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2.2. The healthcare systems: public (welfare state and Beveridge) and private (Bismark)

Bruno Corda, Angelo Barbato, Angela Meggiolaro

The welfare state is based on the principle of equality and characterizes the modern states of law. The rights and the welfare state guaranteed services are basically health care, public education and social security. The ordinances of the nations with a greater development of the welfare state also provide greater investment and programs for the defense of the natural environment and unemployment benefits (citizen income).

The health care models are essentially two: a mutualistic system (Bismarck) based on private appeal and a National Health Service (Beveridge) with public and universal vocation.

In relation to the welfare state of the post-war Europe until the 80s, four main areas can be classified: Scandinavia, Anglo-Saxon, Continental Europe and Southern Europe. Although for large schematization it can be said that historically the north of Europe as a matrix refers to the universal model (Beveridge) while continental Europe and southern historically is characterized as originally mutualistic (Bismarck).

Scientific and popular literature offer a wide variety of treaties on the History of Public Health, providing a definitely eclectic and comprehensive view on the various aspects and focus areas. In 1989, Mullan wrote about the history of public health in the US; Duffy in 1992 focused on the work of Health Care Workers; Fee in 2002 has followed a wide variety of articles on the historical aspects of public health while Warner and Tighe in 2006 have emphasized the link between Public Health and Clinical Medicine¹² .

In ancient civilizations, public health was geared exclusively towards the protection of public hygiene. During the Roman Empire, the care of the poor sick was entrusted to archiatrists paid by the city. The creation of the first hospital-like structures dates back to the Middle Ages: they were centers who had a more charitable rather than health purpose, in fact the first institutions of its kind developed in the vicinity of bishoprics, monasteries and along pilgrimage routes¹³ .

During the Renaissance the first attempt of a systematic classification of diseases was undertaken; while during the Enlightenment took place the first investigation of diseases and of the overall health of the population. The French Revolution and the first industrial revolution (about 1760-1870 ) with the consequent urbanization, contributed to giving a strong incentive to the concept of public health.

The Health Movement has been a product of the second industrial revolution, a new approach to public health developed in England between 1830 and 1840. With the growing industrialization and urbanization, increasing awareness about the importance of personal hygiene and the human waste treatment has led as a strategic choice in the fight against infectious diseases to sanitation and removal of filth from the cities. However, as understood by Edwin Chadwick, urban cleaning in the literal sense, has become, over time, a deviant figurative meaning, and was seen as the removal of a potential health threat represented by "dangerous classes." Other European cities such as Paris and Naples followed suit, undertaking reconstruction projects on a large scale. However, these technological reforms marked an undeniable step forward for public health, often leading to the exclusion of economic and educational reforms¹⁴ .

The concept of Public Health, therefore, has over time expanded its scope of application and interest, taking shape first as action towards the Community for the prevention of diseases and threats to health, for the wellbeing of individuals and the population; successively reaching to include both the promotion and the protection of health¹⁵ .

In the eighteenth century, in Europe, the organization of Public Health was the exclusive competence of judicial and police organs with tasks limited to the management of epidemics and outbreaks.

In England, the British factory act is approved for the regulation of the workloads in factories (1833) and in 1948 the NHS (National Health Service) is founded. Doctors of Public Health were appointed: the Medical Officer of Health.

Surprisingly, it is up to America to lead the first attempt to establish a Health System of Universalistic nature, extended to the majority of the population. In 1910 C. Chapin wrote what later became the reference text of the 'Public Health', not only American.

Appearing between the lines of the ideal of a Public Health, is not only 'science and art of preventing disease' but also the promotion of a quality of life, preservation and extension of the state of health and physical efficiency. In that sense, the participatory role of the entire community becomes fundamental. In this model of 'distributed' Public Health, the community becomes, albeit with still a passive role, starring in ensuring the maintenance of adequate living standards, appropriate for the extension of health conditions. Among the main action lines of the document was education of the patient on common preventive measures, the elementary rules of hygiene, and the promotion of environmental health.

Public Health therefore becomes 'Health System', beginning to take a tangible organizational configuration and initially structured in centers of power and control and in systems of provision of health actions. Just as we will see later in the historical evolution of these public models in different countries, the inability to keep separate and distinct the commissioners’ roles (the centres of power and control) and the role of the regulator has heavily contributed to the crisis of the system.

Currently, the concept of New Public Health ¹⁶ is emerging, according to which health is an investment in the life of the community. The New Public Health focuses on the behavior of individuals in their environment and the conditions that influence such behavior.

The application fields of public health include not only the scientific, but also the social, cultural and political spheres.

In addition to the classic notion of disease prevention, the work of Public Health is dedicated to promoting physical and mental health of individuals. Those objectives are reflected in trying to influence the habits and living conditions, but also in promoting self-esteem, human dignity and respect.

Public Health is the set of actions undertaken by the company to improve the health of a population.

A commonly accepted classification of health systems is based on the terms of financing and is distinguished between insurance-based systems (Social Health Insurance) and tax-based systems (general taxation).

The more established Health Systems in Europe are: the Beveridge model, the Bismarck model, the Mixed model and the Semasko model.

While the last two have hybrid features, among the first two substantial differences can be identified.

The mixed model instead provides for the simultaneous presence of taxation mechanisms and forms of social insurance, providing coverage of the entire population.

The Semasko model, finally, is typical of those countries which currently or in the past decade have seen a political and social environment in transition (Central Europe and the former Soviet Union). This system is similar to the Bismarck model for the connotations related to social insurance mechanisms, even though it is funded by directly withholding tax on salary.

In the Beveridge model, health systems are primarily financed through tax revenues and should provide all of the services. The taxation may be direct or indirect, national or local.

The British National Health Service, or NHS, was founded in 1948 in order to provide free healthcare to the entire population of Britain. It is the first National Health System of the Beveridge style: universal, free, financed by general taxation¹⁷ .

A first attempt of de-verticalization of the healthcare system took place in Britain in 1990 with the 'NHS and Community Care Act', better known as the Thatcher Reform.

History, ever since the first reforms and the Darwinian evolution of the healthcare system would not seem to have favored vertically integrated organizational models, centralized or monocratic in the regulation of supply and demand, but have rather veered towards more 'distributed forms' for the provision and management of health. In the specific case of the Thatcher Reform, this was targeted towards precise incentivizing objectives to enhance the efficiency of Services. Therefore the hierarchical and monolithic model was shattered in favor of a separationist approach between buyer and distributor, introducing competition mechanism between producers; nevertheless maintaining the underlying principles of solidarity financing and access to the proper services of a public system.

In the late '80s, the proposal of the economist Enthoven [1988] to reform European healthcare systems in the light of the US HMO integrated organizations meets the favor of conservative governments, such as Reagan and, precisely, Thatcher. With the reform of 1990, England adopts a quasi-market variant called the internal markets model, in which the competition between public or private producers is enabled by special public agencies that act as patient representatives (sponsors) and, given a default loan, buy from producers through health services contracts for the assisted population. The idea of the quasi-market goes from England to the rest of Europe, with diverse applications in different European healthcare systems, oscillating between the two opposite poles of the total programming and pure market, thereby adopting intermediate hybrid forms of health care organization with various combinations of hierarchical mechanisms of control and competition¹⁸ .

In the Bismarck model, born in Germany in 1883 and introduced by Chancellor Otto von Bismarck to help reduce the mortality and injury in the workplace and to establish an early form of social security, the systems are financed by social insurances. The private style Bismarck model is characterized, on one hand by contributions generally assessed based on salaries, and on the other hand the organizations, which are called Funds diseases, act as administrative structures of the system and payers for care. The number of funds and their size vary widely with respect to the number of members and their employment status. In most cases up to the government to determine the contribution rates. In some countries you can choose the fund to support, (as is the case for example in Germany, Holland, and Switzerland), in others not. As regards to the German health system we must go back in time, until January 18, 1871 at the time of birth of the German Empire or Deutsches Kaiserreich, the Second Reich, following the victory of Germany in both the Austro-Prussian and the Franco-Prussian wars. After which, comes a period characterized by a strong fear by the part of the monarchies of the various states that the French Revolution could also happen in Germany. German nationalism rapidly moves from its liberal and democratic character in 1848 to Otto von Bismarck's authoritarian Realpolitik, which uses the "carrot and stick approach". The socialist movement was banned, but an especially advanced welfare state is created; based on compulsory social insurance, financed by contributions from companies and workers. In 1883, insurance for illness is established, in 1884 for accidents on the workplace, in 1889 disability and old age pensions are institutionalized.

This created what was at the time the most advanced welfare system in the world. A model (Bismarck model) that became an example, since the early twentieth century, adopted in most of the industrialized countries and which still exists in Germany and other countries. An expensive model, since - after the US - in the Organisation for Economic Co-operation and Development (OECD) ranking regarding the percentage of GDP spent on health care (year 2012), appear all countries belonging to the Bismarck model, with Germany in 5th place with 11.3%.

The same applies to the health expenditure per capita, which is $ 4,811 in Germany in 2012 (of which $ 3,651 - 75.9% - public health expenditure). This represents a much lower cost than the one corresponding to the US ($ 8,745), but much higher than the OECD average ($ 3,484), or that of Britain ($ 3,289) and Italy ($ 3,209).

Following the financial crisis of 2008, Germany, parallelly to the average of the OECD countries, has seen a sharp slowdown in annual growth in health spending that from + 4% in 2008 rose to a little less than +1%, while other Southern European countries have suffered a net reduction of resources available in real terms: -2% Spain, Italy -3%, Portugal 6%, Greece -10%.

In terms of burdens on citizens, Germany spends a lot on health care, but still produces a huge amount of services, with a low level of direct spending by patients. This shows that we are faced with a technically efficient system.

The German population consists of 81.8 million citizens. The 85% of them are enrolled in one of the 132 social "compulsory" insurances (Krankenkassen). These are "non-profit" insurances, "friendly societies", not definable as public, nor private. Until 1996 the inscription was attached to the profession; since then a liberalization has taken place, thereby allowing the possibility of choice between different insurance companies competing with each other for charges and coverings offered to its members.

The registration requirement applies to all employees (and their families) with a gross monthly income equal to or less than € 4462.60. It is the state itself that pays, through specific funding of the Länder, for assistance of the disabled, the unemployed, minors or for categories that otherwise can not subscribe to insurance.

The contribution paid to the Krankenkassen varies depending on the employee's income and corresponds to 15.5% of the monthly salary (53% of which is paid by the employee and 47% by the employer). Thus a financial equalization is applied to compensate for the different capacity of contribution of members: Each person pays proportionally to their income. The contribution of employees and businesses has grown over the past 15 years, going from 13.6% in 1998 to currently 15.5% of the monthly income.

On top of the monthly contribution, supplements (Zuzahlungen) are added: you have to pay € 10 every three months to take advantage of medical consultations with all doctors recognized by the health insurance funds, and thereafter each time that you are using one visit to the doctor or dentist (including those covered by the policy) you have to pay a fee of 10 € (this "Praxisgebühr" has led to an observed reduction of 10% of the accesses). Even for the medicines you pay 10% of the price, and 10 € per day for hospitalization. Recently, an annual limit for additional expenses has been set (generally 2% of annual income, 1% for recipients of a continuing care because of a serious chronic disease), those who pass such percentage are reimbursed their insurance. Minors do not pay any additional charge.

In Germany there is an obligation to be insured; those with a monthly income of more than € 4462.60 may choose to subscribe to private insurances (Private Krankenversicherung-PKV), rather than social ones.

Private insurances, unlike the mutualistic funds in which the contribution depends on income, calculate the premium depending on the personal risk (in fact, it is provided thorough medical examination before enrolling). Private insurances often offer superior services of social insurance, pay better doctors, and also offer reimbursements for hospitalization in non-contracted private clinics. For young people with a high salary and no health problem, the contribution towards the private enterprises often costs much less; with age the insurance policy increases in price. However, even in case of serious diseases it may not exceed certain standard levels (for this reason it is custom for young people to appeal to insurances to create a capital backup with their savings). Nine million Germans, equal to 11% of the population are privately insured. The use of private insurance can also be a complementary purpose for those who are enrolled in the Krankenkassen (about 23 million). The main reason is to expand the financial protection in case of illness or hospitalization. The remaining 4% of the population is represented by people who get insurance coverage through special channels, such as the military or those with refugee status.

The funding of the German health system is mainly based on the takings of the compulsory social insurance (57%) and on private insurances (9%). The central government is not involved in the health system neither as a financier nor as manager, or as the owner of sanitary manufacturing companies (except detailed cases, such as military hospitals). However, it governs the whole system, defining the rules by which the actors can move. Mutual aid societies and associations of physicians operate within administrative rules, only modifiable by the central government, just as they are regulated by laws and relations between the different actors of the system. Although the general health policies for the country are decided by the Central State, the management and the funding of the system takes place at regional level, where there are three institutions: the Land (through its Ministry of Health), mutual aid societies, associations of panel doctors and hospitals. It is the individual Länder who plan and finance investments and infrastructure (hospitals, departments, equipment, access to the conventions and specialized training), credit the volume of production, finance the hospital-area system integration and perform the review of legality. These can, for instance, control the activity of doctors and guide their prescription behavior towards less expensive drugs, as well as carry out surveillance on the quality of hospital care.

The sickness insurance funds programming negotiate and acquire the services for their patients. The German system’s financing mechanism is therefore dualistic: the Land defines and funds investment, while the mutual aid society negotiates and finances the current healthcare costs by dealing with both hospitals and affiliated physicians.

For hospital functions, the regional association for mutual aid signs a contract with each hospital, while for outpatient functions it negotiate a global agreement with the regional association of doctors.

Mutual aid is called to protect the interests of its members, trying to influence the volume and the producer’s case mix, as well as to respect the insurance spending thresholds, implicitly set out by the Government through the maximum rate of contributions payable by the subscribers.

With an excess of hospital beds (8.3 per 1,000 inhabitants compared to the OECD average of 4.8 and 2.6 in Sweden and 3.4 in Italy), the rate of hospitalization (25 admissions per 1,000 inhabitants compared to the OECD average of 15.5, 16.2 in Sweden and 12.8 in Italy) and the average duration of hospital stay (9.2 days compared to the OECD average of 7.4, 6.0 in Sweden and 7.7 in Italy); in terms of financial resources, Germany has the most important hospital network in Western Europe¹⁹ .

The acute care hospitals were 2,017 in the year 2012, with 501,475 beds: 601 public, 719 private non-profit and 697 private for-profit, with a split percentage split of respectively 48%, 34% and 18% of beds. In addition to acute care hospitals, 1212 structures specializing in rehabilitation exist, holding 168,968 bed places. Among these institutions, only 19% are public, 26% are private non-profit and 55% private for-profit. 18% of hospital beds are in public facilities while the other structures respectively host 16% and 66%. Next to a progressive reduction of beds for acute illnesses, the number of beds in rehabilitation and psychiatric facilities has more than doubled.

German citizens have full freedom of choice of care and professional place, with no distinction between general practitioners and medical specialists.

This model - which does not include the role a of gatekeeper doctor, or a doctor who acts as a filter for access to specialist care - is typical of the Bismarck model, but is rapidly changing as a result of a reform approved in 2004.

Such reform, since 2004, has introduced several innovations in order to strengthen local services (and to reduce the pressure on hospitals): among them is the need to encourage the enrollment of the clients to a general practitioner who in addition to playing the role of filter for access or "gatekeeper", also is responsible for the coordination of care. There is no obligation, but who does not comply is subject to reduced co-payments and waiting lists. The number of patients assisted by the "gatekeeper" or General Practitioner (GP) is growing (in 2012 to 4.6 million).

Another innovation is the overcoming of the model of care based a single physician, with the development of medical centers of interdisciplinary care (increased from 70 to 1,814 from 2004 to 2012).