Abstract
BackgroundIn Germany and Chile, substitutive private health insurance has been shaped by its co-existence with statutory social health insurance. Despite differences in the way choice is available to users in the health insurance regimes of Chile and Germany, the way in which each country has managed choice between private health insurance and statutory social health insurance provides a unique opportunity to comparatively assess the consequences of such an arrangement that has been previously underexamined.MethodsWe conducted a Most Similar Systems Design comparative policy analysis of the co-occurring private health insurance and statutory social health insurance systems in Germany and Chile. We describe and review the origins and development of the German and Chilean health care insurance systems with an emphasis on the substitutive co-existence between private health insurance and statutory social health insurance. We provide a critique of the market performance of the private health insurance regime in each country followed by a comparative assessment of the impact of private health insurance on financial protection, equity, and risk segmentation.ResultsSegmentation of insurance markets in both Germany and Chile has had significant consequences for equity, fairness, and financial protection. Due to market failures in health insurance and differences in the regulatory frameworks governing public and private insurers, the choice of public or private coverage has produced strong incentives for private insurers to select for risks, compromising equity in health care funding, heightening the financial risk borne by public insurers and lowering incentives for private insurers to operate efficiently.ConclusionsThe degree of conflict arising from the substitutive parallel private health insurance system and the statutory social health insurance system varies between Germany and Chile, though policy goals remain similar. Recent reforms in both countries have attempted to improve the financial protection of the privately insured through regulation; nevertheless, concerns about risk segmentation remain largely unresolved.
Highlights
In Germany and Chile, substitutive private health insurance has been shaped by its co-existence with statutory social health insurance
We decided to base our analyses on Germany and Chile based on a Most Similar Systems Design (MSSD) [11] because: a) they present crucial similarities in their respective health system designs, such as the substitutive nature of both private insurance regimes, b) the public-private insurance mix, different, has the potential to inform discussion around policy reform in both countries and their World Health Organisation (WHO) sub-regions, c) the choice between public and private insurance has been available for significant periods, with Germany being the only country in Europe still allowing substitutive choice [4, 7]
Statutory insurance has expanded over time and since 1989, all workers with earnings above a certain threshold were given a choice between statutory health insurance (Gesetzliche Krankenversicherung - GKV) and private coverage (Private Krankenversicherungen - Privaten Krankenversicherung (PKV)) except for civil servants who have always had private coverage in addition to support from the state
Summary
In Germany and Chile, substitutive private health insurance has been shaped by its co-existence with statutory social health insurance. In Germany and Chile, substitutive private health insurance coexists with social health insurance schemes which cover the majority of their respective populations [1,2,3,4]. Taking into account the different dimensions of regulation, financing and provision [10], choice and the free flow of users between insurance regimes [7], the main objective of this comparative policy analysis is to analyze how the designs of the German and Chilean substitutive private health insurance regimes have led to risk segmentation and created financial barriers to health coverage [5, 7, 10]. Debates about the choice between public or private insurance in these countries have been framed in terms of offering some, or all, of the population the possibility of opting out of the public insurance scheme [7]
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