Publicatie Two centuries of solidarity

K.P. Companje, K.F.E. Veraghtert en B.M. Widdershoven, Two centuries of solidarity. German, Belgian and Dutch social health insurance 1770-2008 (Amsterdam 2009); HiZ-reeks Geschiedenis Zorgverzekeringen 3

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[Dutch Abstract]

The social health systems of the Netherlands, Belgium, Germany, Hungary and Poland are an important part of modern-day social security within the European Community, in addition to the care systems financed from tax revenue, as in England, Spain, Italy and the Scandinavian countries. Modern health-insurance funds and health-insurance companies are an essential link in this gigantic and complex whole. Many outsiders – as well as people who live and work within the world of insurance – do not realise that these modern institutions have a fascinating history that extends back over many centuries, and that, even today, traces of this history are visible in the organisation of health insurance, national health-fund structures and the activities of health-insurance funds.

The social insurance systems implemented by health-insurance funds have their roots in Western Europe. In countries such as the Netherlands, Belgium and Germany, some of the large-scale health-insurance funds – with hundred of thousands or even millions of insured persons – owe their existence to modest local initiatives taken in the nineteenth century, when groups of people with a social conscience (e.g. community leaders, employers, physicians) worked together to provide more secure financial circumstances and medical care for those in need. Elsewhere, it was the artisans or labourers themselves who joined forces to build an independent mutual support fund from their modest wage. It is this historical continuity and geographical proximity that enable us to compare the development of health insurance in Germany and Belgium with that of the Netherlands.

In this study, our aim is to assess the development of the German and Belgian health-insurance funds, and medical-expenses insurance against their development in the Netherlands. The development of the health-insurance fund system will be studied in seven successive periods, reflecting changes in the socio-political context. Chapter 1 briefly describes the origins of modern-day health-insurance funds in the guild system before the French Revolution (1789). This is followed by a description of the influence of French revolutionary ideologies and the sudden or gradual abolition of the guild system (1820-1850). Chapter 3 is a concise account of the gradual development of interprofessional health-insurance funds (1820-1850). This is followed by a discussion of the period of liberal class society and the beginning of social struggle (1850-1914). Readers may find it surprising that this study pays a great deal of attention to the period between the mid-nineteenth century and the beginning of the First World War. In our view, however, it was the evolution of health insurance and health-insurance funds during this period that largely formed the foundation for the structure of health insurance as it is today. This chapter places particular emphasis on the early introduction of compulsory health insurance in the German Empire. In Chapter 5, the focus shifts to the ideological struggles relating to attempts in Belgium and the Netherlands to introduce compulsory insurance. As a deus ex machina, the German occupier finally brought an end to the struggle in 1941 in the Netherlands with the introduction of the Ziekenfondsenbesluit (Sickness fund Decree).

Chapter 6 describes the development of the health-insurance system in the post-war period. The apparently unlimited growth in the welfare state, with its system of ‘pillars’ drawn along socio-political lines, was brought to an abrupt end by the prolonged depression that began in 1973. But crises are also challenges. In the search for ways to address growing deficits, the health-insurance funds find themselves in the eye of the storm. In the 1980s, politicians began wondering out loud whether it was possible to organise health insurance more cheaply and efficiently.

The most important recent decisions on health-insurance reforms have been made since 2000. Chapter 7 discusses how, in the period to 2007, governments, politicians, health-insurance funds and health insurers and other social parties involved in the insurance of health care in the three countries, attempted to secure the healthcare and insurance systems for the future. Is the desired shift towards the market mechanism continuing? What form are the system reforms taking in the three countries, whether or not under the influence of supranational regulation from the European Community? Given the recent nature of these developments, this chapter was written by authors who are in a position to give individual and specific accounts of the relations and reforms in the countries discussed.

Karel-Peter Companje, lecturer at the KHZ, outlines the development of the various forms of healthcare insurance in Germany: Pflegeversicherung (long-term healthcare insurance), Gesetzliche Unfallversicherung (accident insurance) and Gesetzliche and Private Krankenversicherung (mandatory and private health insurances). What choices are being made in Germany with regard to tenability of the health-insurance and care system? Are decisions being made in favour of radical structural reforms, as in the Netherlands, or will existing structures be reinforced?

Karel Veraghtert, the author of the original edition of this book, describes the possibilities and constraints with regard to reforming the Belgian healthcare and social-security system. How can access to care be balanced against the need for financial control? How does the established position of the old mutualities or health-insurance funds ‘square’ with the commercial activities of indemnity insurers?

Ron Hendriks, board member of the Foundation for the History of Health Insurance, discusses the changes in the Dutch healthcare system in its political and social context. How is the market mechanism affecting day-to-day practice and, above all, social solidarity?

In the concluding chapter, the main similarities and, above all, the historical differences and contradictions between healthcare insurance and the health-insurance funds in the three countries studied are set out. Hopefully this chapter will provide input for contemplating the role and functioning of health-insurance funds and health insurers in the European Community.