SESSION 23. Public and private health insurance in historical perspective: between competition and complementarity

23. Public and private health insurance in historical perspective: between competition and complementarity.

Margarita Vilar Rodríguez (Universidade da Coruña). mvilar@udc.es
Jerònia Pons Pons (Universidad de Sevilla).


The literature has established the historical creation of two basic models of public health insurance system in developed countries: one inherited from the Bismarck system, based on funds from contributions, and the other derived from the National Health System, based on universalist principles and, to a large extent, public funds. Not all countries joined this process at the same rate, and moreover the two categories have not remained stable or homogenous over time, which has given rise to a situation that is more complex than that reflected by these two theoretical models. In Europe, from a historical point of view, and although with significant variations in each case, the public systems of health insurance coverage generally prevailed. These models based on public insurance, however, contrast with other countries, such as the United States, where the population’s medical care has been covered by private insurance companies; a system considered by some authors to be more expensive in the long run due to its high cost, fragmentation and anti-democratic corporate structure. In these countries, the private interest groups involved in this process gained ascendancy over medical professionals and the politicians in government, thereby consolidating a system of private coverage.

On the other hand, private health insurance has become increasingly important in recent decades in the countries with public health insurance systems due to the economic crisis, which has led to waves of privatisations and a crisis of the welfare state. As a result of this process, some countries have a private health insurance that complements the public coverage. This means that the private sector offers services already provided by the compulsory system, but with additional advantages such as shorter waiting lists and other benefits and conveniences. In other countries, private health insurance plays a supplementary role by covering services and specialties excluded from the basic state package (e.g. Denmark, Hungary and the Netherlands). Finally, in some countries, private insurance provides substitute cover for people excluded from the system due to various factors, such as level of income or type of work (e.g. Germany). In general, the causes of the growth of private health insurance are very heterogeneous and a result of historical evolution, the power of different interest groups and the public policies implemented. Its increasing importance, however, is a common trend in all countries.

The main objectives of the session will be the creation of private and public health insurance schemes, an analysis of the financial, medical, institutional, political, cultural and social factors that determine their creation and the conflicts generated in their development until each country establishes its own public or private model. Contributions in historical perspective are welcome from all disciplines and geographical areas.