9 The changing role of the state in healthcare systems

This article focuses on two major questions concerning the changing role of the state in the healthcare systems of OECD countries. First, we ask whether major changes in the level of state involvement (in healthcare systems) have occurred in the past 30 years. Given the fact that three types of healthcare system, each of which is characterized by a distinct role of the state, evolved during the ‘Golden Age’, we discuss how this distinctiveness – or more technically, variance – has changed in the period under scrutiny. While many authors analysing health policy changes exclusively concentrate on finance and expenditure data, we simultaneously consider financing, service provision and regulation. As far as financing is concerned, we observe a small shift from the public to the private sphere, with a tendency towards convergence in this dimension. The few data available on service provision, in contrast, show neither signs of retreat of the state nor of convergence. In the regulatory dimension – which we analyse by focusing on major health system reforms in Germany, the United Kingdom and the United States – we see the introduction or strengthening of those coordination mechanisms (hierarchy, markets and self-regulation) which were traditionally weak in the respective type of healthcare system. Putting these findings together we find a tendency of convergence from distinct types towards mixed types of healthcare systems.