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Global Innovations |
PROLOGUE
Global Innovations In Payment And Coverage
One can reform a health system anywhere along the spectrum from how it is financed to which services it delivers. If the system is universal or nearly so to start with, these two reforms can affect everyone, even if no other part of the system undergoes any change. The providers who are paid to deliver services may continue to be organized and to operate in essentially the same way even after massive reforms upstream or downstream from them.
In 2006 the Netherlands overturned its traditional health care financing system by a law requiring essentially everyone to buy private insurance covering at least a publicly specified package of interventions. As U.S. state governments have realized, such a mandate requires subsidy for those who cannot afford coverage. In the Dutch model, it also requires a Risk Equalization Fund (REF) to offset the incentives for risk selection by insurers. The effect is to free the system in one respect—citizens’ choice of where to get their insurance—and to complicate and constrain it in other ways, to prevent the outcomes that a completely free market would deliver. Wynand van de Ven of the Institute of Health Policy and Management and Frederik Schut of Erasmus University, both in Rotterdam, describe the background of the reform and suggest that "Americans may be interested in the Dutch system because it combines mandatory universal health insurance with competition among private health insurers."
A few years earlier, in 2002, Chile launched a program of Explicit Guarantees and Universal Access to incorporate more health services into the package that the public sector finances and that private insurers are also required to cover. The interest in this expansion isn’t in the services themselves, but in how they were chosen. For the first time ever in a middle-income country, the government undertook an explicit exercise in priority setting, taking account of nine partially overlapping economic, medical, and social criteria to determine whether a particular medical procedure merited inclusion. As Verónica Vargas of the Universidad Alberto Hurtado in Santiago and Sergio Poblete of the Central Bank of Chile explain, many services fulfilled five or more of the criteria, but some procedures were included even if they met only one or two. Other governments struggling to balance what they can afford with what the public wants should find the Chilean experience instructive.
These reforms, applied at opposite ends of the geographic and political spectrum, nonetheless meet in two respects: they both highlight the importance of a clearly defined and socially acceptable package of services that all insurers must deliver; and its financing has to make it affordable to everyone.
Related Articles
- Wynand P.M.M. van de Ven and Frederik T. Schut
Universal Mandatory Health Insurance In The Netherlands: A Model For The United States?
Health Affairs, May/June 2008; 27(3): 771-781.
[Abstract] [Full Text] [PDF]
- Verónica Vargas and Sergio Poblete
Health Prioritization: The Case Of Chile
Health Affairs, May/June 2008; 27(3): 782-792.
[Abstract] [Full Text] [PDF] [Appendix Exhibit]
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