-related contributions, not by taxes. The health systems of the OECD countries have been in a dynamic transformation process since the early 1990s, and Germany is no exception. Change in the German health system has proceeded at a pace and to an extent that would have been almost inconceivable just a few years ago. We currently have a situation where elements of different systems exist side by side. In this contribution we argue that this transformation has already robbed the core elements of the Bismarck system of a great deal of their importance, and that it must be expected that their significance will continue to decline as the reform process progresses--probably to a point where they will be only a marginal factor in a health system that is fundamentally shaped by other structural elements. Further, we argue that the underlying paradigm shift for system transformation was accomplished in the first half of the 1990s by the Health Care Structure Act that came into effect in 1993, but that since then restructuring has been more a process of progressive incremental change. The decisions of policy-makers are shaped by two factors whose inherent dynamics lead away from core elements of the Bismarck system: a strategic health policy paradigm that strongly prioritizes economic incentives (especially competition mechanisms) and pragmatic problem-solving in situations arising from earlier health policy reforms (muddling through). In the following we will first describe the basic thrust of the health policy transformation, before turning to the aforementioned core elements of the Bismarck system and the reasons why their importance has declined since the early 1990s. In a concluding section on the outlook for the future we explain why the process of sidelining these core elements is likely to continue. 2 The Transformation of the German Health System At the heart of the health policy transformation is the goal of reducing public spending on health and with it the financial burden on employers--whether in the form of taxes or social security contributions--in order to enhance their competitiveness in an increasingly globalized economy. The first efforts to contain costs began as the Fordist growth model expired around the mid-1970s, but these were largely restricted to cautious modification of existing structures (e.g. Rosewitz/Webber 1990; Alber 1992; Rosenbrock/Gerlinger 2006). Efforts concentrated on limiting administrative spending, a moderate shift of treatment costs to patients and minor corrections to the existing regulatory system. …" @default.
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- W606738497 date "2009-03-22" @default.
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- W606738497 title "A Long Farewell to the Bismarck System. Incremental Change in the German Health Insurance System" @default.
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