Explaining Different Paths in Social Health Insurance Countries - Health System Change and Cross-border Lesson-drawing between Germany, Austria and the Netherlands

Abstract

The issues of ‘policy diffusion’ or ‘policy transfer’ and ‘mutual learning’ have become important topics in comparative research on social policy and health systems. In current debates on explaining reform in ‘Bismarckian’ social (health) insurance systems, however, these issues have been neglected. In particular, the role of ‘negative lesson-drawing’ in the sense of avoiding mistakes of others has not often been considered. This article compares health system change in Germany, Austria and the Netherlands, three countries with health systems of the social insurance type. In contrast to the existing literature, our analysis stresses that these countries have taken different reform paths since the 1990s. By applying a most similar systems design, we analyze how far cross-border lesson-drawing has contributed to health system divergence in the three countries. The empirical basis of the analysis is semi-structured qualitative expert interviews, a method appropriate for tracing processes of lesson-drawing. We argue that in order to fully understand the diverging reform trajectories, we need to take into account how political decision-makers refer to (negative) experiences of other countries. Generally, national driving forces for health system change were at the heart of many crucial reforms during the period studied. Nevertheless, we claim that it was the German bad practice role model that kept the reform paths of Austria and Germany apart in the Austrian health reform discussion between 2000 and 2005.