Health in Europe: health systems with hybrid characteristics

Three types of organization of the health care system coexist in the European Union. DREES analyzes in detail the characteristics of private health insurance markets in 6 EU countries.

Europe sees different health insurance systems cohabiting, summarized in three main categories: the national health system (this is the case of the United Kingdom, Denmark, Italy, Spain, Ireland, from Norway or Portugal), a system based on compulsory insurance cover (France, Germany, Greece, Luxembourg, Poland, Austria and Belgium), called the “Bismarckian” system, and finally a system of compulsory health insurance managed by private insurers in a competitive situation (Switzerland, the Netherlands).

These three systems also have different modes of financing (by tax for the first, based on contributions or social contributions for the second and finally insured by insurance premiums for the last). “European systems often have hybrid characteristics between these different theoretical models”, explains in this register the last study of the DREES devoted to the place of private insurance in six European countries. In Germany, for example, about 10% of the population opted for private health care coverage. This private coverage would thus finance 4.5% of the “expenditure on care expenses”. In the Netherlands, where the management of health insurance has been entrusted to private insurers since 2006 and competed with one another, this share has risen to 81.5%. In Switzerland, it stands at 46.7%. In Spain, civil servants can leave the national health system and be covered by an insurance system. The share of private insurers stands at 4%. Despite these differences, “a common trend seems to be binding on all of these European systems,” notes the study. “That of a sickness cover tending towards the universality”.

“In all countries, compulsory basic coverage leaves co-payments to the insured, which aims to make them aware of the cost of care and encourage them to consume reasonably,” adds DREES. These co-payments may result in user fees, excess fees, flat-rate contributions or deductibles. “In practice, these different types of co-payments can be combined, modulated (depending on income or compliance with the care path for example), or capped, thus giving rise to a wide variety of situations. ”

Remains with variable charges

In the six countries studied, an optional health insurance offer, offered by private insurers, has grown outside the basic coverage. It is structured and positioned in addition to the basic health coverage, sometimes considered insufficient. It will be defined as extra “when it aims to cover benefits left outside the basket of low care. It is qualified as “complementary” when it is intended to cover all or part of the co-payments left to the patient’s expense.

The optional supplemental insurance covers 96% of French people in 2014, compared with only 23% of Germans. Because across the Rhine, basic compulsory coverage is indeed wider than in France (87.5% against 78.0%) where user fees are higher. In the Netherlands, supplementary insurance covers 85% of the population. National health systems offer private insurance openings to 16% of the population in Spain and 11% in the United Kingdom.
In total, the share of expenditure on care expenses covered by optional private insurance remains the highest in France, at 13.4% in 2014, compared to 7.8% in the Netherlands or Switzerland and 1.5% in % in Germany. “Of the six countries, it is in the Netherlands and France that the dependent remains the weakest, since it amounts respectively to 7.9% and 8.6% of the expenditure on care costs” , concludes the DREES study, “while it is slightly higher in Germany and the United Kingdom (respectively 11.0% and 12.4%). Spain and Switzerland, on the other hand, have the highest remaining charges, accounting respectively for 26.7% and 28.4% of the expenditure on care costs.