National health schemes

The first national compulsory health insurance scheme, introduced in Germany under Bismarck’s law in 1883, built upon precedents going back many years in the separate German states. Health insurance had developed mainly on an occupational basis and was a requirement for that occupation. The feudal obligation of the employer to his workers was given legislative substance in a society developing national markets, in which the employer without an obligation to pay to a sick fund might undercut the employer who had such an obligation. But the main reason for the scheme, as mentioned earlier, was to try to contain socialist tendencies.

The administration of compulsory health insurance was left in the hands of numerous local sick funds operating under legislative regulations. They became jointly controlled by employers and employees and made their own contracts with particular doctors and hospitals for the provision of services. All lower-earning workers were eventually required to be members of a fund. Doctors were paid in a variety of different ways, including salary and capitation. In the course of time there were major protests from doctors excluded from contracts with the funds, and the profession demanded the right for any doctor to undertake health insurance work. The substitution of payment per case and later fee-for-service payment, which the German medical profession fought for and eventually won, was a means of establishing open competition between all doctors wishing to take part in the scheme.

Health insurance was enacted in Austria in 1888 and Hungary in 1891 on a similar basis. A bill to introduce such a scheme in Switzerland was, however, decisively rejected by a plebiscite in 1900. The British Radical politician David Lloyd George visited Germany in 1908 to see the scheme firsthand and subsequently introduced compulsory health insurance for persons with earnings below an upper limit in Britain by a law of 1911. However, the scheme provided only for the services of the general practitioner and the drugs he prescribed; hospital benefits were excluded except for some provision for tuberculosis, partly so as not to disturb the charitable hospitals that provided free care to those in need. Moreover, as a result of pressure from the medical profession, the benefit in kind was administered by statutory committees for each area, which enabled every general practitioner to participate who wished to do so, rather than by the large number of friendly societies that had previously provided medical benefits under voluntary insurance and had made their own contracts with particular doctors. Payment was on a capitation basis, as in the previous friendly society schemes.

The introduction of compulsory health insurance was considered in Sweden in 1884 and Denmark in 1885, but both countries decided instead to encourage voluntary insurance by government subsidy. Whereas Norway introduced compulsory health insurance in 1911, Denmark did not follow until 1933, and Sweden not until 1955. In these countries public hospitals were well developed and heavily subsidized. A compulsory health insurance law was passed in France in 1920 but, as mentioned earlier, did not come into effect until 1930 owing to disagreement about the local control of the scheme and a dispute with the doctors about the method of payment. Fee-for-service payment was finally substituted for the capitation system originally proposed. Moreover, as the doctors refused to accept the intrusion of any third party between them and their patients, the scheme operated on a reimbursement basis; the patient paid the fee and claimed a refund for the major part of it from the relevant insurance fund. This reimbursement system was adopted later in Sweden, Finland, and Australia (under subsidized voluntary insurance).

When health insurance was established in Russia in 1912, insurance doctors were paid salaries and practiced from government-owned premises. This was the pattern adopted in Chile in 1924. Payment of doctors on a part-time salaried basis for work performed on premises owned by the sick fund became the general pattern in Latin-American countries and in Spain, Portugal, and Greece. In most of Europe and Australasia, however, existing hospitals began accepting insured patients when hospital care became covered by insurance; special hospitals for insured persons were built in Spain, some parts of Italy, and a number of countries in Latin America.

The next major step in the evolution of medical benefits was for countries to make them available to the entire resident population, financed wholly by taxation or financed in part by social insurance contributions. This step was taken first by Hungary in 1920 and then by the Soviet Union in 1937. New Zealand implemented similar coverage in a series of steps—free inpatient treatment for the whole population in 1939 and outpatient treatment, free pharmaceuticals, and part payment of general practitioners’ bills in 1941, with further steps later on. The United Kingdom established its National Health Service in 1946. Norway made services available to all residents in 1956, Sweden in 1962, Denmark in 1973, Portugal in 1979, and Italy in 1980. By the 1980s more than 20 countries had adopted this system. This does not necessarily mean that all services are free at the time of use. Nor does it necessarily follow that all services are government-owned. Of the eastern European countries, some (Bulgaria, the Czech Republic, Slovakia, Hungary, and Romania) have adopted this approach; others (such as Poland) have not. About half of all countries retain an element of financing by social security contributions after adopting this approach.

Canada was relatively late in establishing compulsory health insurance. The first province to do so was Saskatchewan in 1962. By 1971 all provinces had done so, spurred on originally by a 50 percent grant from federal funds; the provincial schemes became available to all residents. The not-for-profit general hospitals were given budgets by the provinces to provide this care. Australia was also late in changing from subsidized voluntary insurance to compulsory health insurance. The United States and Switzerland are left as the only highly industrialized countries without general compulsory health insurance or a health service available to all residents. There have been many attempts, against strong opposition from the American Medical Association, to introduce compulsory insurance in the United States. However, a limited scheme of compulsory health insurance for the aged (Medicare) was finally introduced in 1966 along with a system of means-tested medical care operated by each state for the indigent and medically indigent (Medicaid).

Some countries in Europe have succeeded in securing high coverage of the population under compulsory health insurance without switching to a service available to all residents. Schemes cover the employed, the self-employed, and all social security beneficiaries and their spouses and dependent children: this can amount to 99 percent of the population. Other European countries (Germany and the Netherlands), nearly all of which have some system of private insurance, exclude the higher income groups from statutory health insurance. Alternatively, some benefits (e.g., hospital care) are available to the whole population, while higher income groups must make their own arrangements for certain other benefits (Ireland).

Apart from Cuba, which has a national health service, only three countries in Latin America (Argentina, Brazil, and Costa Rica) have managed to cover 80 percent or more of the population by health insurance. Moreover, coverage may not necessarily mean that services are equally available. Coverage extends to about half the population in Mexico, Panama, and Uruguay, and more than a quarter in Bolivia and Venezuela. In the remaining countries coverage is 10 percent or less. By no means do all of these countries extend the same rights to the spouse and children of the insured person. Several provide only maternity care and pediatric care for dependents. Coverage is more easily provided for the employees of larger establishments, which tend to be concentrated in urban areas. Even in urban areas those excluded tend to be the self-employed, domestic servants, and itinerant workers. The obstacles to expanding rural coverage include the much lower levels of earnings, the geographic dispersion, the less formal employment conditions, and more extensive self-employment and seasonal employment. Most important of all, some schemes have become too costly to extend on the same basis with tax subsidy to cover the whole population. Thus the remaining population must depend on poorly financed and staffed services provided by ministries of health. Health insurance is, therefore, increasingly criticized for exacerbating inequality in health care by outbidding government health services for trained manpower and for creating a heavy emphasis on sophisticated and expensive curative services in urban areas while the main health need is for preventive services to cut the incidence of infectious diseases in both urban and rural areas.

Japan has managed to avoid the worst of these effects and to achieve high coverage. India, conscious of the damage that health insurance could do to government services, has developed health insurance slowly as resources have become available for doing so in particular states. South Korea has introduced health insurance for the urban employed population and also has provided rights to those with low incomes in urban areas; the problem of covering the remaining half of the population in rural areas remains to be solved.

Many developing countries, particularly those that were previously British colonies, have made health services available to the whole population, providing free or nearly free services. This is the pattern, for example, in the West Indies, Kenya, Zimbabwe, India, Sri Lanka, Malaysia, and many Arab states in the Middle East. In most cases services were originally developed for the expatriate colonialists and extended in the course of time to local residents. The services tend for this reason to be heavily concentrated in urban areas, with little or no coverage of the rural population. With their limited resources, these countries are striving, as part of the World Health Organization’s program Health for All, to extend rural coverage with primary health care to all areas by the year 2000.