The relationships and configuration of universal and optional healthcare financing schemes in Czechia

Mertl, Jan Article The relationships and configuration of universal and optional healthcare financing schemes in Czechia DANUBE: Law, Economics and Social Issues Review Provided in Cooperation with: European Association Comenius (EACO), Brno Suggested Citation: Mertl, Jan (2018) : The relationships and configuration of universal and optional healthcare financing schemes in Czechia, DANUBE: Law, Economics and Social Issues Review, ISSN 1804-8285, De Gruyter, Warsaw, Vol. 9, Iss. 3, pp. 177-192, https://doi.org/10.2478/danb-2018-0011 This Version is available at: https://hdl.handle.net/10419/242131 Standard-Nutzungsbedingungen: Die Dokumente auf EconStor dürfen zu eigenen wissenschaftlichen Zwecken und zum Privatgebrauch gespeichert und kopiert werden. Sie dürfen die Dokumente nicht für öffentliche oder kommerzielle Zwecke vervielfältigen, öffentlich ausstellen, öffentlich zugänglich machen, vertreiben oder anderweitig nutzen. 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If the documents have been made available under an Open Content Licence (especially Creative Commons Licences), you may exercise further usage rights as specified in the indicated licence. https://creativecommons.org/licenses/by-nc-nd/4.0 DANUBE: Law, Economics and Social Issues Review, 9 (3), 177–192 DOI: 10.2478/danb-2018-0011 177 THE RELATIONSHIPS AND CONFIGURATION OF UNIVERSAL AND OPTIONAL HEALTHCARE FINANCING SCHEMES IN CZECHIA Jan Mertl1 Abstract In developed countries, both universal and optional parts of healthcare exist. This article shows the importance and fiscal position of universally available care and suggests where it can be extended by optional financing schemes such as prepaid health programmes. We use a comparative approach, SWOT analysis and synthesis of individual mechanisms of health financing into a single health system. A simple scheme of possible health system financing configuration is created, and we classify the financial resources and schemes used accordingly. Overall this article introduces a theoretically substantiated overview of health policy options for Czechia based on principles of universally available care, solidarity, fiscal neutrality, adequate fiscal space for health and voluntary private health expenditure. Keywords Health System, Health Insurance, Earmarked Taxation, Prepaid Health Programmes, Solidarity I. Introduction Healthcare has long been the second most important fiscal subsystem and its role in the national economy is indisputable. Its analysis cannot be reduced to economic efficiency in the narrow sense of the word, as the results at best comprise the positive economic balance of its individual parts. This is certainly useful, but it is not enough for an accessible and well-functioning healthcare; such healthcare also has not only its ethical, civic, and solidarity dimension, but also an individual utility dimension. Similarly, healthcare is a factor of competitiveness for both the whole economy and every citizen and thus a major determinant of economic development (Mertl & Vychová, 2009). We can theoretically classify health systems’ configurations according to social models, which illustrate also their fiscal position and approach to their financing (Vostatek, 2013). 1The University of Finance and Administration, Estonská500, 101 00 Prague 10, Czech Republic. E-mail: jan.mer[email protected] 178 Jan Mertl: The Relationships and Configuration of Universal and Optional Healthcare Financing Schemes in Czechia Of great importance is the availability and quality of healthcare in both the universal and optional part (Krebs, 2015). Although the optional part was considered problematic for ethical and ideological reasons in the past, the development of both economics and medicine shows that the availability of different treatment methods, the needs of social groups and the differentiation of patients’ claims lead to accepting the possibility of offering health services that are not directly required to maintain and improve health, and can therefore be provided on an optional basis. At the same time, the need for general availability of health care in the population, both for medical (effective prevention and treatment of illness) and for social reasons, continues to be urgent and indispensable. At a time of increasing income and wealth differentiation (IMF, 2015), it is impossible at the current stage of development of civilization to expect that every citizen can obtain the needed health care individually or accept the reduction of universal health care to cover basic or only catastrophic care for the poor in the sense of the liberal social model (Titmuss, 1974). Such trends would mean a systemic creation of a socalled two-tiered healthcare system with a weak, unclear and charity-based universal part, resulting in negative impact on the health status of the population, availability of care, but also on the nature of medical practices themselves. Certain signals in this direction can be seen, for example, in Czech stomatology, where even the dentists themselves see problems, as there are considerable differences in the standards of care between dentists, depending on the location, the individual approach of the doctor and the clientele’s creditworthiness (Šmucler, 2016). It is hard to imagine the acceleration of these trends in other fields of medicine. Although some variations will always exist, a good universal system depends on the degree, character, and existence and cultivation of standards available to every patient. A tough issue for health care financing can be population ageing, which puts pressure on universal health care financing and complicates the affordability of an optional one. There are projections made under various scenarios that suggest that the impact could be significant, especially when improperly or inadequately managed (European Union, 2018). Given the length and scope of this article, we cannot cover this aspect in detail, but we recognize its importance. The aim of this article is to define the elementary attributes of universal and optional health care financing and show their possible application in the Czech health care system. The methods used include a comparison of health expenditures at the macroeconomic level, SWOT analysis of prepaidhealthfinancing schemes,comparative approach tothe universal and voluntary part of healthcare and synthesis on the application of those two parts in a single functional health care system. We have studied how particular schemes of health care financing (including health savings accounts) are defined in theory and researched their practical implementation in developed countries. When designing prepaid health programmes and their position in the system, we have tried to avoid common points of failure that have been observed internationally. Since their construction is intentionally simplein financialterms,we evaluated theirposition withinthehealthsystemand classified their attributes into a SWOT matrix so that the reader can see what they can offer and where are their limitations. We use positive economics to describe how health financing schemes work and what their characteristics are, but part of the statements concerning DANUBE: Law, Economics and Social Issues Review, 9 (3), 177–192 DOI: 10.2478/danb-2018-0011 179 the health system’s configuration is normative, suggesting how the Czech health system should be configured to maintain and expand its performance for the future. II. Macroeconomic Dimension of Health Expenditure In this chapter we utilize graphs that serve as a starting point for our analysis and as an overview of the macroeconomic situation in health financing in OECD countries. The following Figure 1 shows the level of public (compulsory) and inversely (100-public) the level of private (voluntary) expenditures in selected OECD countries. Figure 1 shows that over 15 years, except for the Netherlands, Latvia, Slovakia, Switzerland and Turkey, this share remained relatively stable and the fluctuations were within 10 percentage points, e.g. one tenth of the health budget. In addition, it shows that Czechia is within a group of countries that have a high share of public expenditure on health – above 80 percent. But we can also note that over the last 15 years this share has decreased slightly, having been nearly 90 percent in 2000, so the trend can be characterized as slightly decreasing the role of public (compulsory and solidarity-based) financing. Figure 1: Share of public exp. on total health exp., selected OECD countries, 2000–2015 Source: (OECD, 2017). 2015 OECD Estimation If we compare the overall expenditure for health care relative to GDP (Figure 2), Czechia ranks among those countries with a low share of total health expenditure to GDP – 7.3% GDP in 2015 (OECD, 2017). 180 Jan Mertl: The Relationships and Configuration of Universal and Optional Healthcare Financing Schemes in Czechia Figure 2: Share of total health exp. on GDP, selected OECD countries, 2000–2015 Source: (OECD, 2017). 2015 OECD Estimation We can see that the significant differences between countries (e.g. Czechia – 7.3% vs the Netherlands – 10.7% vs the USA – 16.9% in 2015) support the statement about multifactorial causes of the health expenditure level and overall system effectiveness. Health spending growth has been moderate since 2000 but has been markedly slower since the global financial crisis in 2008–2010. Despite the recent slowdown in health spending, concerns about the fiscal sustainability of the health system remain large (OECD, 2015). We can still say that countries with a more centralized or government-budget based system tend to have a lower share of health expenditure on GDP (which was a general rule of health economics, e.g. 20 years ago), but the case of the United Kingdom or Denmark shows that even their shares increased and can now be compared to systems with a more decentralized institutional structure with autonomous health insurance budgeting like Germany, France or Switzerland (OECD, 2015). In this sense, we can imply that, even if the Czech system might be perceived as having problems with internal effectiveness (Hrstková, 2015), which is often cited as a reason to limit public expenditure, statistical data (OECD, 2017) support (at least) keeping Czech public health expenditure at current levels, and possibly increasing private health expenditure if it is desired by public policy in order to decrease total solidarity and increase total equivalency. DANUBE: Law, Economics and Social Issues Review, 9 (3), 177–192 DOI: 10.2478/danb-2018-0011 181 III. The Significance and Financing of the Health System’s Universal Part A universally accessible health care system must provide every citizen with the care he/she objectively needs to maintain and improve his/her health. Such care must therefore be medically complete and based on best practice methods. Its content changes over time based on advances in medicine, the situation of patients and the incidence of diseases in the population. At the same time, it is expedient to support positive externalities – prevention, healthy lifestyle, dispensing of chronic diseases, complex multidisciplinary treatment of diseases. This is by no means merely a solidarity reimbursement to those in need or the remediation of an acute worsening of the health conditions – such care is usually the least effective (e.g. increased use of emergency services). On the theoretical level, there are several ways to fund universally available health care. •General taxation – healthcare is financed from the government budget as a mixed public good, similarly to primary and secondary education, the army, the police or the judiciary (Peková, 2011). •Social health insurance – healthcare is funded through individual social insurance schemes for selected population groups, it is mandatory for these groups, premiums are set as a percentage of working income up to the ceiling and the range of covered health care is limited by the level of those groups (Vostatek, 2000), (Vostatek, 2010). •Earmarked health tax (Bloom, Cashin, & Sparkes, 2017) – healthcare is funded by earmarked (hypothecated) proportional payroll or personal income tax, or part of excise taxes, in the form of automatic direct fiscal allocation of these resources for health care. •Regulated competition for multiple health insurance plans – the so-called basic healthcare package offered by health insurers is sold at a market price, strong regulation and government support for the sale of these products is required. If a model is to be used in a given country and there is a motivation to implement it within a public choice that subsequently occurs, a country typically sticks with the chosen model in the long term despite consciousness or manifestations of its disadvantages. At the same time, in practice the chosen model typically becomes dominant and is supplemented by a smaller system for situations or citizens that are not satisfactorily served by the dominant model (Donabedian, 1971), (Williams, 1997). In Great Britain, this dominantly concerns the National Health Service (NHS) funded by the government and regional health authorities (Cylus & Richardson, 2015); in Germany, a significantly modified social health insurance funded through the central health insurance fund and the pluralist insurance companies structure (Busse & Blumel, 2014); in the Netherlands, the compulsory two-component nominal premium funding basic packagehealthcare (Boerma, Kroneman, Berg, & Groenewegen, 2016), in the US the Obamacare system organizing a regulated market for exchange plans (Gineken & Saltman, 2013). The last option, i.e., the regulated competition of insurance plans with pressure to provide a universally offered range of care, is the most complicated and costly, forming the basis for countries where 182 Jan Mertl: The Relationships and Configuration of Universal and Optional Healthcare Financing Schemes in Czechia there is no or weak consensus on universally accessible and financed health care for every citizen. In European countries, there is no need to deal with it because there is a long-term consensus on universality and there is no need to complicate this with the detailed and demanding regulation of commercial providers, who cannot, in principle, guarantee it in the long term by means of market-based methods (Němec, 2008). From the fiscal point of view, it is possible to directly allocate funds for healthcare and make up the fiscal space for health (Barroy, Dale, & Sparkes, 2016) based on the following techniques, mechanisms and principles: •Proportional tax (% of income) – “earmarked” health tax (Mertl, 2017b). It is possible to collect it either from labour income/wages (§ 6, 7 of the Act No. 586/1992 Coll.), then it is a payroll health tax. Or also from all other categories of income (§ 8, 9, 10 No. 586/1992 Coll.), then it is a classic proportional income health tax. •Insurance premium ceilings, the possibility of differentiating the premium rate at the level of individual insurance companies and social groups, defined benefits linked to the premiums paid and social groups – if they are introduced, these are typical elements of social insurance (Vostatek, 2000). At present, however, given the universality of the care and sharing of health risk at national level, social health insurance in its original pure form is virtually absent in health financing. •Solidarity in health – the premium (health tax) depends only on income rather than on health status =the prohibition of cream-skimming among insured. If this is desired, participation in the system must be mandatory at least for selected social groups (ideally for all citizens). •Solidarity in income – given (as stated above) by a relative share (percentage rate) of income allocated for healthcare financing. That is important, since in the case of a single absolute amount (as it is in private healthcare financing), there would be the destruction of income solidarity, and it would be a form of “earmarked poll tax on health”, which would result in a significant burden on citizens with medium and lower incomes. •Shareofrevenue (subsidy)fromexciseorgeneraltaxes– theresultis,amongothers, a reduction in the direct burden of the labour factor (in the wake of wider aspects of the efficiency of the tax mix). This role is currently fulfilled in Czechia with the amount paid for state-insured persons (who generally are not expected to have working income), that health insurance companies receive from the government budget (969 CZK per person since 1. 1. 2018). Ceteris paribus, the reduction or cancellation of this amount would put pressure on an increase in the existing health insurance rate (13.5%). For Czech conditions, our previous analysis recommended maintaining the “earmarked” proportional tax on wages or whole personal income and their guaranteed allocation to the health services (Mertl, 2017b). Maintaining a subsidy from general or excise taxes to reduce the burden of the labour factor and partially offset when using the excise tax ratio, the negative externalities of tobacco, alcohol and transport is also possible (Bloom, DANUBE: Law, Economics and Social Issues Review, 9 (3), 177–192 DOI: 10.2478/danb-2018-0011 183 Cashin, & Sparkes, 2017). Simultaneously, the degree of simplicity and transparency of the relevant tax mechanisms must also be considered, as they are a significant efficiency factor of public financing (Mertl, 2017b). In case there exists a multi-payer system, central redistribution of collected health contributions is required based on the cost indices of the individual insurance groups or clients. This means that a particular health insurance company receives a different amount of money than an individual client’s compulsory payment. Therefore, it does not make sense to continue to pay the contributions directly to individual health insurance companies (as is done now in Czechia), but to the central fund organized by the Financial Administration or Ministry of Health, from which redistributed premiums will be paid to health insurance companies. As far as direct payments are concerned in the universal part of the system, it is obvious that they haveanalmost exclusively regulatorysensehere,asthepatientdoes notgain additional benefit for them, but instead directs his behaviour in a system with possible problematic consequences.TheexperiencefromGermany(Busse&Blumel,2014)showsthattheyhave been criticized for not having big impact for high income people because of their relative level, while they can limit access to care to poor people with budget limitations. It seems possible to leave them where they are clearly penalizing (overuse of emergency services) or the patient pays for non-medical activities (hospital stay, administrative confirmation). We ought to note that theoretically, the financing of healthcare purely from the government budget, directly from a share of general taxes and without insurance companies, or more precisely “one insurer” as a regional structure of public administration in the style of the British NHS (single-payer), is technically feasible and, from the point of view of classical public finance theory, easier to manage and potentially cheaper. However, it depends significantly on the quality of governance, the consistent application of public governance practices, the willingness to introduce/increase the tax progression from personal income and the acceptance of a monopoly in health care payments in the existing pluralist structure of health care facilities, including outpatient care. These conditions are not fulfilled in Czechia, and a multi-payer system has already been put in place, the cancellation of which does not have significant political support. The choice between a single-payer and multi-payer model is regularly the subject of expert analysis and public discourse. Comparative analyses show (OECD, 2015) that neither model is better or more effective in itself; what matters much more is the implementation andcompatibilitywiththecountry’senvironment andpriorities. Atthesametime,however, we have observed the surprising stability of model selection within one country. Therefore, this choice is typically a decision for decades, which must have political support for a long time ahead and therefore possible more radical reform in this direction should be approved, for example by a three-fifth (constitutional) majority in parliament. Within the universal system, it is desirable to work more with techniques of positive motivation, i.e., the systematic evaluation of participation in preventive activities and preventive examinations, effective behaviour (Madrian, 2014) within the system (e.g., patient movement between physician, specialist and hospitals, reduce drug overuse and overtreatment, etc.). If support is provided within public choice, consideration may also 184 Jan Mertl: The Relationships and Configuration of Universal and Optional Healthcare Financing Schemes in Czechia be given to allocating a specified small percentage of the health budget to the level of health insurers in the form of health tax credits or other benefits (e.g. once per year). All such measures, however, predict first the fiscal financial pillow, from which they will be funded before any positive effects from the better health of the insured can arise. Conversely, negative motivation in the sense of penalizing for undesirable behaviour cannot be recommended, even in accordance with the knowledge of behavioural economics (Matjasko, Cawley, Baker-Goering, & Yokum, 2016), as this works very weakly or not at all. Moreover, patients must be treated even when their health condition in relation to their behaviour or choice deteriorates. Nevertheless, the universal part of the system must not be subject to permanent pressure on the erosion of the medical standard that it guarantees. It is not true that there are no additional options, as shown in the next chapter, current medicine and the development of associated services offer a range of voluntary options for private spending. The often-heard theory that “we should pay for banal illnesses directly so that the more serious could be paid through solidarity” is not applicable, especially when we know that the overall volume of health expenditure in Czechia is already relatively low within OECD. Moreover, serious illnesses often arise through neglect or non-treatment of malignancies or their early stages. Similarly, the costs of treating serious illnesses are such an essential component of reimbursements that any savings on “banal” care do not address the situation of their coverage. In any case, it is necessary to maintain the medical standard of treatment for all illnesses, while recognizing that it is a difficult task and that in the universal system there is always the risk that accessibility of care will become formal in a certain segment, region or diagnosis. However, this is better than when it is inaccessible apparently and ex ante, because in cases of such unavailability it is always possible to claim the relevant rights of patients who are refused in commercial systems for simple financial reasons on the principle that there is no objective requirement for their treatment in those systems. IV. Optional Prepaid Health Programmes’ Role The development of medicine and the socio-economic environment has brought new treatment options and health services for patients. Likewise, some patients’ demands for comfort, the time of health professionals and the extent of consumed health services are increasing. Although this has several ethical connections, it is currently recognized in developed countries that health professionals can also provide care to those patients who have higher requirements than others, and these requirements are not strictly objectively justified by their health status. This moves us from the category of care that must be provided into the category of care a patient may or will want to consume. In this context, optional healthcare schemes can be created that can be used to finance and provide it. The first option is logically private health insurance. Although it has suitable features for some scenarios, it also has many problems that are not addressed well using the market mechanism. This is mainly due to information asymmetry and adverse selection issues, whichinmanycaseslead tothefailureofthe healthinsurancemarket(Cutler &Zeckhauser, 1997). The individual’s health risk is one of the worst quantifiable and insurable risks on the market, develops unpredictably among individuals, and its possible evaluation through DANUBE: Law, Economics and Social Issues Review, 9 (3), 177–192 DOI: 10.2478/danb-2018-0011 191 References Avera. (2017). Avera health plans. 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