By Hans-Ulrich Deppe
[This article published in: SoZ-Sozialistische Zeitung, February 2007 is translated abridged from the World Wide Web, http://www.vsp-vernetzt.de/sozkoeln/index2.htm Hans-Ulrich Deppe is a professor of medical sociology and social medicine at the Frankfurt University Clinic,]
In many areas of the public sector of society, changes are now occurring that should be controlled with free enterprise instruments (competition, market and privatization). This is true for health insurance. Economic determinants are always the foundation of health insurance. The questions are: Where are the economic limits? Where are political or ethical questions decisive?
The complete transfer of economic laws and instruments to non-economic realities is termed economization – when the profit calculus (exchange value) gains the upper hand. Persons are reduced to the anthropology of the homo oeconomicus (the egoist person maximizing advantages). This should be criticized.
Criticism of its claim of omnipotence is central here, not a general condemnation of the economy. Whether the instruments are suitable to the reality should be probed, not only the excess of the economy. The economy – when torn out of society – succumbs to the danger of breaking its limits and becoming the norm of cooperative human life. Under the hegemonial conditions of capital, market and competition, society is reduced to the working model of the pure market society.
Health or sickness does not have the character of a marketable commodity. Worldwide there is no health system organized in an exclusively free enterprise way. This results from the following facts:
• Health is a vital good with a high practical value. Health is a collective and public good like air, drinking water, education, road safety and legal security.
• Consumer goods can be turned down, not sickness.
• The patient does not know when and why he becomes sick or what sicknesses he will suffer. As a rule, he cannot determine the moment and extent of the services to be claimed. Sickness is a public life risk.
• The demand of the patient is first unspecific and then is defined by the competence of a medical expert. A considerable information- and competence advantage exists in favor of the physician with his diagnostic and therapeutic procedures.
• The patient through his sickness is in a position of uncertainty, weakness, dependence and neediness often joined with anxiety and shame.
The description of the relation of market and patient makes clear that public protection functions must be observed here. The supply of sickness cannot be subject to the mechanism of supply and demand. Therefore the public health system can also be seen as an example for the theory of market failure. The outcomes produced by the market and forms of distribution are inadequate. The market is aimless. Goals must be given to the market. Therefore the state, the democratic polity, must fulfill important tasks. The state has to guarantee the protection and security of its citizens and make political decisions.
HEALTH REFORM 2006
The German health system has a long tradition. It is well known in the world as the Bismarckian model. Its core elements are:
• Direct coupling of financing to economic development. Financing is through contributions, not through taxes.
• Contributions should be financed on a parity basis by capital and labor.
• The solidarity principle in legal health insurance (GKV) is more than an insurance principle. With the solidarity principle, the socially insured have a claim to equal benefits despite different contributions.
• Cashless contact between physician and patient.
• Free access of the socially insured to outpatient facilities.
The German health system seems very flexible after surviving two world wars and two great inflations. This system had to be adjusted again and again to the respective social development…
TAX FUNDS OR CONTRIBUTIONS
…On principle there can be no objection against a tax financing of health care since health care is a social task. However doubts are raised in view of the current policy of the “trim state.” For years, the public budgets have been short of money. The German finance minister has great problems in fulfilling the Maastricht criteria. We do not need to speculate long on what can happen in times of empty treasuries. The 4.2 billion Euros for the GKV from the tobacco tax was cancelled to close the federal budget holes. This politics according to the budgetary situation is detrimental for a lasting health policy. This policy may not be shaken by short-term political decisions. A solid health insurance requires a reliable foundation of planning. Sicknesses do not happen according to the day-to-day financial situation of the state. The question is raised as a matter of principle whether tax-financing or contribution-financing is more socially just. The tax system must be scrutinized as to who is favored and who is disadvantaged.
CANCELLATION OF PARITY
…Neoliberal economic- and labor market policy, stagnating working income and the continuing mass unemployment have withered the extent of employment paying into social security. As long as no basic reorientation occurs and neoliberal conditions are accepted as unchangeable, the next financing crisis of health insurance is pre-programmed with or without the health fund.