Learning from variations in institutions and politics : the case of social health insurance in France and Japan
Résumé
A theoretical model, such as the social health insurance system (SHI), always
foots on different societal relationships, administrative structures, and political
institutions. The aim of this comparative study is to deepen our understanding of how
different institutional settings affect the politics of health care reforms and impact the
policy outcome of those politics. The paper first isolates the most strategic institutional
differences and similarities between the two countries, including: arrangement of health
insurance schemes, actors, state intervention, regulations on additional charges by
physicians, public-private combination in finance and provision, central-local
relationship, coordination between hospital and ambulatory sectors. The Japanese health
insurance system links employment- and community-based insurance schemes, each of
which have distinct principles for eligibility, financial sources and political actors, whilst
demands for universalism and possible mutual co-operation between these existing
institutions have now penetrated policy debates. The French system, characterized by its
“liberal universalism”, consists of three occupation-based schemes, completed by
residence-based schemes for people without sufficient income, most but not all of whom
are unemployed. Although both systems are essentially unique, because of their historical
development, they both maintain the principle of compulsory contributions by employers
and beneficiaries, rather than tax funding, and free choice of providers by the patients as
well as universal access to medical care. The second part of the paper analyses the policy
debates in each country, together with the policy outcomes in terms of care reforms, with
a particular focus on reforms on financing and on cost containment. The third and
conclusive part interprets the comparative results, with special attention given to the ways
social and political factors push, or not, towards unification in these institutionally
divided “statist SHI” systems.
Domaines
Science politique
Origine :
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