An evolution in health care

Every analysis of the Belgian health care system has to start by correcting some common but misleading stereotypes. Belgium does not have the best health care system in the world, at least if we focus on quality and accessibility. The subjective satisfaction of the population is indeed exceptionally high, but this is caused in the first place by the large degree of freedom of choice and by the provider competition on service quality. Whereas most Belgian policy makers express a deep aversion towards introducing market forces in the system, in reality market forces are already dominating on provider markets with considerable freedom of choice both at the demand and at the supply side and even a degree of free price setting. Removing waste will not be costless – and even more so as it will require reducing the freedom that all players enjoy so much. The growth of health care expenditures is mainly caused by technological and scientific progress and curbing this growth is likely to have a large welfare cost and to threaten the solidarity within the system.
This analysis inspires a series of general policy proposals:

1. More and better quality information on providers and hospitals has to be made available to the citizens.
2. Co-payments can stimulate responsible patient behavior but only if they are differentiated for different treatments (“value based”) and refer to items that can be controlled by the patients themselves.
3. Ambulatory and hospital care must be better coordinated. Stimulating collaboration between providers requires decreasing the relative weight of the fee-for-service component in provider payments.
4. Alternatives have to be developed for the present system of price setting of pharmaceuticals.
5. Decisions about the reimbursement of specific treatments and pharmaceuticals have to be communicated to the population in a transparent way.
6. The debate about the government budget must differentiate between different forms of government revenues and expenditures. An open debate is needed about the optimal trade-off between health and private consumption in a rich society.
7. Willingness-to-pay for health insurance implies willingness-to-pay for solidarity.

Translating these general ideas into policy requires a careful analysis of the pros and cons of specific policy measures. The devil is in the details and specific design features may be crucial for the ultimate success (or failure) of a policy reform. These issues are not only technical, however: they all involve difficult trade-offs between different social values. Protecting the solidarity in our society is one of the most important social challenges in a period where citizens seem to become more and more individualistic. If we cannot keep solidarity in the domain of suffering, pain and death, the future of solidarity in other social domains looks very bleak indeed.