OBS_42_A4_WHO_A4 18/02/16 17:28 Page 1 42 BUILDING PRIMARY CARE IN A CHANGING EUROPE CARE BUILDING PRIMARY 42 No two markets for voluntary health insurance (VHI) are identical. All differ in some way Voluntary health because they are heavily shaped by the nature and performance of publicly financed health systems and by the contexts in which they have evolved. insurance in Europe This volume contains short, structured profiles of markets for VHI in 34 countries in Observatory Observatory Europe. These are drawn from European Union member states plus Armenia, Iceland, Studies Series Georgia, Norway, the Russian Federation, Switzerland and Ukraine. The book is aimed at Country experience policymakers and researchers interested in knowing more about how VHI works in practice in a wide range of contexts. Edited by Each profile, written by one or more local experts, identifies gaps in publicly financed health coverage, describes the role VHI plays, outlines the way in which the market for Anna Sagan VHI operates, summarises public policy towards VHI, including major developments over Sarah Thomson time, and highlights national debates and challenges. The book is part of a study on VHI in Europe prepared jointly by the European Observatory on Health Systems and Policies and the WHO Regional Office for Europe. A companion volume provides an analytical overview of VHI markets across the 34 countries. The editors STUDIES CASE Anna Sagan, Research Fellow at the European Observatory on Health Systems and Policies, London School of Economics and Political Science Sarah Thomson, Senior Health Financing Specialist at the WHO Barcelona Office for Health Systems Strengthening, Division of Health Systems and Public Health, WHO Regional Office for Europe and Senior Research Associate at the European Observatory Allen Hutchinson, Richard D. Saltman D. Richard Hutchinson, Allen on Health Systems and Policies Boerma, G.W. Wienke Kringos, S. Dionne by Edited 9 7 8 ISBN 9289050371 9 2 8 9 0 5 0 3 7 1 Voluntary health insurance in Europe: country experience The European Observatory on Health Systems and Policies supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in Europe. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. The Observatory is a partnership hosted by the WHO Regional Office for Europe, which includes the governments of Austria, Belgium, Finland, Ireland, Norway, Slovenia, Sweden, the United Kingdom and the Veneto Region of Italy; the European Commission; the World Bank; UNCAM (French National Union of Health Insurance Funds); the London School of Economics and Political Science; and the London School of Hygiene & Tropical Medicine. The Observatory has a secretariat in Brussels and it has hubs in London (at LSE and LSHTM) and at the Technical University of Berlin. Voluntary health insurance in Europe Country experience Edited by: Anna Sagan Sarah Thomson European on Health Systems and Policies a partnership hosted by WHO Keywords: INSURANCE, HEALTH HEALTHCARE FINANCING HEALTH SERVICES ACCESSIBILITY EUROPE © World Health Organization 2016 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies) All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about the publication to: Publications, WHO Regional Office for Europe, UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro.who.int/en/what-we-publish/ publication-request-forms). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the European Observatory on Health Systems and Policies to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the European Observatory on Health Systems and Policies be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the European Observatory on Health Systems and Policies or any of its partners. ISBN 978 92 890 5037 1 Printed in the United Kingdom Typeset by Peter Powell Cover design by M2M Contents Acknowledgements vii List of tables and figures viii List of abbreviations x Contributors xii Note xiv page page Introduction 1 11 France 51 Anna Sagan and Sarah Thomson Karine Chevreul, Karen Berg Brigham and Marc Perronnin 1 Armenia 5 12 Georgia 57 Varduhi Petrosyan and Hripsime Martirosyan Erica Richardson and Nana Gugeshashvili 2 Austria 11 Thomas Czypionka and Clemens Sigl 13 Germany 61 Stefan Greß 3 Belgium 17 Sophie Gerkens 14 Greece 67 Charalampos Economou 4 Bulgaria 23 Antoniya Dimova 15 Hungary 71 Szabolcs Szigeti, Ferenc Lindeisz and Péter Gaál 5 Croatia 27 Karmen Lončarek 16 Iceland 75 Sigurbjörg Sigurgeirsdóttir 6 Cyprus 31 Mamas Theodorou and Antonis Farmakas 17 Ireland 77 7 Czech Republic 35 Brian Turner Martin Dlouhy 18 Italy 83 8 Denmark 38 Francesca Ferré Karsten Vrangbæk 9 Estonia 43 19 Latvia 89 Triin Habicht Girts Brigis 10 Finland 47 20 Lithuania 93 Lauri Vuorenkoski Gintaras Kacevicius vi Voluntary health insurance in Europe: country experience page page 21 Malta 97 28 Slovakia 129 Natasha Azzopardi-Muscat Peter Pazitny and Peter Balik 22 Netherlands 101 29 Slovenia 133 Hans Maarse Anja Milenkovic Kramer 23 Norway 105 30 Spain 139 Jan Roth Johnsen Joan Costa-i-Font 24 Poland 109 31 Sweden 143 Alicja Sobczak Caj Skoglund 25 Portugal 115 32 Switzerland 147 Mónica Duarte Oliveira and Sofia Nogueira da Silva Viktor von Wyl and Konstantin Beck 26 Romania 121 33 Ukraine 151 Victor Olsavszky Valery Lekhan 27 Russian Federation 125 34 United Kingdom 157 Elena Potapchik Thomas Foubister and Erica Richardson Acknowledgements We are indebted to the many country experts who (LSE Health) for financial management of the study and contributed to the study by writing the chapters in this our colleagues at the European Observatory on Health book and reviewing parts of its companion volume. We Systems and Policies and the WHO Barcelona Office are also grateful to Anna Maresso (European Observatory for Health Systems Strengthening for vital project and on Health Systems and Policies) and Sherry Merkur production support. The production and copy-editing (European Observatory on Health Systems and Policies) process for this book was coordinated by Jonathan North for their help with earlier drafts of the 34 country profiles. with the support of Caroline White. Additional support We thank Erica Richardson (European Observatory came from Aki Hedigan and Sonia Cutler (copy-editing) on Health Systems and Policies) for translating the and Peter Powell (typesetting). Ukrainian profile into English, Champa Heidbrink List of tables and figures Tables Table 0.1 VHI market roles 2 Table 13.2 Reform of private health insurance in Germany, 2000–2011 64 Table 0.2 Summary of VHI markets in Europe, 2014 2 Table 13.3 Comparison of health care expenditure and Table 1.1 Public policy promoting VHI in Armenia, premiums in the statutory scheme and 1996–2012 8 substitutive private coverage in Germany, Table 2.1 Premiums and claims in the Austrian VHI 2002–2010 64 market, 2014 12 Table 14.1 Development and regulation of the VHI market in Table 2.2 Number of VHI policyholders in Austria by Greece, 1970–2013 69 state, 2014 13 Table 17.1 Entitlement to publicly financed health benefits Table 2.3 Development and regulation of the VHI market in Ireland, 2015 78 in Austria, 1889–2012 14 Table 17.2 VHI take-up in Ireland by social class, Table 3.1 Development of publicly financed health 2003–2008 79 coverage in Belgium, 1944–2012 18 Table 17.3 Overview of VHI insurers in Ireland, 2015 79 Table 3.2 Market shares of the leading 15 private insurers Table 17.4 Development and regulation of the VHI market in Belgium, 2010 19 in Ireland, 1957-2015 80 Table 3.3 Development and regulation of the VHI market Table 18.1 Types of VHI providers in Italy, 2010 85 in Belgium, 1990–2012 20 Table 18.2 Development and regulation of the VHI market Table 4.1 Financial indicators of Bulgarian VHI companies, in Italy, 1886–2012 86 2007–2013 25 Table 20.1 Market shares of VHI companies (%), Table 5.1 Development and regulation of the VHI market at the end of 2011 94 in Croatia, 1993–2012 29 Table 23.1 Distribution