Healthcare Standards in Europe

HEALTHCARE STANDARDS IN EUROPE:
COMPARATIVE STATE PRACTICE

Legal Memorandum

July 2013

HEALTHCARE STANDARDS IN EUROPE: COMPARATIVE STATE PRACTICE

Executive Summary

The purpose of this memorandum is to identify healthcare standards set forth
by the European Union (EU) for Member States and Switzerland and to analyze
the implementation mechanisms used to meet those standards.

Healthcare in Europe is organized through statewide systems, which are
primarily funded through taxation, and which provide universal healthcare to
citizens. Though the EU does not directly administer healthcare, states must abide
by any EU regulations that protect and promote public health. The United
Kingdom (UK), Belgium, Germany, and Switzerland illustrate the differing ways
in which European states have organized healthcare systems. Although
Switzerland is not a member of the EU, its healthcare system has elements of EU
Member States systems.

The UKs healthcare is a tax-financed, state-run system that is slowly
devolving away from the UKs Department of Health to regional and local health
centers. However, the Department of Health (through the National Health Service)
regulates healthcare guidelines and the distribution of healthcare funds. Local
governments retain responsibility for the management of local healthcare concerns.

Belgiums healthcare system is a mixed public-private healthcare system that
covers nearly every Belgian citizen and allows those insured to choose any
healthcare provider they desire. The federal government is responsible for
regulating and supervising health insurance, while the Communities deal with such
issues as health education and preventative medicines.

German healthcare consists of a multi-payer, statutory system comprised of
state insurance and private insurance. The Federal Ministry of Health and Social
Security legally supervises the healthcare system, while individual German state
governments and civil society organizations remain responsible for the proper
functioning of the healthcare system in their specific geographic areas.

Switzerland is well known for its high-functioning, decentralized healthcare
system. The federal government rarely involves itself with healthcare, except to
oversee big-ticket items of public health; otherwise, responsibility for citizens
healthcare falls primarily to the individual Swiss Cantons. Cantons, however, must
enforce any healthcare laws and ordinances issued by the federal government.

TABLE OF CONTENTS

Statement of Purpose 1

Introduction 1

Healthcare Standards in the EU 1

Healthcare Standards in Switzerland 6

Implementation of European Healthcare Standards 6
Healthcare in the UK 8
The Healthcare System: Centralized 9
Financing 10
Services and Benefits 11
Challenges and Criticisms 12
Healthcare in Belgium 13
The Healthcare System: Mixed 13
Financing 16
Healthcare in Germany 20
The Healthcare System: Universal 20
Financing 23
Healthcare in Switzerland 26
The Healthcare System: Decentralized 26
Financing 29

Conclusion 33

Healthcare Standards in Europe, July 2013

1
HEALTHCARE STANDARDS IN EUROPE: COMPARATIVE STATE PRACTICE

Statement of Purpose

The purpose of this memorandum is to identify healthcare standards set forth
by the European Union for Member States and Switzerland and to analyze the
implementation mechanisms used by Member States and Switzerland to meet those
standards.

Introduction

There is a broad accordance within the European Union (EU) that healthcare
provisions must be regulated differently than other services. Those who most need
healthcare are often least able to afford it, and the relationships between patients,
insurance companies, and healthcare providers are often characterized by
disparities concerning information and decision-making, leaving patients in
potentially vulnerable positions. In adhering to the EUs principle of mutual
solidarity, each Member State has established a system to provide universal (or
near universal) healthcare to its citizens.
1
These systems, though organized
diversely, all delicately balance the relationships between the bodies collecting and
disbursing funds and the bodies providing care and insurance.
2

The United Kingdom (UK) has a centralized system headed by the National
Health Service, which is state-run and tax-financed, and the UK grants all citizens
affordable healthcare. In Belgium, though some health issues receive federal
oversight, much of the healthcare takes place at the Community level. Germany
boasts a universal, multi-payer healthcare system comprised of statutory health
insurance and private insurance that necessarily covers all German citizens.
Switzerland, though not a member of the EU, also utilizes a healthcare system that
resembles many healthcare standards of EU Member States. The Swiss federal
government itself rarely interferes with healthcare, instead allowing the Cantons to
fully monitor health issues.

Healthcare Standards in the EU

Per its founding treaty, the EU is required to protect human health in all of
its policies and to work with Member States to prevent human illness, eliminate

1
European Observatory on Health Systems and Policies, Health policy and European Union Enlargement, 13
(2004), available at http://www.euro.who.int/__data/assets/pdf_file/0004/98392/E82999.pdf.
2

2
sources of danger to physical and mental health, and improve public health.
3

Access to healthcare is an essential element of human dignity and a basic human
right guaranteed by the European Unions Charter of Fundamental Rights, which
maintains that, everyone has the right of access to preventive healthcare and the
right to benefit from medical treatment.
4
The Treaty on the Functioning of the
European Union (TFEU), however, explicitly provides that healthcare is mainly the
responsibility of each individual EU Member State.
5
However, the EU does have a
shared competence with Member States when addressing concerns in public health
matters.
6
The EU complements the work of the individual states by bringing
countries together to address common challenges such as ageing populations and
associated health problems.
7

Article 168 of the TFEU expounds upon the EUs main responsibilities
related to healthcare policy, which mostly involve combating major health
scourges through public education, research, and monitoring cross-border public
health threats.
8
Though the EUs main prerogatives concern cooperation between
Member States and third party states, it also helps establish measures regarding the
safety and quality of donated human organs and blood; measures respecting the
veterinary and phytosanitary fields, as they influence public health; and measures
relating to the quality and safety of medical devices for medical use.
9
The EU may
also adopt measures concerning tobacco and the abuse of alcohol.
10
The EU
respects any actions taken by the Member States towards defining their own
healthcare policies and providing their own medical services.
11

The EU also oversees coordination to encourage cooperation between
Member States to improve cross-border health services.
12
Furthermore, when

3
European Commission, Public Health (July 12, 2012), http://ec.europa.eu/health/programme/policy/index_en.htm.
4
Charter of Fundamental Rights of the European Union, 2000/C364/01, art. 18 (2000), available at
http://www.europarl.europa.eu/charter/pdf/text_en.pdf.
5
Treaty on the Functioning of the European Union, art. 168 (2010), available at http://eur-
lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:C:2010:083:0047:0200:en:PDF.
6
Treaty on the Functioning of the European Union, art. 4(2)(k) (2010), available at http://eur-
lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:C:2010:083:0047:0200:EN:PDF.
7
Public Health, EUROPEAN UNION (Dec. 14, 2012), http://europa.eu/pol/health/index_en.htm.
8
Treaty on the Functioning of the European Union, art. 168 (2010), available at http://eur-
9
Treaty on the Functioning of the European Union, art. 168(4)(a) 4(c) (2010), available at http://eur-
10
Treaty on the Functioning of the European Union, art. 168(5) (2010), available at http://eur-
11
12
lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:C:2010:083:0047:0200:EN:PDF.

3
citizens of a Member State travel outside their states borders, they are often
entitled to receive healthcare in other Member States and to have that healthcare
reimbursed by their home authorities.
13

Directive 2011/24/EU on patients rights to cross-border healthcare clarifies
the rules on access to healthcare in other EU states, including reimbursement for
outside treatment.
14
Under the Directive, Member States retain responsibility for
providing safe, high quality, efficient, and quantitatively adequate healthcare to
citizens on their territory, though citizens are discouraged from seeking healthcare
outside of their states of affiliation.
15
If a patient opts to travel outside of his/her
state for healthcare, the treating Member State organizes and provides the
healthcare, and the patients Member State of affiliation handles his/her
reimbursement, provided that his/her treatment is covered under state legislation.
16

Additionally, the Directive authorizes development of European reference
networks, which aim to share healthcare providers and centers of expertise
between Member States.
17
EU Member States have until October 25, 2013, to pass
state laws implementing the Directive.
18

The EUs strategy for protecting and improving human health is primarily
implemented through the European Commissions (EC) Second Programme of
Community Action in the Field of Health 2008-2013.
19
The Programme came into
force on January 1, 2008 to complement, support and add value to the policies of
the Member States and contribute to increased solidarity and prosperity in the [EU]
by protecting and promoting human health and safety and by improving public

13
Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the Application of
Patients Rights in Cross-border Healthcare, 2011/24/EU, 11, 36 (2011), available at
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2011:088:0045:0065:EN:PDF.
14
Patients Rights in Cross-border Healthcare, 2011/24/EU (2011), available at
15
Patients Rights in Cross-border Healthcare, 2011/24/EU, 4 (2011), available at
16
Patients Rights in Cross-border Healthcare , 2011/24/EU, 11, 36 (2011), available at
17
Patients Rights in Cross-border Healthcare, 2011/24/EU, 54 (2011), available at
18
Patients Rights in Cross-border Healthcare, 2011/24/EU, art. 21(1) (2011), available at
19
Decision No 1350/2007/EC of the European Parliament and of the Council of 23 October 2007
Establishing a Second Programme of Community Action in the Field of Health, 1350/2007/EC (2008), available at

4
health.
20
According to the Programme, the transnational nature of healthcare
prevents Member States from achieving suitable healthcare measures on their
own.
21
The EC has the authority to adopt additional healthcare measures, so long
as the additional measures abide by Article 5 of the TFEU, which protects the
health and safety of EU citizens.
22
The Programme focuses on three overarching
objectives. First, it seeks to improve citizens health security by strengthening the
capacity of the EU to respond to public health threats, such as communicable
diseases and bio-terrorism.
23
Second, it seeks to promote public health and reduce
healthcare inequalities between men and women.
24
Third, it seeks to develop and
disseminate information related to best practices on public health issues.
25

The ECs Communication on the Future of Health Care and Care for the
Elderly of 2001 identifies general accessibility, good quality, and financial
viability of healthcare services as major long-term policy objectives of the EU.
26

In light of these objectives, the Communication acknowledges Member States
diversity of healthcare laws and funding and calls attention to three EC policies
that must influence state-level healthcare adaptations and reforms: (1) the ECs
health strategy (COM(2000) 285 Final), which addresses the challenge of ageing
and the growth of new medical techniques, as well as the more international
dimension of health care;
27
(2) the improvement of the quality and viability of
public funds through implementation of the principles listed in the Broad
Economic Policy Guidelines for 2001, which include reform of pension and
healthcare systems, care for the elderly, promotion of the accumulation of
physical and human resources, and improvement of the effectiveness of

20
Second Programme of Community Action in the Field of Health, (200813), available at
http://ec.europa.eu/health/programme/policy/2008-2013/index_en.htm.
21
Second Programme of Community Action in the Field of Health, 37 (2008-2013), available at
22
Second Programme of Community Action in the Field of Health, 37 (2008-2013), available at
23
Second Programme of Community Action in the Field of Health, art. 2(2) (2008-2013), available at
24
25
26
Commission of the European Communities, Communication from the Commission to the Council, the European
Parliament, the Economic and Social Committee and the Committee of the Regions, 4 (2001), available at http://eur-
lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2001:0723:FIN:EN:PDF.
27
Parliament, the Economic and Social Committee and the Committee of the Regions, 8-9 (2001), available at
http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2001:0723:FIN:EN:PDF.

5
expenditure through institutional and structural reforms;
28
and (3) the growing
impact of internal markets, especially those involving social security.
29
Though
the EC may not instruct Member States on how to organize their social security
systems, Member States must give regard to Community law when implementing
this responsibility.
30

The EU has the necessary resources to support Member States and to
promote their cooperation in the field of healthcare, especially in upholding the
high quality of healthcare within each Member State. The core objectives in
healthcare systems universal access for all citizens, effective care for better
health outcomes, efficient use of resources, high-quality services, and
responsiveness to patient concern only become more important as the
interconnectedness of the EU increases.
31
Member State health systems often
involve interactions with people, goods, and services, all of which are granted
freedom of movement across borders under TFEU.
32
Member States face a
situation in which state healthcare systems officially fall outside EU law, even
though EU law directly governs elements relating to the systems financing,
delivery, and provision.

In accordance with the EUs health policy and the distribution of
competencies between the EU and the Member States, responsibility for the
management of health systems remains with the Member States. The EU only
intervenes in healthcare when health matters cannot be resolved at the state level
and where cooperative action at the EU level is most efficient. Such matters
include major health threats, issues with a cross-border or international impact
including pandemics and bioterrorism and matters relating to free movement of
goods, services and people.
33

28
Parliament, the Economic and Social Committee and the Committee of the Regions, 9 10 (2001), available at
29
Parliament, the Economic and Social Committee and the Committee of the Regions, 10 (2001), available at
30
Parliament, the Economic and Social Committee and the Committee of the Regions, 9 (2001), available at http://eur-
lex.europa.eu/LexUriServ/LexUriServ.do?uri=COM:2001:0723:FIN:EN:PDF.
31
32
Treaty on the Functioning of the Functioning of the European Union, Titles II, IV (2010), available at http://eur-
33
Commission of the European Communities, White Paper: Together for Health: A Strategic Approach for the EU,
3 (2007), available at ec.europa.eu/health/ph_overview/Documents/strategy_wp_en.pdf.

6
Healthcare Standards in Switzerland

The Swiss Constitution guarantees healthcare for its citizens by stating,
Every person has access to health care that they require.
34
It also provides that
the Confederation legislates on health insurances and that the Confederation may
deem health insurance compulsory for the population in general or for specific
portions of the population.
35
The Federal Council and Parliament are responsible
for the planning of Swiss health policy on the federal level by drafting and
adopting laws and regulations.
36
However, most of the extensive health expertise
and authority lies within the Cantonal divisions.
37

Each Canton is responsible for the health of its residents, and the Cantonal
health authorities are tasked with implementing the laws and ordinances issued by
the federal government.
38
Cantonal laws often supplement federal regulations in
four broad areas: regulation of health matters; provision of healthcare; disease
prevention and health education; and implementation of federal laws.
39
At times,
the federal government has expressly delegated implementation powers to the
Cantons, and federal oversight mechanisms are limited to those devices granted to
it by the Swiss Constitution.
40

Implementation of European Healthcare Standards

The EUs healthcare goals include guaranteeing minimum income and
medical care for the entire population.
41
Health systems in the EU can be
classified into three types of social systems: public tax financed system (the
Beveridge model); the compulsory social insurance system (the Bismarck model);

34
SWISS CONST. art. 117 (1999), available at http://www.admin.ch/ch/e/rs/1/101.en.pdf.
35
SWISS CONST. art. 41(1) (1999)
36
Swiss Federal Office of Public Health, The Swiss Health System: Structure Service Providers-The Health
Insurance Act, 7 (Dec. 1, 2005), available at
http://www.bag.admin.ch/org/index.html?lang=en&download=NHzLpZeg7t,lnp6I0NTU042l2Z6ln1ad1IZn4Z2qZp
nO2Yuq2Z6gpJCHeYN8f2ym162epYbg2c_JjKbNoKSn6A--.
37
European Observatory on Health Care Systems, Health Care Systems in Transition: Switzerland, 3-5 (2000),
available at http://www.euro.who.int/__data/assets/pdf_file/0003/96411/E68670.pdf.
38
Insurance Act, 10 (Dec. 1, 2005), available at http://www.bag.admin.ch/org/index.html?lang=en.
39
European Observatory on Health Care Systems, Health Care Systems in Transition: Switzerland, 14 (2000),
40
41
Inclusive Growth: A High-Employment Economy Delivering Economic, Social and Territorial Cohesion,
EUROPEAN COMMISSION (May 16, 2012), available at http://ec.europa.eu/europe2020/europe-2020-in-a-
nutshell/priorities/inclusive-growth/index_en.htm.

7
and voluntary privately financed insurance.
42
In the Beveridge model, taxes
finance the public health care system.
43
The government owns and runs many
hospitals and clinics, and service providers (e.g., doctors and pharmacists) are
employees of the state.
44
European states that utilize the Beveridge Model include:
the UK, Ireland, Denmark, Finland, Sweden, Italy, Portugal, and Spain.
45

In the Bismark model, both employers and employees fund health insurance
through payroll deductions.
46
Bismark model insurance covers everyone, and the
insurance industry does not make a profit, which leads doctors and hospitals to be
privately run.
47
European states following the Bismarck model include: France,
Germany, Belgium, Switzerland, and the Netherlands.
48

Like the Beveridge model, the Bismarck model is based on the principle that
a medically necessary level of care must be provided, regardless of the income or
the individual contribution of the insured. Unlike the Beveridge model, however,
coverage in the Bismarck model is usually based on an employment relationship.

Participating in health care systems in the EU is mandatory because it is
primarily financed through taxation and payroll contributions.
49
However, there
are sometimes exceptions where participants are allowed to substitute statutory
protection with voluntary privately financed health insurance.
50
Substitutive
voluntary privately financed health insurance is limited to those who are excluded
from participating in some or all aspects of the statutory health insurance scheme
and those who are exempt from contributing to the statutory health insurance

42
Elke Jakubowski, Healthcare Systems in the EU: A Comparative Study, EUROPEAN PARLIAMENT, 18 (Mon. day,
year), available at http://www.europarl.europa.eu/workingpapers/saco/pdf/101_en.pdf.
43
Physicians for a National Health Program, Health Care Systems: Four Basic Models Title (Jun. 29, 2013),
available at http://www.pnhp.org/single_payer_resources/health_care_systems_four_basic_models.php.
44
45
Physicians for a National Health Program California, Summary of International Health Systems, 1 (April 2004),
available at http://pnhpcalifornia.org/wp-content/uploads/2011/04/International-Comparison.pdf.
46
47
48
Physicians for a National Health Program California, Summary of International Health Systems, 1 (April 2004),
available at http://pnhpcalifornia.org/wp-content/uploads/2011/04/International-Comparison.pdf.
49
Elias Mossialos and Sara Thomson, Voluntary Health Insurance in the European Union, EUROPEAN
OBSERVATORY ON HEALTH SYSTEMS AND POLICIES, page 26 (2004), available at
http://www.euro.who.int/__data/assets/pdf_file/0006/98448/E84885.pdf.
50

8
scheme because they are allowed to opt out of it.
51
Participants can also purchase
supplementary voluntary privately financed health insurance, which allows for
more choices in the health care system and access to other types of health services
not covered in the statutory insurance.
52
Belgium, Germany,
53
the United
Kingdom,
54
and Switzerland all have some form of voluntary privately financed
health insurance available for participants.
55

The following sections will discuss the British, Belgian, German, and Swiss
healthcare systems, respectively. Examining each systems structure, financing,
services/benefits, and problem areas will allow for a thorough understanding of
various types of healthcare models that comply with the EUs standards.

Healthcare in the UK

The healthcare system in Britain is a tax-financed, state-run system that
guarantees all citizens basic medical care.
56
Since the implementation of major
healthcare reforms in 1997, responsibility for healthcare has shifted away from the
UKs Department of Health towards regional and local centers.
57
In addition to
implementing such reforms, the Department of Health has created a number of
semi-independent bodies to assist in setting priorities and monitoring standards
for different parts of the health care system.
58

51
52
53
54
U.S. Social Security Administration, Social Security Programs Throughout the World: Europe 2010 (Jul. 7,
2013), available at http://www.ssa.gov/policy/docs/progdesc/ssptw/2010-2011/europe/switzerland.html.
55
Thomas Foubister, et. al., Private Medical Insurance in the United Kingdom, EUROPEAN OBSERVATORY ON
HEALTH SYSTEMS AND POLICIES, 15 (2006), available at
http://www.euro.who.int/__data/assets/pdf_file/0007/98422/Private_Medical_Insurance_UK.pdf.
56
Sen Boyle, United Kingdom (England): Health System in Review, EUROPEAN OBSERVATORY ON HEALTH
SYSTEMS AND POLICIES, 288 (2011), available at
http://www.euro.who.int/__data/assets/pdf_file/0004/135148/e94836.pdf.
57
58

9
The Healthcare System: Centralized
The UK health system is centralized, with the Department of Health as its
highest authority.
59
The Department monitors the National Health Service (NHS)
and is responsible for defining healthcare guidelines as well as distributing funds to
regional authorities.
60
The Permanent Secretary heads the Department and often
deals with policies concerning public health, clinical quality, and health
improvement and protection.
61
Independent bodies that assist the Department of
Health in its regulation of the healthcare system include the Care Quality
Commission (CQC) and the National Institute for Health and Clinical Excellence
(NICE).
62
The CQC inspects health care services to ensure that patients are safe
and receive high-quality care.
63
NICE is a Non Departmental Public Body that
provides guidance to the Department of Health to improve the quality standards in
health and social care.
64

The legal basis for the NHS was established in 1948.
65
At its inception, the
service did not list any certain health rights granted to British beneficiaries.
66
Over
time, however, the NHS gained responsibility for inpatient and outpatient
treatment for sickness, accidents, and nursing care, and control over virtually all
health services, with a focus on preventative medicine, primary care, and hospital
services.
67
Eight regional offices (known as Strategic Health Authorities or SHAs)

59
60
SYSTEMS AND POLICIES, xxii-xxiii (2011), available at
61
62
63
Care Quality Commission, About Us (Jun. 29, 2013), available at http://www.cqc.org.uk/public/about-us.
64
National Institute for Health and Care Excellence, Who We Are (Jun. 13, 2013), available at
http://www.nice.org.uk/aboutnice/whoweare/who_we_are.jsp.
65
SYSTEMS AND POLICIES, 21, 26, 28 (2011), available at
66
SYSTEMS AND POLICIES, xxii, 21 (2011), available at
67
SYSTEMS AND POLICIES, xxii, 21 (2011), available at

10
provide the link between the regional levels and the NHS.
68
The SHAs are
responsible for developing plans for improving health services in their localities,
maintaining the performance and the quality of local health services, increasing the
capacity of health services, and incorporating state priorities into regional plans.
69

Local governments, elected every four years, deal extensively with local
services, and play an important role in the organization and provision of social
services and education.
70
Additionally, a small private healthcare sector
consisting of hospitals, clinics, and independent sector treatment centers
marginally influences the UKs healthcare system.
71
Finally, charities and
volunteer organizations traditionally major contributors to the healthcare system
continue to provide a small number of citizens with healthcare that is financed, in
large part, by charitable donations.
72

Financing
Tax revenues fund approximately 80 percent of the NHS, which allows NHS
patient services to be mostly free of charge.
73
Certain services and benefits,
including drug prescriptions, dental care, and eyeglasses, do require a co-
payment.
74
However, children, adolescents, and socially vulnerable persons are
exempt from the co-payment obligation.
75
The National Insurance Fund (NIF)
also funds approximately 13 percent of the NHS.
76
As part of the National
Insurance Scheme, money from the NIF is allocated towards healthcare at the will

68
SYSTEMS AND POLICIES, xix, xxii, 22, 32, 210 (2011), available at
69
70
71
72
73
European Observatory on Health Care Systems, Health Care Systems in Transition: United Kingdom, 33 (1999),
available at ://www.euro.who.int/__data/assets/pdf_file/0011/96419/E68283.pdf.
74
75
76

11
of the government. The UK typically spends about 8.4 percent of its GDP on
healthcare.
77

Services and Benefits
The NHS was established on the principle that all people, regardless of their
material situation or employment status, should have equal access to free
comprehensive medical service.
78
It also mandates that services should be made
available to the extent necessary to meet all reasonable requirements.
79

General practitioners (GPs) largely provide primary care in the UK.
80
In
England, there are approximately 36,000 general practitioners working at around
8,200 practices to provide primary medical services.
81
GPs are self-employed and
provide general medical services under NHS contracts.
82
GPs fees and contracts
are negotiated between the British Medical Association and the Department of
Health.
83
Patients can select their GP; however, they are restricted to certain
geographic boundaries.
84
GPs act as gatekeepers and refer patients to hospitals
and specialists (except in cases of emergencies). Patients have a little flexibility
when selecting which hospital to receive treatment.
85

Taxes partially finance home and residential care for the elderly, which is
planned by regional health authorities.
86
Residential care is the statutory
responsibility of 152 local councils, which have slowly shifted such care toward

77
Center for Strategic and International Studies, OECD Figures for Healthcare (Apr. 23, 2013),
http://csis.org/blog/oecd-figures-health-care-gdp.
78
79
80
81
United Kingdom Department of Health Primary Medical Care (Apr. 8, 2011), available at
http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Healthcare/Primarycare/DH_288.
82
83
84
85
86

12
community-based institutions.
87
Home care funding is based on public funds
taxes raised by local governments and councils and private funds mostly out of
pocket costs, with some aid from insurance companies.
88

The NHS is primarily funded through general taxation (with approximately a
13 percent contribution from the NIF) and provides a comprehensive range of
health services, the vast majority of which are free at the point of use to residents
of the UK. A majority of the tax revenue finances doctors, hospitals, and local
social support services, all of which report to the NHS in some capacity. Taxes
also partially finance in-home care for the elderly, though an intricate mixture of
private funds covers the remainder of those costs.

Challenges and Criticisms
Though the British healthcare system possesses certain admirable qualities,
it has experienced negative backlash from organizations such as the European
Observatory on Health Systems and Policies (which partners with the World
Health Organization, among other international organizations) for the quality of its
healthcare. In its 2008 report, the Observatory cited the main concerns of the
British Medical Association were poor implementation of new healthcare
strategies, oftentimes resulting in bullying in the workplace and low morale
amongst workers; confusion about clinical guidelines; insufficient resources;
workforce shortages; and shortages of beds, especially in community care
centers.
89
Though the UK places great emphasis on choice (i.e., the patients
choice of when, where, and from whom to receive healthcare), the structural
organization of bodies such as the Department of Health places less emphasis on
choice and more emphasis on central planning and regulation and uniform services
across the state.
90
Critics also argue that the UK does not effectively manage the
relationship between staff morale and clinical outcomes.
91

87
SYSTEMS AND POLICIES, xxv (2011), available at
88
SYSTEMS AND POLICIES, xxv (2011), available at
89
Helena Legido-Quigley, et. al., Assuring the Quality of Health Care in the European Union: A Case for Action,
EUROPEAN OBSERVATORY ON HEALTH SYSTEMS AND POLICIES, 189 (2008), available at
www.euro.who.int/document/e91397.pdf.
90
91

13

The UKs healthcare system operates as a centralized system, governed by
the Department of Health, the NHS, and various local and regional organizations
throughout the state, which strives to provide free healthcare to all of its citizens.
Tax revenues and insurance contributions finance most of the system, with the
remaining costs paid through out-of-pocket fees and NHS aid. The NHS also
governs most doctors, hospitals, and local social support services. Though
seemingly effective, the UK system has been criticized for its lack of uniformity
and its ineffectiveness in managing relationships between various levels of
healthcare providers.

Healthcare in Belgium

Belgian healthcare is considered to be one of the best healthcare systems in
Europe.
92
Belgium has a mixed publicprivate healthcare system, with state-
organized reimbursements and private providers, that allows patients to choose any
hospital, doctor, or dentist they desire based on their needs.
93
Nearly all Belgian
citizens are eligible for mandatory health insurance and as of January 1, 2008, that
health insurance covers both major and minor risks.
94
A state-established fee
schedule details available healthcare services and their reimbursement rates.
95
Any
service that falls outside of the fee schedule is the patients burden.
96
The Belgian
healthcare system is comprised of four tiers of operation that include the central
government, state associations, federations of local societies, and local mutual aid
societies.
97

The Healthcare System: Mixed
Belgium has a compulsory social insurance system through which nearly the
entire population is insured.
98
The system itself is characterized by its
heterogeneity and fragmentation . . . based on the patients freedom to choose

92
Expatica, Belgian Healthcare System (Apr. 2, 2009),
http://www.expatica.com/be/health_fitness/healthcare/belgian-healthcare-system-1493_8299.html.
93
Dirk Corens, Belgium: Health System Review, EUROPEAN OBSERVATORY ON HEALTH CARE SYSTEMS, xvi (2007),
94
Dirk Corens, Belgium: Health System Review, EUROPEAN OBSERVATORY ON HEALTH CARE SYSTEMS, 59 (2007),
95
96
97
98
Dirk Corens, Belgium: Health System Review, EUROPEAN OBSERVATORY ON HEALTH CARE SYSTEMS, xiv (2007),

14
between a wide range of independent providers.
99
Healthcare is, therefore,
privately managed, mainly delivered by a range of non-profit organizations, and
shared between numerous public authorities.
100
Since the early 1980s, most
responsibility for healthcare has passed to the Communities.
101
However, there are
many healthcare situations where the federal authorities are responsible for
healthcare.
102

Belgiums federal authorities determine the general legislative framework
for the health care system by issuing laws and fixing the annual budget.
103
Thus,
overarching regulation and supervision of health insurance also takes place at this
federal level. Among other responsibilities, the federal authorities primary
obligations include: enacting health and disability insurance law; enacting laws
regulating hospitals; enacting agreements addressing professional qualifications,
drug control, wage schedules, and labor conditions; allocating resources to the
different levels of healthcare governance; and controlling healthcare technology.
104

The Ministry of Public Health and Environment defines healthcare policy at the
state level.
105

The National Insurance Institute for Sickness and Invalidity (INAMI)
controls health insurance in Belgium.
106
INAMI is a nongovernmental, public
body that is accountable to the Minister of Social Affairs.
107
It is comprised of four
primary services: the Medical Care Service; the Sickness Benefits Service; the
Medical Control Service; and the Administrative Control Service.
108
INAMI
primarily administers, supervises, and financially manages sickness and invalidity

99
100
101
Dirk Corens, Belgium: Health System Review, EUROPEAN OBSERVATORY ON HEALTH CARE SYSTEMS, 1-2
102
103
European Observatory on Health Care, Health Care Systems in Transition: Belgium, 11 (2000) available at
104
105
106
Eurofund, National Institute of Sickness and Invalidity Insurance (Aug. 14, 2009), available at
http://www.eurofound.europa.eu/emire/BELGIUM/NATIONALINSTITUTEOFSICKNESSANDINVALIDITYINS
URANCE-BE.htm.
107
108

15
insurance.
109
Although IMANI oversees the general application of compulsory
health insurance, statutory sickness funds actually provide the insurance, which are
called mutualities.
110
Belgiums mutualities are organized into the following non-
profit organizations: the Christian Health Association; the Neutral Health
Association; the Socialist Health Association; the Liberal Health Association; and
the Occupational Health Association.
111

Belgian policyholders can supplement their mandatory insurance with an
additional plan and may freely choose between health insurance companies.
112

Competition between insurers is therefore limited to health benefits and the
complementary services each mutuality offers.
113
Regardless of which type of
insurance Belgians select, they may utilize any doctor, clinic, or hospital in any
location in Belgium.
114

Belgiums Flemish, French, and German-speaking Communities are
responsible for providing health education and most preventative medicines.
115

The Communities also implement hospital norms and standards, coordinate home
care, uphold environmental health standards, and maintain health professionals
licenses.
116
The Communities may require healthcare providers to go beyond
federal standards in the best interests of meeting Community objectives.
117

The EU requires states to uphold a certain quality of healthcare, and Belgium
upholds this quality through a 2003 government program that makes healthcare

109
Eurofund, National Institute of Sickness and Invalidity Insurance (Aug. 14, 2009), available at
http://www.eurofound.europa.eu/emire/BELGIUM/NATIONALINSTITUTEOFSICKNESSANDINVALIDITYINS
URANCE-BE.htm.
110
111
112
113
114
Healthcare, FLANDERS INVESTMENT & TRADE, GOVERNMENT OF FLANDERS (Apr. 23, 2013),
http://www.investinflanders.be/en/flavor/Working-and-living/page/Healthcare.
115
116
117
European Observatory on Health Systems and Policies, 86 (2008), available at

16
providers more accountable for their services.
118
Belgiums quality initiatives
include promoting good healthcare practices by providing feedback to healthcare
providers, and preventing subpar healthcare practices with the use of sanctions and
mandatory observance of existing stipulations.
119
The Federal Public Service for
Public Health, Food Chain Safety, and Environment, and the National Institute for
Sickness and Disability Insurance, in partnership with Belgiums three
Communities, enforce the systems compliance with the EUs quality standards.
120

Financing
Social security contributions and federal government subsidies comprise the
major funding sources for Belgiums mandatory health insurance.
121

Approximately 13.8 percent of healthcare financing is obtained through indirect
tax revenues.
122
Every year, approximately 10.2 percent of Belgiums GDP goes
towards healthcare.
123
The Belgian government subsidizes the difference between
social security contributions and the states predicted healthcare budget, often
relying on the indirect tax revenues to ease the financial burdens on Belgian
employers.
124
Each of the five mutualities is financed by the state based on its
membership numbers.
125
Belgiums payment system relies on a fee-for-service
method, which it implements in one of two ways: directly, where a patient pays
for the costs of treatment up front and is later reimbursed by the sickness fund; or
indirectly, through a third-party payment system, where the patient only pays for

118
119
120
121
122
123
124
125
Steve Gold, How European Nations Run National Health Services, GUARDIAN (May 11, 2011), available at
http://www.guardian.co.uk/healthcare-network/2011/may/11/european-healthcare-services-belgium-france-
germany-sweden.

17
certain co-payments or non-reimbursable fees, and the sickness fund pays the
healthcare provider immediately.
126

Patients co-payments for healthcare services vary, depending on the type of
service provided, and are equal for everyone who has health insurance.
127
Major
diseases do not require a co-payment, and in all other cases, co-payments vary
between 25 and 80 percent of the cost of treatment. The upper limits for co-
payments are staggered according to income and vary from 450 to 2,000 Euros
annually.
128
For socioeconomically vulnerable groups, there is a preferential
system that automatically limits co-payments to 450 Euros per year.
129

Additionally, the Belgian system has provisions for people in particular social
situations, such as the disabled and the poor, which provide a higher
reimbursement for health services and pharmaceuticals.
130

Patients are can select any doctor they choose in Belgium.
131
Patients do not
need a referral to be treated by a specialist.
132
GPs primarily work in private
practices because they are not allowed to work in hospitals except to provide
delivery care in maternity wards or emergency units.
133
Specialists can work in
hospitals or in private practices.
134
Doctors can register their fees in one of two
ways: they can set prices for treatment close to the insurance charge; or they can
set their own fees.
135
After treatment, the doctor will give the patient a green
certificate to submit to his/her insurance company for reimbursement.
136
The co-
payment for patients for GP care ranges from 20 to 30 percent, and the co-payment

126
Sophie Gerkens & Sherry Merkur, Belgium: Health System Review, EUROPEAN OBSERVATORY ON HEALTH
SYSTEMS AND POLICIES, 83 (2010), available at http://www.euro.who.int/en/who-we-
are/partners/observatory/health-systems-in-transition-hit-series/countries-and-subregions/belgium-hit-2010.
127
128
129
130
European Observatory on Health Care Systems, Health Care Systems in Transition: Belgium, 24 (2000) available
at http://www.euro.who.int/__data/assets/pdf_file/0003/75126/E71203.pdf.
131
Brussels-Europe Liaison Office, Choosing a Doctor (Jun. 30, 2013), http://www.blbe.be/en/choosing-doctor.
132
133
Dirk Corens, Belgium: Health System Review, EUROPEAN OBSERVATORY ON HEALTH CARE SYSTEMS, 106
134
135
136

18
for specialist care ranges between 25 to 40 percent.
137
Socially disadvantaged
patients may opt for direct payments by their health insurance to their doctors.
138

There is no referral system between doctors and hospitals, so patients are
free to select any hospital to get treatment.
139
Hospitals are either private or public
non-profit organizations,
140
and not many are for-profit hospitals.
141
Hospitals are
categorized as either psychiatric or general hospitals.
142
The general hospital
category is divided into different types of care: acute care hospitals; geriatric
hospitals; and specialist hospitals, which specialize in cardiopulmonary diseases,
locomotive diseases, neurological disorders, palliative care, chronic diseases, and
psycho-geriatric care.
143
The cost of a shared hospital room is mostly covered by
insurance.
144
However, if a patient opts for a single room, he/she must pay extra
for his/her privacy.
145
In the event of hospitalization, a patient must pay certain
costs up front and provide the hospital with the proof of his/her membership in a
Belgian mutuality.
146

Prescription drugs are placed onto a positive list if they are reimbursed
either fully or partially.
147
The percentage that the insurance reimburses is based
on the type of drug prescribed.
148
The amount the insurance company will
reimburse within the positive list varies from zero-percent to 75-percent
reimbursement.
149
Insurance companies will reimburse a patient 100-percent for

137
138
139
140
141
142
143
144
Brussels-Europe Liaison Office, Hospitals (Jun. 30, 2013), http://www.blbe.be/en/hospitals.
145
146
147
(2007), available at: http://www.euro.who.int/__data/assets/pdf_file/0007/96442/E90059.pdf.
148
149

19
drugs for series illnesses.
150
The reimbursement amount is based on the national
generic price, which is set at 30-percent below the name-brand prescription with
the same active ingredients.
151

Four categories of long-term care include: home care; centers for day care;
residential homes; and rest and nursing homes.
152
Home care is regulated and
implemented by the Communities.
153
For instance, in the Flemish Community, the
Cooperation Initiatives in Home Care (SITs) coordinates home care.
154
In the
French Community, Coordination Centres for Home Care and Services coordinates
home care to ensure cooperation between care workers, GPs, home nurses, aid for
the elderly, etc.
155
Day care centers assist the elderly during the day with care or
supervision.
156
Residential homes are for elderly who are still in good medical
condition and require very little treatment.
157
Those who depend on care or
permanent medical supervision are admitted to rest or nursing homes.
158
The Katz-
scale determines the amount of insurance reimbursement for day care, residential
homes, and rest/nursing homes depending on the level of a patients dependency.
159

Though Belgiums healthcare system is renowned across Europe, it also
faces some challenges in its implementation. One main concern is a lack of
direction for the systems new programs, the overuse of healthcare professionals,
and limited financial resources.
160
Future reforms will likely focus on increasing

150
151
152
153
154
155
156
157
158
159
160

20
efficiency within the system, strengthening primary care, and improving the
quality of healthcare providers.
161

Because patients are free to see either a general practitioner or a specialist at
their choosing, this can potentially lead to shopping around for care and over-
using the medical care system, which drives up health care expenditures.
162

The Belgian healthcare system allows its citizens to choose from a number
of independent healthcare providers. The federal government controls the
overarching reach of the healthcare system, fixing the annual budget and issuing
laws concerning healthcare topics. The Communities are responsible for localized
healthcare concerns, though they may require stricter standards than at the state
level. Social security contributions, federal subsidies, and indirect tax revenues
mostly fund the healthcare system.

Healthcare in Germany

Social insurance in Germany dates back to the 1880s and the days of Otto
von Bismarck, who introduced the idea of social healthcare.
163
Today, Germany
has a universal, multi-payer healthcare system comprised of statutory health
insurance and private insurance. Insurance compensation rates are negotiated on a
federal level through complex corporatist social bargaining among specified,
autonomously organized interest groups, such as physicians' associations.
164

The Healthcare System: Universal
Germanys healthcare system operates under the principle of universal
access to health care.
165
Health insurance is mandatory for all citizens and
permanent residents, and they may choose between public and private insurance
providers.
166
Statutory Health Insurance (SHI) consists of competing health
insurance funds (sickness funds) that are regulated by law and includes

161
Dirk Corens, Belgium: Health System Review, EUROPEAN OBSERVATORY ON HEALTH CARE SYSTEMS, xvii xviii
162
163
United States Social Security Administration, Social Security History: Otto von Bismarck (Jan. 3, 2013),
http://www.ssa.gov/history/ottob.html.
164
David Green & Benedict Irvine, Healthcare Systems: Germany, CIVITAS, 3 (Jan. 2013), available at
http://www.civitas.org.uk/nhs/download/Germany.pdf.
165
David Green & Benedict Irvine, Healthcare Systems: Germany, CIVITAS, 2 (Jan. 2013), available at
166
The Commonwealth Fund, International Profiles of Health Care, 2011, 57 (2011), available at
http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2011/Nov/1562_Squires_Intl_Profi
les_2011_11_10.pdf.

21
autonomous, non-profit, and non-governmental bodies and organizations.
167
SHI is
required for those who earn up to 49,500 Euros per year, and their non-income-
earning dependents are covered free of charge.
168
Persons with incomes above
49,500 Euros per year may opt to either stay on the public insurance plan or obtain
private healthcare.
169
The government regulates private health care insurance to
protect patients from large premium increases because of their age, and the
government also protects patients from being overburdened by their insurance
premiums if their income decreases.
170

About 85-percent of the population is insured under statutory health
insurance, around 10-percent of the population opts for private health insurance,
and the remaining 5-percent are covered by special regimes, such as those created
for the military.
171
Private insurance may cover certain co-payments under the
statutory health insurance scheme (i.e., dental care) and allot additional benefits to
statutory insurance holders, such as access to single hospital rooms.
172
Any citizen
who is not covered by statutory health insurance must purchase private
insurance.
173
Individuals who elect for private insurance will likely pay higher fees
while they are young and healthy in order to avoid high fees later in life as they age
and become sickly or in need of care.
174
Often, patients cancel their private
insurance as they age, and return to the sickness fund regulated by the
government.
175

167
The Commonwealth Fund, International Profiles of Health Care Systems 2011, 58 (Nov. 2011), available at
les_2011_11_10.pdf.
168
les_2011_11_10.pdf.
169
les_2011_11_10.pdf.
170
les_2011_11_10.pdf.
171
The Commonwealth Fund, International Profiles of Health Care Systems 2011, 57 (2011), available at
les_2011_11_10.pdf.
172
David Green & Benedict Irvine, Healthcare Systems: Germany, CIVITAS, 5 (2012), available at
173
174
175
David Green & Benedict Irvine, Healthcare Systems: Germany, CIVITAS, 3, 5 (2012), available at

22
The Federal Ministry of Health and Social Security oversees policies and the
administrative regulation of the healthcare system.
176
The Lnder, the federal
government, and civil society organizations share the responsibility for a
functioning healthcare system, combining vertical policy implementations with
strong horizontal decision-making.
177
The Federal Assembly, the Federal Council,
and the Federal Ministry of Health and Social Security are the main actors at the
federal level.
178
The Lnder are divided into separate ministries, responsible for
passing laws, supervising local authorities, and financing hospitals.
179
Each Lnd
is further subdivided into administrative districts and local authorities (i.e., towns,
cities, and municipalities), which control areas such as health promotion and
hospital planning.
180
However, the various levels of government have almost no
role in the direct delivery of healthcare to patients.
181
Instead, self-governing
corporatist bodies of both the sickness funds and the provider associations are
responsible for such healthcare delivery. Of these, the Federal Joint Committee is
most prominent.
182
This nongovernmental agency has the regulatory power to
determine the services that will be covered by all sickness funds and the quality
measures that care providers will be required to implement.
183

Germany seeks to uphold the EUs quality of care standard by making the
topic a priority in state healthcare discussions.
184
Quality requirements for both
inpatient and outpatient care have been codified in the fifth Social Code Book
(SGB-V) and various other German initiatives since the late 1980s.
185
Currently,

176
Federal Ministry of Health, The Federal Ministry of Health: Profile (May 23, 2013), available at
http://www.bmg.bund.de/ministerium/english-version/ministry/the-federal-ministry-of-health.html.
177
178
179
180
181
les_2011_11_10.pdf.
182
les_2011_11_10.pdf.
183
les_2011_11_10.pdf.
184
185

23
Germanys Federal Ministry of Health promotes the publication of hospital quality
reports, the legal obligation of hospitals and ambulatory services to provide quality
care, and the establishment of the Institute for Quality and Efficiency.
186
Various
federal and regional bodies continuously ensure quality healthcare throughout the
state. In 2002, for instance, Germany passed a law creating statewide Disease
Management Programs to increase the quality of care for persons suffering from
chronic diseases.
187
Additionally, the state requires continuous medical education
for physicians and frequent health technology assessment of all drugs and
medical procedures.
188

Financing
Approximately 10.4-percent of Germanys GDP is used for healthcare
purposes.
189
SHI is based on the principle of solidarity, which means that those
who are financially better off assist those with lower incomes.
190
The statutory
sickness fund is financed through uniform contribution payroll rates at 15.5 percent
of gross wages.
191
SHI is financed primarily from employees and the insured.
192

The healthcare premium is borne almost equally between employers (7.3-percent)
and employees (8.2-percent).
193
All premiums are paid into the sickness funds,
which are then combined with government revenue to form the Central Health
Fund.
194
Individual, private health insurers receive funding for each of their
members on a lump sum basis, modifying the amount according to the age, sex,
and health risks of each of their members.
195
Thus, individuals battling cancer,

186
187
The Commonwealth Fund, International Profiles of Health Care, 2011, 61 (Nov. 2011), available at
les_2011_11_10.pdf.
188
The Commonwealth Fund, International Profiles of Health Care, 2011: The German Health Care System, 30
(2010), available at
http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jun/1417_Squires_Intl_Profil
es_622.pdf.
189
190
Deutsche Sozialversicherung, Health Insurance: Financing (Jul. 1, 2013), available at http://www.deutsche-
sozialversicherung.de/en/health/financing.html.
191
192
Deutsche Sozialversicherung, Health Insurance: Financing (Jul. 1, 2013), available at http://www.deutsche-
sozialversicherung.de/en/health/financing.html.
193
194
195

24
AIDS, or any number of chronic diseases receive more funding than those
individuals not grappling with long-term illnesses.
196

Physicians are required by law to be members of regional associations.
197

Physicians associations negotiate contracts with sickness funds, are responsible
for organizing care, and act as financial intermediaries.
198
Physicians with their
own practices rely on the associations contract negotiations for their fees.
199

Physicians working in public or non-profit hospitals are paid a salary.
200

General practitioners do not have a gatekeeper function, which means that
patients do not need to see a general practitioner before visiting a hospital or a
specialist.
201
Health insurance companies offer members the option to enroll in a
family physician care model that enables the patients to participate in a bonus
program for complying with gatekeeping rules and receive better service.
202
Most
physicians work in private practices, though others work in polyclinic care
centers.
203

Most hospitals are either public or private non-profit institutions; however,
there is a shift towards for-profit privatization.
204
Private non-profit hospitals tend

196
197
198
les_2011_11_10.pdf.
199
les_2011_11_10.pdf.
200
The Commonwealth Fund, International Profiles of Health Care Systems, 30 (Jun. 2010), available at
es_622.pdf.
201
es_622.pdf.
202
es_622.pdf.
203
es_622.pdf.
204

25
to be affiliated with a religious order and are partially funded by church taxes.
205

Hospitals primarily provide inpatient care; however, hospitals may be able to
provide highly specialized outpatient care.
206

The Ministry of Health is responsible for drafting the legislation for long-
term care (LTC).
207
It also is responsible for the implementation of the Long-
Term Care Act and monitors financing of the LTC Fund.
208
The Lnder are
responsible for financial investments in LTC facilities.
209
LTC is financed
similar to SHI; it is financed through payroll rates from employers and
employees in a pay-as-you-go system.
210
To claim benefits of LTC
insurance, the claimant must be frail, which the SGB-XI defines as a person
who requires for a minimum period of apparently six months, permanent,
frequent or extensive help in performing a special number of Activities of
Daily Life (ADL) and Instrumental Activities of Daily Life (IADL) due to
physical, mental or psychological illness or disability.
211
In addition, the
claimant must require help with personal care, nutrition, mobility, and
housekeeping.
212
The Medical Review Board of Statutory Health consists of
doctors and nurses who approve LTC insurance funds based on the severity of
care needs.
213

The healthcare system in Germany has faced challenges, leading the federal
government to implement a number of reforms in recent years. In an effort to
promote transparency within long-term care, Germany has implemented a system

205
206
les_2011_11_10.pdf.
207
Federal Ministry of Health, The Structure of Long-Term Care Insurance in Germany (Nov. 16, 2012), available
at http://www.bmg.bund.de/ministerium/english-version/long-term-care/article-long-term-care.html.
208
209
210
Melanie Arntz, et. al., The German Social Long-Term Care Insurance: Structure and Reform Options,
INSTITUTE FOR THE SOCIETY OF LABOR, 3-4 (Feb. 2007), available at http://ftp.iza.org/dp2625.pdf.
211
INSTITUTE FOR THE SOCIETY OF LABOR, 5 (Feb. 2007), available at http://ftp.iza.org/dp2625.pdf.
212
213

26
of evaluating LTC facilities and making their grades known to the public.
214

Germany has also worked to increase the competition amongst its healthcare
services after receiving criticism for a lack of available choices.
215
Finally,
Germany has worked to decrease the amount of money each citizen spends on
healthcare through reforms targeted at areas such as co-payments and charges for
non-prescription drugs.
216

The German healthcare system stands as a model for universality: every
citizen pays into the system and every citizen utilizes the system, which is
governed by the Federal Ministry of Health and Social Security. Since 2009, all
German citizens must purchase healthcare, though many still have the choice
between public and private healthcare providers. Germanys statutory health
insurance is governed by the principle of mutual solidarity and financed on a
pay-as-you-go basis, making it one of the more successful systems in the EU.
217

Healthcare in Switzerland

Although not formally a member of the EU, Switzerland is known for its
high-functioning, decentralized health system. The Health Insurance Law of 1994
(which came into effect in 1996) regulates healthcare in Switzerland.
218
It requires
all persons residing in the state (nearly 7.5 million) to purchase health insurance
from one of the competing private insurers operating under the market rules
determined by the social insurance law.
219

The Healthcare System: Decentralized
The Swiss insurance system is highly decentralized, with insurance plans
operating and premiums set at the Cantonal level, which has 26 divisions.
220
The
Swiss government rarely intervenes in healthcare (leaving it to major actors in the

214
es_622.pdf.
215
The Commonwealth Fund International Profiles of Health Care Systems 2010, 31 (2010), available at
es_622.pdf.
216
217
World Health Organization, The World Health Report 2000: Health Systems: Improving Performance (2000),
available at http://www.who.int/whr/2000/en/whr00_en.pdf.
218
Claire Daley & James Gubb, Healthcare Systems: Switzerland, CIVITAS, 2 (2011), available at
http://www.civitas.org.uk/nhs/download/switzerland.pdf.
219

27
private sphere) because the Swiss Constitution only grants the government limited
power over the healthcare system.
221

The federal government primarily addresses wider-scale issues of healthcare,
including: the eradication of communicable or very widespread or virulent
diseases of humans and animals; the promotion of exercise and sport; social
insurance provision; medical examinations and qualifications; promotion of
science and tertiary education; genetic engineering and other types of medical
research; statistics; labor law; environmental protection; and international
relations.
222

The Federal Office of Public Health (FOPH), for instance, works towards
preserving and promoting the health of all people living in Switzerland to enable
them to live productive and self-determined lives.
223
The FOPHs concentrations
include: epidemiology and infectious diseases; substance abuse and drug
prevention; food safety; noise and radiation protection; assessment and checks on
chemicals and toxic products; stem cell research and bioterrorism; and health and
accident insurance.
224

Cantons are responsible for the health of their residents, and the Cantonal
health authorities implement federal laws and regulations.
225
Important areas under
Cantonal control include: in-patient care and hospital planning; construction and
operation of Cantonal hospitals and nursing homes; nursing care, social psychiatric
services, school health services, and emergency and rescue services; disease
prevention and health education; oversight of hospitals, homes, and clinics;
regulations on entry into medical and paramedical professions (the training of
which follows the federal regulations on medical examinations and qualifications);
emergency, rescue, and disaster-aid services; food safety, poison control, and

220
221
222
223
Swiss Federal Office of Public Health, Health in Switzerland (Jul. 1, 2013),
http://www.bag.admin.ch/index.html?lang=en.
224
Swiss Federal Office of Public Health, Health in Switzerland (Jul. 1, 2013),
http://www.bag.admin.ch/index.html?lang=en.
225
Insurance Act, 10 (Dec. 1, 2005), available at http://www.bag.admin.ch/org/index.html?lang=en.

28
environmental protection; and the financing and subsidization of premiums.
226

Under the basic healthcare package, individuals may only obtain care
within their Canton of residence.
227
If an individual receives treatment outside of
his/her Canton of residence, the amount of reimbursement from the individuals
insurer and/or Canton of residence will depend on whether the individual had a
valid medical reason for seeking treatment outside of his/her Canton of residence,
such as in cases of emergency or when a service is unavailable in the insureds
Canton of residence.
228
Individuals may purchase supplementary insurance to fund
additional health care.
229

Insurance companies are non-profit organizations that must accept all
applicants during specified open-enrollment periods.
230
Healthcare providers
must also accept all applicants and cannot vary premiums based on the health of
individual consumers.
231
Insurers must register with the Federal Office of Social
Insurance (FOSI).
232
The number of registered insurance companies fluctuates
between 80-90 and they offer a range of different premiums and types of health
plans from which individuals are free to choose.
233
The 10 largest of these
companies insure nearly 80 percent of the population.
234
This leaves a large cost
variation for health insurance both within and between Cantons.
235

226
227
Claire Daley & James Gubb, Healthcare Systems: Switzerland, CIVITAS, 1-2 (2011), available at
228
OECD and World Health Organization, OECD REVIEWS OF HEALTH SYSTEMS SWITZERLAND 59 (2006).
229
230
Robert E. Leu, et. al., The Swiss and Dutch Health Insurance Systems: Universal Coverage and Regulated
Competitive Insurance Markets, THE COMMONWEALTH FUND, 2 (2009), available at
http://www.commonwealthfund.org/usr_doc/Leu_swissdutchhltinssystems_1220.pdf?section=4039.
231
Competitive Insurance Markets, THE COMMONWEALTH FUND, viii (2009), available at
232
233
234
235

29
Financing
The healthcare system is largely financed through compulsory health
insurance premiums,
236
though Switzerland spends 10.8 percent of its GDP on
healthcare each year.
237
As of January 1, 2004, the individualized fee schedules
were replaced by a nationalized fee schedule for all of the Cantons.
238
However,
the Cantons have the authority to bargain over monetary point values for the
schedule.
239
Cantonal governments can approve the fee schedules that the service
providers and health insurance associations in their respective Canton negotiated
and agreed.
240
If these groups cannot agree on a fee schedule, the Cantonal
government where the provider is located will use its authority to determine the
level of fees.
241
The Cantonal governments fee determination can be appealed to
the Federal Council.
242

All individuals must purchase a basic package insurance plan.
243
Within the
plans, there can be no differentiation between individual members, regardless of
socioeconomic status or preexisting conditions.
244
Under the plan, premium
charges cannot be based on the health status of patients; any services not covered
by the compulsory health insurance are covered by supplemental insurance.
245

To ensure that insurers abide by basic healthcare rules, a risk equalization
solidarity body called Foundation 18 redistributes funds from those people with
low health risks to those people with high health risks, based on their age and
sex.
246
Individual Cantons provide tax-financed, means-tested subsidies directly
to the people who are unable to afford basic package premiums.
247

236
237
238
Uwe E. Reinhardt, The Swiss Health System: Regulated Competition Without Managed Care, JAMA, 1229 (Mar.
17, 2008), available at http://www.allhealth.org/briefingmaterials/JAMA-Uwe-1183.pdf.
239
Uwe E. Reinhardt, The Swiss Health System: Regulated Competition Without Managed Care, JAMA, 1229 (Mar.
17, 2008), available at http://www.allhealth.org/briefingmaterials/JAMA-Uwe-1183.pdf.
240
241
242
243
244
245
246

30
The basic healthcare package covers appropriate, medically-effective, and
cost-effective treatments.
248
Individuals may only receive treatment in their
Canton of residency.
249
Hospitals that are unauthorized to receive insurance
reimbursement may not treat individuals with the basic healthcare package.
250
The
basic package itself contains three categories of protection: sickness insurance,
accident insurance, and maternity insurance.
251
Examples of the services covered
by such insurance include hospital stays, outpatient care, physiotherapy,
emergency treatment abroad, routine maternity exams, and serious and inevitable
dental treatments.
252

Compulsory sickness insurance covers medical services related to sickness,
accidents not covered by accident insurance, and maternity.
253
Employers are
required to insure their employees for compulsory accidence insurance.
254
Persons
not employed can purchase supplementary non-employment accident insurance.
255

Supplementary insurance is voluntary and includes healthcare beyond the scope
of the basic package. Swiss citizens may opt to purchase or decline it.
256

Supplementary insurance packages often include dental care, free choice of
hospitals, more comfort/privacy during treatments, and guarantees of being treated
by senior physicians.
257

247
248
249
250
251
252
253
JustLanded, Health Insurance: Public and Private Health Insurance in Switzerland (Jul. 1, 2013), available at
http://www.justlanded.com/english/Switzerland/Switzerland-Guide/Health/Health-insurance.
254
European Observatory on Health Care Systems, Health Care Systems in Transition: Switzerland, 31 fn.10
255
European Observatory on Health Care Systems, Health Care Systems in Transition: Switzerland, 31 fn.10
256
257

31
Most Cantons operate their own hospitals.
258
Some Cantons help subsidize
private hospitals, which are also subsidized by municipalities and independent
foundations.
259
Only certain hospitals are eligible for reimbursement under the
compulsory health insurance. While this list includes public and publicly
subsidized hospitals, it may also include private providers.
260
The Cantons are
responsible for providing reliable after-hours care, which they delegate to the
Cantonal doctors association.
261

Basic care covers a range of other services, including: mental illness (only
when certified physicians provide treatment); the costs of select vaccinations;
certain general health exams; and nursing home care (this responsibility is often
delegated to the municipalities).
262
Dental care is largely excluded from the basic
package.
263
More than 90-percent of all expenditures on dental treatments are paid
by patients themselves or by supplemental insurance.
264
The Federal Department
of Home Affairs determines the medicines covered under health insurance and
their prices; insurance companies cover any drug mentioned on this positive
list.
265
Even though generic drugs cost 50 percent less than brand-name drugs,
their sales comprised a mere 9.7 percent of all drugs sold in Switzerland in 2010.
266

258
259
260
261
Paul Camenzind & David Squires, The Swiss Health Care System, 2011, THE COMMONWEALTH FUND, 3 (2011),
available at
http://www.commonwealthfund.org/Topics/International-Health-
Policy/Countries/~/media/Files/Topics/Country%20Profiles/1562_Squires_Intl_Profiles_2011_Swiss.pdf.
262
available at
263
264
Paul Camenzind & David Squires, The Swiss Health Care System, 2011, THE COMMONWEALTH FUND (2011),
available at
265
266
available at

32
Cantons also provide nursing and home care, and they can also delegate these
duties to the municipalities.
267

Although Switzerland boasts a model healthcare system, the state has
worked to revamp a number of its programs and services. Perhaps the area most in
need of reorganization is Switzerlands health care expenditure growth, a topic
that the Swiss government has addressed recently in two bills before parliament.
268

The first bill addresses healthcare costs, especially as those costs relate to
insurance companies; the second bill deals with hospital funding and managed
care.
269
The Department of Home Affairs has also worked diligently to improve
regulations of drugs and decrease the costs of prescription pharmaceuticals.
270

The Swiss healthcare system is known for its decentralization, with most of
its management at the Cantonal level. The federal government maintains
responsibility for public health concerns, such as communicable diseases, exercise
and sport promotion, and medical research; the Cantons, conversely, take charge of
everything from inpatient care to hospital management to health education. Under
the Health Insurance Law of 1994, every Swiss citizen must purchase health
insurance from any number of competing private insurers, who may not distinguish
the costs of the package according to an individuals health conditions. The
healthcare system itself is largely financed through mandatory health insurance
premiums. Though not a part of the EU, Switzerland has a healthcare system
comparable or superior in quality to most EU states; many external assessments
applaud the states accomplishments in providing equitable access to all of its
citizens.
271

267
268
available at
269
available at
270
available at
271
Claire Daily & James Gubb, Healthcare Systems: Switzerland, CIVITAS, 9 (2013), available at

33
Conclusion

The EU maintains no major administrative responsibility in the field of
healthcare. Each Member State may create its own unique system of healthcare
while abiding by the overarching public health agenda of the EU. In turn, the EU
promotes cooperation between Member States and works to prevent human illness
throughout Europe, eliminate sources of danger to physical and mental health, and
improve public health. Through laws such as the ECs Communication on the
Future of Health Care and Care for the Elderly of 2001, the Second Programme of
Community Action in the Field of Health 2008-2013 of the EC, and Article 168 of
the TFEU, the EU guarantees certain healthcare standards for its citizens.

Most of the state-run healthcare systems in the EU can be classified in three
basic types. Beveridge model provides health care funding through the tax system,
and it includes the UK, which is centralized and looks to the federal government
for leadership. In the Bismark model, both employers and employees fund health
insurance through payroll deductions. The Bismark model includes: Belgium,
which has devolved most of its healthcare responsibilities to the Communities;
Germany, which mandates universal health insurance for all of its citizens through
vertical policymaking and horizontal implementation and decision-making; and
Switzerland, which allocates most healthcare responsibilities to the Cantons.

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