Health Care System Change

and the Cross-Border Transfer of Ideas:

Influence of the Dutch Model on the
2007 German Health Reform
Simone Leiber
Institute of Economic and Social Research
Stefan Gre
University of Applied Sciences Fulda
Maral-Sonja Manouguian
Scientific Institute for Benefit and Efficiency in Health Care

Abstract To increase understanding of the cross-border transfer of ideas through

a case study of the 2007 German health reform, this article draws on Kingdons
approach of streams and follows two main objectives: first, to understand the extent
to which the German health reform was actually influenced by the Dutch model and,
second, in theoretical terms, to inform inductively on how ideas from abroad enter
government agendas. The results show that the streams of problem recognition and
policy proposals have not been predominantly influenced by the cross-border transfer of ideas from the Netherlands to Germany. The Dutch experience was taken into
consideration only after a policy window opened by a shift in politics in the third,
the political, stream: the change of government in 2005. In many respects, the way
Germany learned from the Netherlands in this case sharply contrasts with an image
of solving policy problems by either lesson drawing or transnational deliberation.
Instead, the process was dominated by problem solving in the sphere of politics, that
is, finding a way to prove the grand coalition was capable of acting.

Introduction: Health Care System Reform

and the Cross-Border Transfer of Ideas

At the beginning of this decade, Moran (2000: 135) pointed out that general welfare state literature and health care literature were often semidetached, with literature on health care policy being immersed . . . in its
A preliminary version of this article was presented at the conference Explaining Healthcare
System Change, December 45, 2008, in Bremen. We would like to thank all participants of
the conference, in particular Thomas Gerlinger and Mirella Cacace, as well as the two anonymous referees of the journal for their very helpful comments.
Journal of Health Politics, Policy and Law, Vol. 35, No. 4, August 2010
DOI 10.1215/03616878-2010-016 2010 by Duke University Press

540 Journal of Health Politics, Policy and Law

own specialist controversies. Nevertheless, there is a tradition of important studies using the theoretical frameworks of comparative welfare state
research applied to health care system reforms. Their theoretical focus is
on institutional veto points (e.g., Immergut 1991), path dependence (e.g.,
Giaimo and Manow 1997, 1999; Wilsford 1994; several contributors in
this issue), institutional drift (Hacker 2004), or the importance of organized interests and actor constellations in shaping health reforms (e.g.,
Rosewitz and Webber 1990; Dhler and Hassenteufel 1995; Hassenteufel
1996; Bandelow and Hassenteufel 2006). Even the ideational turn of comparative welfare state research has now reached some strands of health
care research, and there is growing interest in studying policy transfer,
learning, and policy diffusion in the health care field (e.g., Klein 1997;
Brown 1998; Freeman 1999, 2000; Braun and Gilardi 2006; Braun et al.
2007; Greener 2002; Marmor, Freeman, and Okma 2005; Hassenteufel
and Palier 2007; Schmid and Gtze 2009; Bland 2010). However, studies
that carefully link theory with empirical results are still quite rare. The
same is true of studies on the cross-border transfer or diffusion of ideas.
Because of new means of communication and growing economic interdependence, it has become more likely that countries are influenced by each
others experience; however, we still have limited knowledge of the precise
mechanisms of cross-border influence. In addition, the theoretically most
sophisticated analyses in comparative health policy still tend to ignore (if
not implicitly deny) the cross-national exchange of information and ideas
in health policy (Marmor, Freeman, and Okma 2005: 343). What is more,
many studies on policy transfer or diffusionnot only in the health care
fieldsuffer from severe methodological problems. Dobbin, Simmons,
and Garrett (2007: 463) in their seminal review article of diffusion theoristsconstructivists, coercion theorists, competition theorists, or learning
scholarsconclude that perhaps the most frustrating empirical tendency
across these studies is that champions of each theory often take simple
evidence of diffusion to be adequate to prove their particular theory. Thus
evidence of parallel institutional development is, for example, not sufficient
proof for policy learning. To test theories of policy learning, we would
at least need evidence that the supposed model and its functioning were
known to the government presumably engaged in policy learning. Furthermore, if our assumption was that cross-border diffusion was driven by a
learning mechanism where deliberative problem solving was the primary
rationale for action, we would need further empirical evidence for the presence of this interaction, for example, from expert interviews.
This article seeks to address our still-limited knowledge of the cross-

Leiber, Gre, and Manouguian Dutch Model for German Reform 541

border
transfer of ideas in health policy through a case study on the German health reform of 2007. There are two questions we would like to
answer: First, to what extent was the 2007 reform influenced by the model
of the Netherlands? And, second, what can we learn from this case about
potential mechanisms for the entry of ideas from abroad into government
agendas? To date, scholars have analyzed the Dutch reform of 2006 as a
potential model for Germany or the United States (e.g., Gre, Manouguian,
and Wasem 2006; Agasi 2008; van de Ven and Schut 2008; Rosenau and
Lako 2008; Okma 2008). The latest German reform is studied either
by estimating its effects and failures (e.g., Gerlinger, Mosebacher, and
Schmucker 2007; Gpffarth et al. 2007) or by analyzing its emergence
from the perspectives of different national actors involved in the reform
process (Schroeder and Paquet 2009). The question of the extent to which
this reform was inspired by a cross-border transfer of ideas from the Netherlands has, however, not yet been studied in depth.
The rather close institutional similarity of the German health (finance)
system after 2009 to the Dutch system (before 2006) is well known.1
Above all, the new health fund model (see also the third section, below)
was accompanied by the possibility of installing a small flat-rate premium
in Germany, which is markedly similar to the former system used in the
Netherlands prior to 2006. In addition, media reports both before and
during the reform process often referred to the Netherlands as a potential
model for Germany, and in the media some politicians, Germans as well
as Dutch (see the fourth section, below), also referred to Dutch inspiration
of the German reform. At first sight, it is tempting to conclude that this is
an example of nonspurious policy diffusion.2
Rather than stop at this point and take this occurrence as proof of policy diffusion or even policy learning, our article draws on this case for
a deeper understanding of which mechanisms and under which conditions ideas might cross borders and influence policy reforms. In particular,
we use the example of the 2007 German reform as a case in point for
cross-border policy transfer where transnational problem solving was not
the main rationale. A problem-solving model of policy transfer implies
that becoming aware of policy problems (e.g., by comparing ones own
1. The reform was adopted by the German parliament in March 2007. However, core elements such as the health fund were not implemented until 2009. The latest reform plans by the
Christian Democrat and Liberal government elected in 2009 are not part of this analysis.
2. According to Braun and Gilardi (2006: 305) spurious diffusion occurs if countries experience similar problem pressure andindependently of each otherreact with similar policy
measures. In contrast, nonspurious, or interdependent, diffusion is driven by the interdependence of actors.

542 Journal of Health Politics, Policy and Law

performance with better-performing neighboring countries) and finding

good solutions for them in elite networks or epistemic communities
are at the heart of cross-national policy transfer or policy learning.3 The
research on the European Unions Open Method of Coordination (for a
critical review of this literature, see, e.g., Fleckenstein 2006) has contributed greatly to a rather deliberative understanding of politics, seeking
good-practice solutions to be transferred from more successful to less successful member states.
In contrast, our analysis shows that in the case of the latest German
health care reform, the whole process was very much driven by the power
struggle and search for compromise between the two political parties of
the grand coalition. The government had to successfully bring together
two contradictory conceptscitizens insurance and the flat-rate premiumin order not to endanger its future. How does this fit the abovementioned image of Germany learning from the Netherlands in 2007?
To solve this puzzle, we draw on Kingdons (1984, 1993, 2003) approach
of policy streams and policy windows as an analytic framework. Generally, Kingdons framework is considered an interesting starting point for
analyzing policy ideas (Bland 2005). We adapt Kingdons landmark work
on agenda setting and policy formation for our purposeto understand
the cross-border transfer of ideas. Kingdons work seems well suited for
understanding the German case, and we try to show that it allows for looking at policy transfer in health care in a much more differentiated fashion than many existing studies do. It allows us to analytically distinguish
between the streams of problem definition, policy proposals, and politics.
On this basis, the case study provides an opportunity to learn more about
how ideas might be used as a power resource and howas suggested by
Hall (1993)powering and puzzling are intertwined. To avoid the methodological problems of diffusion studies mentioned above, the examination is based on document analysis as well as expert interviews with those
involved in the decision process.4
This article is organized as follows. In the second section, we explain
our analytic framework based on Kingdons approach. In the third section, we provide an overview of important similarities and differences
3. For our understanding of the concepts of policy learning, diffusion, and transfer, see the
second section, below.
4. Interviews were carried out with politicians, scientists, and members of the Ministry of
Health administration. To preserve anonymity, we refer to these as interview G [Germany]
1, interview G 2, and so forth. Interviews were conducted in German and translated into
English by the authors.

Leiber, Gre, and Manouguian Dutch Model for German Reform 543

between the Dutch and German health reform paths. The fourth section
analyzes the 2007 reform process in Germany by distinguishing between
the streams of problem definition, policy proposals, and politics. The fifth
section sums up our results, discusses their theoretical implications, and
identifies tasks for future research.
How Does an Ideas Time Come?:
Kingdons Approach of Policy Streams
and Policy Windows

In particular the application of the so-called Open Method of Coordination (OMC) to social policy issues in the European Union (EU), as
well as generally increasing transnational communication and processes
of economic globalization, has (re)intensified research interest on issues
such as policy learning, policy transfer, diffusion of ideas, framing, and
lesson drawing over the last decades. The diversity of studies is immense,
and even a brief overview would go beyond the scope of the present article.5 Definitions are not uniform and rather often not made explicit.6 The
interest of the analysis is on cross-national policy transfer in the sense
of Dolowitz and Marsh (2000: 5), understood as the process by which
knowledge about policies, administrative arrangements, institutions and
ideas in one political system (past or present) is used in the development
of policies, administrative arrangements, institutions and ideas in another
political system. As regards the notion of policy diffusion, although we
are aware of different emphases of the two literature strands (for an overview, see, e.g., Marsh and Sharman 2009, Holzinger and Knill 2005), like
Marsh and Sharman we argue that these strands are complementary. Both
aim to specify mechanisms capturing how and why a policy in country A
is transferred to country B. It is also important to specify which processes
are not regarded as policy transfer or policy diffusion in this article: this is
when countries experience similar problem pressure and introduce similar
policy measures, but independently of each other (what Braun and Gilardi
2006 called spurious diffusion; see note 2).
While policy transfer and diffusion are the more-encompassing con5. For more-recent studies on ideas and welfare state reform, see, for example, Taylor
Gooby
2005; on policy learning, Hall 1993; on lesson drawing, Rose 1991; on policy transfer,
Dolowitz and Marsh 1996, 2000; on diffusion, Holzinger and Knill 2005; on learning through
the OMC, Zeitlin 2005; and for applications to the field of health care, Freeman 1999, 2000,
and Greener 2002.
6. On differences and overlapping elements of these concepts, see, for example, Holzinger
and Knill 2005.

544 Journal of Health Politics, Policy and Law

cepts, for the purpose of this article policy learning is conceived of as one
of several potential mechanisms of policy transfer and diffusion.7 In addition, policy learning may be understood as a mechanism of voluntary policy transfer (Dolowitz and Marsh 2000), as opposed to other mechanisms
based, for example, on (external) coercion or competition (Dolowitz and
Marsh 2000; see also Dobbin, Simmons, and Garrett 2007), which are not
central in this case. Learning across countries may be further distinguished
in the mechanisms of transnational problem solving (Holzinger and Knill
2005: 778779, with further references), on the one handa form of
rational learning driven by the joint development of common problem perceptions and solutions in elite networks or epistemic communitiesand,
on the other, lesson drawing (Rose 1991). The latter mechanism refers to
policy transfer in which governments in a voluntaristic process rationally
use experience from abroad to solve domestic problems.
In the analysis we seek to understand if a voluntary policy transfer from
the Netherlands to Germany has taken place in the 2007 health reform,
and if so, by which of the learning mechanisms and how interests and
ideas were linked in this process. The latter is why we decided to draw on
Kingdons approach. Kingdon moves beyond purely idea-based problemsolving models of agenda setting, and his framework has the potential
to capture the interplay of institutions, interests, and ideasinstead of
contrasting these perspectives (Bland 2005).
Kingdons (1984) concept emerged from a large-scale study on agenda
setting in U.S. federal policy making. The aim of his work was to explain
agenda setting. His main research interest was in the question of how do
issues get on public policy agendas, or how does an ideas time come?
Unlike us, he does not focus on the cross-national transfer of ideas. Thus
his approach is both broader and narrower, as he mainly analyzes problem
definition and agenda setting, while other stages of the policy cycle like
policy formulation, implementation, and evaluation are not central.
In his approach Kingdon develops a revised version of Cohen, March,
and Olsens (1972) garbage can model. Kingdon distinguishes three
so-called streams: problem recognition, policy proposals, and politics.
According to his theory, these streams work largely independent of each
other, but at certain critical points, they come together, and this is when
the greatest agenda change is most likely to happen (table 1).
In the stream of problem recognition, the central question is why gov7. However, learning may also take place without policy transfer. Actors can learn from
negative experiences of others and thus refrain from policy transfer.

Leiber, Gre, and Manouguian Dutch Model for German Reform 545

Table 1 Conditions Favoring Agenda Change according to Kingdon

Agenda Setting

Favorable Conditions

Stream of problem definition (stream 1)

Crisis
Shift in system performance

Stream of policy proposals (stream 2)

Feasibility of proposal
Low cost of proposal
Mass public acceptance of proposal

Stream of politics (stream 3) Changes in the administration, partisan or

ideological composition of
parliament, or interest group pressure
Joining the streams Constant work of policy entrepreneurs
in streams 1 and 2 combined with
policy window opened either by a
pressing problem (stream 1) or by a
shift in politics (stream 3)
Source: Kingdon 1984

ernments pay attention to some problems and not others. According to

Kingdon, sudden shifts in the performance of systems regularly monitored
by standard indicatorsor focusing events, such as crisisare particularly decisive for attracting politicians attention.
In the stream of policy proposals, a policy community of specialists
like bureaucrats, people in planning, evaluation, and budget, academics,
interest groups, and researchers is constantly generating proposals: They
float their ideas up and the ideas bubble around in these policy communities (Kingdon 1984: 92). Kingdon also calls this the policy primeval
soup (ibid.: chap. 6). In a selection process, some ideas or proposals are
taken into consideration, and others are discarded. Kingdon names three
criteria for when policy proposals are more likely to get on a governments short list: they have to be technically feasible, not too expensive,
and acceptable to the mass public.
For the third stream, the political, changes in the administration, partisan or ideological composition of parliament, or interest group pressure
are central factors influencing agenda setting.
According to Kingdon, to join the streams requires policy entrepreneurs
who are more or less constantly at work on pointing attention to particular problems or policies. However, only a policy window enhances their
chances to actually influence the agenda. A policy window can open either
because of change in the political stream (e.g., an administration change

546 Journal of Health Politics, Policy and Law

or a shift in the partisan or ideological distribution of seats in parliament)

or because new problems come to the attention of government officials:
In addition to one opened by the emergence of a pressing problem, a
window can be opened by an event in the political streama change
of administration, a shift in national mood, an influx of new members
of Congress. Politicians decide to undertake some sort of initiative on
a particular subject, and cast about for ideas. Putting themselves in the
market for proposals creates a window for advocates, and many alternatives are then advanced by their sponsors. One or more of the proposals
worked up and available in the policy stream thus becomes coupled to
the event in the political stream that changed the agenda. The problems
may not have changed at all; nor did the solutions. But the availability
of an alternative that responds in some way to a new political situation
changes the policy agenda. (ibid.: 183)
What makes Kingdons framework so attractive as a starting point for
our analysis is that it allows a look at a very differentiated way on how
certain ideas enter government agendas. To be clear about our claims: the
aim of this analysis is not to test Kingdons theoretical approach, and we
do not claim that the cross-national transfer of ideas is the sole explanation for the institutional shape of the latest German health reform. We use
Kingdons distinction between the three streams as an analytic framework
for understanding the 2007 German health reform. Our assumption is, and
we seek to show this below, that looking at the interplay of these three
streams is helpful to better understand the extent to which and how the
Dutch model in this case influenced the German reform. Kingdon does not
distinguish where these ideas come from, whether they stem from purely
national discussions or are inspired from experiences abroad. To him, the
critical thing to understand is not where the seed comes from, but what
makes the soil fertile (ibid.: 81). Our aim is first of all to understand the
German reform, but in addition by applying this framework to our case
study we inductively also seek to learn more about the circumstances of
how ideas from abroad enter government agendas.
Health Care Reform Paths in Germany and
the Netherlands: Parallel Developments but
Important Differences

In this section, we briefly summarize similarities as well as dissimilarities

in recent health care reforms in the Netherlands and in Germany; both

Leiber, Gre, and Manouguian Dutch Model for German Reform 547

health systems belong to the type social health insurance.8 The Dutch
ZFW (Ziekenfondswet) insurance was introduced by decree by the occupying power, Germany, during the Second World War, which accounts for
the similarity in its basic structure. This basic structure has been retained
to the present. During the last thirty years, both countries have been subject to almost constant reform. As opposed to other social insurance countries, like Austria or France (Leiber 2007; Hassenteufel and Palier 2007),
since the 1990s the Netherlands and Germany have followed a common
reform path based on regulated competition between insurance providers.9
When turning to the latest health reforms, the 2007 reform in Germany
was not as fundamental and far-reaching as the Dutch health reform in
2006 (for details, see also Leiber 2007). It can rather be characterized as
a process of layering (Streeck and Thelen 2005), adding new layers of
institutional elements (e.g., small income-independent flat-rate premiums
for the financing systems; additional tax financing; basic tariffs for private
insurance) without completely replacing the previous structure (financing
mainly by income-dependent contributions; private insurance as a substitute system to social insurance).10 Nevertheless, the German reform can
be seen as a reform step, bringing core structures of the two insurance
systems closer than ever before.
To structure our institutional comparison of the latest health reforms,
we adapted the grid to array structural changes in social security systems
introduced by Bonoli and Palier (2000; see also Palier and Martin 2008).
Our adjusted grid analyzes structural changes in three dimensions: access
to health insurance, financing, and delivery of health services.11 Table 2
shows the main institutional features of both the pre-and postreform situation in the Netherlands and Germany. We discuss similarities and dissimilarities between both countries for each feature displayed in the table.

8. In contrast to a national health servicestype system, like in the United Kingdom, or a

private health insurancetype system, like in the United States, health insurance in the Netherlands has a second, universally oriented pillar, which provides for long-term care and long-term
illness. However, the main pillar of the Netherlands health system clearly bears the characteristics of social insurance.
9. For more comprehensive historical descriptions of both systems and their development,
see Helderman et al. 2005; Gre and Manouguian 2007; Leiber 2007; Leiber and Manouguian
2008; and Gtze, Cacace, and Rothgang 2008.
10. Over time, however, these new layers may grow more quickly than the old ones. In particular, under new political circumstances after the 2009 election, the reform bears the potential
to displace core structures of the old system in the long run.
11. The fourth category of Bonoli and Paliers gridadministrative structures and management of the systemis neglected in this analysis for reasons of space, but see, for example,
Haarmann, Klenk, and Weyrauch 2008.

Institutional Feature

Pre-2006

Netherlands
Post-2006

Pre-2007

Post-2009

Germany

Access
Mandatory
Only in social
All insurers
Only in social
All insurers
acceptance health insurance health insurance

Mandatory insurance Only employees and
All inhabitants
Only employees
All inhabitants
self-employed below below income
income ceiling ceiling

Access to substitute
Basic contracts
No separate
No regulation to
Basic contracts
private health (premium determined regulation increase access (maximum premium
insurance by government) determined by
legislation)
Financing
Income-dependent
85% of expenditure
50% of expenditure 100% of expenditure 95100% of expenditure
contributions determined by determined by determined by determined by
government government individual health government
insurers

Risk adjustment
Health based (central
Health based
Demographic (no
Health based (central
fund) (central fund) central fund) fund)

Flat-rate premium
15% of expenditure
50% of expenditure None
05% of expenditure
determined by determined by determined by
individual health individual health individual health
insurers; insurers; insurers;
no transfers for tax-financed maximum amount
low-income transfers for for all individuals
individuals low-income
individuals

Dimension

Table 2 Main Institutional Features in Germany and the Netherlands

Institutional Feature

Pre-2006

Netherlands
Post-2006

Pre-2007

Post-2009

Germany

Sources: Based on Gre and Manouguian 2007; Gre et al. 2008; Gre, Manouguian, and Wasem 2007; Manouguian, Gre, and Wasem 2006; Schut and
van de Ven 2005; van de Ven and Schut 2008
Note: GP = general practitioner

Financing
Taxes
3.6 billion in 2005
Flat-rate premiums 2.5 billion in 2006 Maximum of 14 billion
(continued) for children and in 2012
transfers for
low-income
individuals

Risk-rated premiums Only private insurers
No
Only private insurers Only private insurers
(normal contracts)
Delivery of
Collective contracting Hospitals and

Hospitals and
Hospitals
services specialists specialists

Selective
GPs
GPs, specialists,
Integrated care,
Integrated care, GPs, and
contracting and hospitals GPs specialists

Dimension

Table 2 (continued)

550 Journal of Health Politics, Policy and Law

Access

Both health insurance systems in the past have provided far-reaching,

almost universal coverage. The share of uninsured individuals was below
1 percent of the population in both countries. With the latest reforms,
access to health insurance in both countries has further improvedat
least formally. In the Netherlands, health insurance coverage became
mandatory for the entire population after 2006. All health insurers are
required to accept all applicants. Since 2009 the situation in Germany
is similar. All inhabitants are required to take out health insurance as
well. However, the remaining differences between both countries are considerable. First, Germany intends to reach universal coverage within the
framework of a parallel system of social health insurance and substitute
private health insurance. Although almost 90 percent of the population
in Germany is covered by social health insurance (GKV), there is also a
considerable market for private health insurance (PKV). About 10 percent
of the population has taken out alternative private health insurance as a
substitute for social health insurance (Gre 2007). If individuals are to be
covered by private health insurance, since 2009 they have access to basic
contracts if they are unable to afford risk-rated premiums. These contracts are characterized by mandatory acceptance and flat-rate (incomeindependent) premiums. This is similar to the pre-2006 Dutch situation
but dissimilar to the post-2006 unified health insurance system in the
Netherlands. One core feature of the Dutch reform was to introduce a unified system of health insurance based on regulated competition. Second,
basic contract premiums in private health insurance in Germany post2009 are very expensive (approximately 570 per month). This compares
with less than 200 per month (premium basic contracts pre-2006 and
flat-rate premium post-2006) in the Netherlands. The issue of affordability
will be a major concern for low-income self-employed individuals who are
required to take out private health insurance post-2009 in Germany.
Financing

There are several similarities in health care financing between both countries. Since the 2007 reform in Germany, in both countries a central fund
(health fund) distributes financial resources to health insurers. The health
fund in turn is financed by uniform income-dependent contributions of
enrollees and tax-financed payments by the central government.12 Addi12. Note that in Germany this is relevant for social health insurance only. Private health
insurers charge risk-rated premiums (Gre 2007).

Leiber, Gre, and Manouguian Dutch Model for German Reform 551

tionally, health insurers have to charge flat-rate premiums in both countries

to cover the difference between financial resources received by the central
fund and health care expenditures.13 In contrast to the uniform incomedependent contribution to the central fund, flat-rate premiums may differ
between health insurers in both countries. Moreover, low-income individuals in both countries are not required to pay the full amount of the flatrate premiums. In both countries the central fund uses health-based risk
adjustment to distribute financial resources. Finally, the options offered to
the insured, for example, in terms of cost-sharing tariffs, were expanded
considerably.
While the similarities of these institutional features are rather striking,
there are important differences between both countries as well. First, the
cost of flat-rate premiums differs greatly. Flat-rate premiums in Germany
post-2009 are much lower than in the Netherlands (both pre- and post2006). Second, transfers for low-income individuals in the Netherlands
post-2006 are tax financed. In contrast, individual health insurers in Germany need to cover all expenses above a legally set limit for financial
burdens of private households (1 percent of gross income). This creates
considerable financial disadvantages for health insurers with a disproportionate share of low-income enrollees. Third, tax financing in the Netherlands has been rather reliable in the past, while it has been erratic in Germany. Fourth, risk-rated premiums are still calculated by German private
health insurers for nonbasic contracts. This is the cause for substantial risk
selection against social health insurance (Gre 2007).
Delivery of Services

Most institutional features concerning the delivery of health care services

have remained structurally unchanged in both countries during the latest
reforms. Remuneration systems and capacity planning for general practitioners, medical specialists, and hospitals have not been changed substantially as a consequence of the reforms under consideration. However,
there have been some important readjustments relating to the instruments
available to health insurers to manage health care. In both countries,
13. By law, sickness funds in Germany are also allowed to calculate individual contribution
rates to cover the difference between financial resources from the health fund and health care
expenditures. However, they are not expected to raise income-dependent contribution rates.
This would increase incentives for high-income enrollees to search for lower-priced alternatives
with flat-rate premiums. Should the sickness funds generate a profit, they are permitted to repay
part of the fund capital to the insured.

552 Journal of Health Politics, Policy and Law

selective contracting has become more important. Health insurers in the

Netherlands are now allowed legally to introduce selective contracting for
general practitioners (GPs), medical specialists, and hospitals. Pre-2007,
selective contracting was restricted to general practitioners. In Germany,
health insurers are able to close selective contracts with GPs and medical
specialists, as well as within the area of integrated care. Pre-2007, selective contracting was restricted to GPs and integrated care.
Explaining Health Care System Change
by the Cross-Border Transfer of Ideas:
Dutch Inspiration for the German Health
Reform of 2007?

In this section, we look at the German health reform of 2007 through the
analytic lens of the three streams. We analyze the extent to which the
Dutch model was involved in each stream. Then we explain how the three
streams were combined.
The Stream of Problem Recognition

Although the Health Insurance Competition Strengthening Act (GKVWettbewerbsstrkungsgesetz, or GKV-WSG) finally adopted by the parliament in February 2007 included elements not directly related to health
care financing (e.g., the development of a central umbrella organization
for sickness funds or an obligation to take out insurance), revenue-side
financial problems of the social health insurance were at the heart of the
reform discussions. Starting as early as the 1970s, the German health system had been subject to constant change, which above all aimed at cost
containment and stabilizing the GKV contribution rate. First, this policy
found expression primarily in cost-containment measures, the delisting
of specific services and amoderateincrease of out-of-pocket payments for private households. An expansion of this strategy, the revenueoriented expenditure policy, can be identified from the beginning of the
1990s. In addition, regulated competition between sickness funds and risk
adjustment were introduced in the 1992 Health Structure Act (Gesundheitsstrukturgesetz) (Gre 2006; Gtze, Cacace, and Rothgang 2008). If
the management and service provision structures (e.g., the contractual relationship between the insurance funds and service providers) had remained
largely untouched until then, they were subjected to important changes
by the 2000 GKV Health Reform Act (GKV-Gesundheitsreformgesetz)

Leiber, Gre, and Manouguian Dutch Model for German Reform 553

and the 2003 GKV Modernisation Act (GKV-Modernisierungsgesetz). At

the same time, privatization of health costs by co-payments and services
cuts were further extended (for details, see Gerlinger 2004). However,
after these reforms, political parties across the board agreed that further
reform was still necessary, and there was consensus that the problems on
the revenue side of financing the German health care system had not yet
been solved.
The way that these financial problems were perceived by different
political groups, however, differed fundamentally. The entire discussion
process preceding the 2007 reform and the 2005 national elections was
dominated by two opposed camps of politicians, social interest groups,
and scientific advisers: proponents of a citizens insurance (Brgerversicherung) and proponents of a flat-rate premium (Kopfpauschale).
The former group (among them the Social Democrats, the labor unions,
the Green Party, anda well-known celebrity with a scientific backgroundKarl Lauterbach)14 criticized above all the narrow financial basis
of the German social health insurance, GKV. Revenue was mainly based
on contributions from employment, while capital income was not taken
into account. In addition, the self-employed, public servants, and highincome earners were excluded (or had an opt-out option) from the GKV
system. Although this led to gaps in protection, particularly among the
self-employed, high-income groups with, on average, rather good health
risks had the option of taking out the full private insurance, PKV. Thus
they did not contribute to the solidarity system of the GKV. The main aim
of this camp was to stabilize the financial basis and to lower GKV contribution rates by taking additional groups of people (self-employed, civil
servants, high-income earners) and additional income (capital based) into
account. Another core aim was to abolish the dual system of GKV-PKV,
which was considered to further a two-class provision of services (Gre
2007).
The latter group (among them the Christian Democrats; the Christian
Social Party; and the economist Bert Rrup, often perceived in the media
as the counterpart to Lauterbach) mainly stressed the high burden of rising
health costs on nonwage labor costs. By changing to a system of incomeindependent flat-rate premiums, proponents of a flat-rate premium intended
to uncouple the rising health costs of the future (expected, e.g., because
of technical medical innovation or demographic change) from labor costs.
14. Lauterbach is a university professor who was an adviser to the minister of health, Ulla
Schmidt, at that time and who had a very high profile in the media with his support for the
Brgerversicherung.

554 Journal of Health Politics, Policy and Law

Solidarity with low-income earners was to be sustained through tax subsidies. The degree of such compensation, however, differed substantially
between different concrete models. There were also different positions in
this camp, concerning whether the dual system of GKV-PKV should be
maintained.15 Some advocates of the Kopfpauschale, among them Rrup,
also declared to have found a consistent way to introduce more tax financing into the GKV by combining income-independent flat-rate premiums
with considerable tax subsidies for low-income earners.
The opposition between the two camps, with both scientists and political actors on either side, was so strong that in 2003, even the Rrup Commission, an expert commission on sustainable social security financing
(Rrup-Kommission 2003) initiated by the Schrder government and led
by Rrup,16 was unable to agree on a comprehensive common proposal of
future health care financing when presenting its results.
What is most important for the purpose of this article is that the whole
discussion was very much shaped by the specific German background.
Of course many of the actors involved, especially those in the ministry
administration (interview G 4) and those with scientific backgrounds, have
international academic backgrounds and are aware of what is happening
in other health systems. They know the important features of the Dutch
or, for example, also of the Swiss health system (the latter being based on
income-independent premiums). Indirectly, this may of course influence
how they perceive national problems. However, we still conclude that in
this stream and considering the way the main problems in German health
care financing were perceived, the Dutch experience was not central.
Compared with striking examples in other policy fields where international comparison virtually disrupted problem recognitionfor example,
the external shock suffered by Germany because of its bad performance in
the Organisation for Economic Co-operation and Developments first Program for International Student Assessment (PISA) studyinternational
influence was not significant for problem definition in our case.

15. Generally, this is just a very rough characterization of the two camps, to highlight the
general differences and national orientation in problem perception. In the run-up to the elections in 2005, there was not one but many concrete propositions in each camp on how to institutionalize Brgerversicherung and Kopfpauschale (see also the section on policy proposals,
below).
16. The commission consisted of scientists as well as representatives of labor and industry.
Lauterbach was also a member of this commission.

Leiber, Gre, and Manouguian Dutch Model for German Reform 555

Stream of Policy Proposals

For the stream of policy proposals, it is crucial to distinguish between

the periods before and after the general election in September 2005. As
described above, the policy debate on health care before the election was
dominated by the two concepts of Brgerversicherung and Kopfpauschale,
and there were ample concrete suggestions on how to implement such a
reform. Even among proponents of the same camp, there were striking
differences in the details of their proposals (e.g., some advocates of the
flat-rate premium suggested abolishing the GKV-PKV separation, while
others wanted to maintain the two systems of full health insurance). It is
beyond the scope of this article to describe all these proposals in detail.17
Soon after the 2005 election, it became clear that none of these proposals had any chance of being implemented as they stood. The result of
this election was a grand coalition consisting of the Christian Democrats/
Christian Social Party (CDU/CSU) on the one hand (led by Chancellor
Angela Merkel), and the Social Democratic Party (SPD) on the other. As
far as health reform concepts were concerned, before the election the coalition partners had belonged to opposing camps, one favoring a citizens
insurance, the other a flat-rate premium. Consequently, the big question
became how to combine the two concepts and the coalition partners different interests in health policy.
In this context a policy proposal initiated by the economist Wolfram
Richter, which was clearly designed as a compromise, gained importance.
Richters proposal included a two-step concept with the following core
features (see Richter 2005, 2007).
Step One
Introduction of a Sonderhaushalt GKV (separate GKV budget), later
called the health fund, in which all insured continue to pay incomedependent contributions, but at a uniform average contribution rate.
The insured obtain a kind of voucher for an average fixed sum (total
revenue of the health fund divided by the number of patients) from
the health fund and can choose freely where to insure.
n
Insurers are obliged to offer standard tariffs that cover all costs for
a defined minimum catalog of medical services (cost-sharing tariffs
n

17. However, for a comprehensive overview, see Gre, Pfaff, and Wagner 2005; for the main
party political conflict lines, see Bandelow and Schade 2009.

556 Journal of Health Politics, Policy and Law

are welcomed) and to calculate an income-independent flat-rate premium on this basis.

n
In case of differences between the fixed sum the insured receive and
the flat-rate premiums calculated by insurers, insurers can either
charge additional payments directly from the insured or the health
fund pays out surplus funds to the insured. Richter considered the
income-independent insurance premiums important signals for the
enhancement of competition between the health insurance funds.
Step Two
The separate GKV budget or health fund is to be transferred into
the general tax system; payroll-related health contributions and
income tax are to be combined.
n
Social and private health insurers compete in one market. Both social
and private insurers are allowed to offer standardized full insurance
as well as supplementary insurance.
n

Richter had already developed these ideas before the election in 2005,
but at that time nobody was really interested in them (interview G 1).
Richter generally saw such a two-step model as a way to overcome the
contradictions of a policy based on not only lowering taxes but also offering income-independent flat-rate premiums (with rather extensive taxfinanced compensation for low-income earners).18
After the election the situation had changed. Richter now spread his
ideas by offering a compromise model. He also contributed to an October
8, 2005, proposal of the Scientific Advisory Board of the German Ministry of Finance, of which Richter is a member (see also Feldenkirchen
2006). This proposal took up his core idea of the health fund (here called
zentrale Inkassostelle [central collecting agency]; see Wissenschaftlicher
Beirat 2005) combined with income-independent flat-rate premiums. This
proposal explicitly promotes options for the future development of the
fund approach, either by extending the group of insured persons (toward
a Brgerversicherung) or by lowering the income-dependent contributions (toward a Kopfpauschalenmodell). Richter quite plausibly argued
that his concept was mainly inspired by the specific German reform context, namely, by organizing the transition toward a tax-financed health
system without contradicting the political aim of low-tax policies. As in
18. In particular, CDU and CSU were confronted with such a contradiction, as their health
concepts most likely required additional tax financing, while their tax policy aimed at lowering
tax rates.

Leiber, Gre, and Manouguian Dutch Model for German Reform 557

the stream of problem recognition, international models were also only

very indirectly present at this point:
I think that Switzerland, the Netherlands, and Germany are closely
related in their solutions. But I had studied neither Switzerland nor the
Netherlands before the proposal. I just see . . . that there is a mainstream within economics. If they can exchange ideas around the world
all economists will come to similar conclusions within a certain framework. That is not just my opinion but it is theoretical background that
is shared worldwide. So it does not surprise me that similar solutions
come out. (interview G 1)
Apart from these concrete policy proposals, however, it has to be taken
into account that from the time the Dutch adopted their far-reaching health
reform in 2006, a very lively scientific debate began on the advantages and
limitations of adopting the Dutch reform as a potential model for Germany (e.g., Walser 2006; Gre, Manouguian, and Wasem 2006). After
the election, parallel to Richters proposition, some researchers also seem
to have identified the Dutch health fund as a potential compromise model
for Germany, as a result of their empirical observation of the Dutch health
system (Wasem 2009: 250). The extent to which this finally influenced
the reform process is discussed in the section on joining the streams,
below.
Stream of Politics

It should be clear by now that the latest health reform process in Germany
was very much driven by the necessity of finding a compromise between the
divergent financial concepts of the grand coalition parties, which seemed
difficult to unite. This was the common opinion whenever actors involved
in the process were asked to describe their view of the process (see, e.g.,
Knieps 2007, interviews G 16). In Kingdons terms, a policy window
opened by a shift in politics in the third stream: the election of 2005 and
the change of government from red-green to a grand coalition. Although
the party political context had changed, there was continuity in the Ministry of Health administration. Although Ulla Schmidt lost the responsibility
for pension policy to Labour Minister Franz Mntefering, in the health
care field there was continuity of personnel, and she remained in office as
health minister. This may also be the reason why the ministry is considered
particularly influential in this reform process (Paquet 2009: 32).

558 Journal of Health Politics, Policy and Law

Joining the Streams

This brings us to how the three streams joined in the case of the 2007
health reform in Germany and to a summary of the influence of the Dutch
model. The key driving force of the reform was in the stream of (national)
politics. The health reform was one of the most prestigious objects of
the grand coalition; it had to be successful to prove that the government
was capable of acting. Although, according to Kingdon, policy windows
can generally also be opened in the stream of problem definition (where
cross-border experiences may be even more influential), that was not the
case here. This policy window was the reason that policy entrepreneurs
like Wolfram Richter and researchers concerned with the Dutch health
fund model suddenly had an exceptional chance to bring their ideas forward. While before the elections these ideas had not made it to the politicians short lists, their potential character as a compromise altered this
situation.
It seems that Richter and the proposal of the scientific advisory board
of the finance ministry played the decisive role for the decision to base the
compromise on a health fund model (interviews G 2, 5, 6; see also Wasem
2009). Paquet (2009: 36) reports that Merkel herself is said to have drawn
Schmidts attention to the proposal of the scientific advisory board of the
Ministry of Finance. However, parallel to this, the proposal met preparatory work on a compromise in the health ministry that was based on the
Dutch experience. There was already an extensive and ongoing exchange
with Dutch colleagues at different levels before the 2005 elections, and
the ministry administration perceives itself as internationally oriented and
aware of what happens in other countries (interviews G 4, 5). At a rather
early stage after the election, agreement was reached between the health
ministry and the chancellery to found the compromise on a health fund
model. The ministry was well aware of the Dutch model pre- and post2006 and quickly understood that the health fund was a useful instrument
for achieving some of its aims. Among those aims was to combine the
GVK and PKV into one system, furthering the organizational reform of
the health insurance funds and their representation and bringing more
taxes into the system (interview G 5; see also Paquet 2009 for further
details).19 At the same time, the idea of a central contribution pool (Beitragspool) was not a new idea but had already been discussed by the min19. The argument concerning the taxes was that before convincing fiscal policy makers to
approve additional tax funding of the health system, the system needed to be more transparent
than it was under the previous risk-structure-adjustment scheme (interview G 5).

Leiber, Gre, and Manouguian Dutch Model for German Reform 559

istry within the context of a proposal of the Allgemeine Ortskrankenkasse

(AOK) during the 1990s (interview G 5).20
The decisive time period for the reform compromise was from the
election in September 2005 until the coalition committee decided on the
so-called Eckpunkte fr die Gesundheitsreform (cornerstones for health
reform) in July 2006. The coalition contract of November 11, 2005, did
not yet include any details of a compromise. However, the partners committed themselves to finding a common solution for health care financing,
despite the fact that the Brgerversicherung and Kopfpauschale were previously considered irreconcilable. The first drafts of a compromise proposal came from the influential Ministry of Health (Schroeder and Paquet
2009: 278). Moreover, two working groups, one from the SPD and one
from the CDU/CSU, were installed to work on the details of a coalition
compromise. This was a phase of intensive information exchange with the
Netherlands. There were mutual visits of the Dutch and German health
ministers and also an extensive exchange on a working level. In addition,
scientists such as Jrgen Wasem and Reinhard Busse were invited to the
working groups of the coalition partners to report on the Dutch model;
there was a representative of the Dutch ministry in the coalition working
groups, and the Bundestag Committee of Health also visited the Netherlands (interviews G 2, 3, 4, 6; Wasem 2009). This may be the reason why
the Dutch government was quick to publish information about the Dutch
reform on the Ministry of Healths Web site in German and publicly claim
an influence on the German reform process (interview G 6). In January
2006 the German media reported that Schmidt was planning a reform
according to the Dutch model (e.g., AFP 2006; Niejahr 2006; PolkeMajewski 2006; manager-magazin 2006). In April 2006 Volker Kauder
of the CDU Parliamentary Party took up the health fund proposal for the
first time publicly in a magazine interview (Stern 2006).
So when we examine how the three streams joined, what we see is that
the importance of the Dutch model was rather marginal in the problem
recognition and policy proposals preceding the reform. However, once
the policy window was opened in the political stream and a health fund
solution accepted as a compromise (whether the initial fund compromise
itself was inspired by the Dutch model or Richter or both simultaneously
is not 100 percent clear; surely it was not the Dutch model alone, and the
idea of a central collection of contributions was not new to the ministry),
the Dutch experience was investigated intensely as a kind of background
20. The AOK is one of the largest social insurance providers in Germany.

560 Journal of Health Politics, Policy and Law

information. Our interviews suggest that part of this process actually

consisted of a rather technical or empirical interest in how such a system works, for example, with respect to potentially including the PKV in
the health-based risk-equalization scheme (interview G 4). Concerning
other issues, however, the learning also seems to have aimed at support
for the already existing political interests of the coalition partners (interview G 2). In addition, at the time when the German decision makers
adopted their reform, the new Dutch model was only beginning to show
the first effects in terms of cost containment, quality, and access. This
sharply contradicts the image of an evidence-based policy transfer that is
taken seriously. Also, Richters proposal was only taken as leverage for
the compromise. Richter himself was never invited to further explain his
ideas (interview G 1; Feldenkirchen 2006). In addition, when comparing
the final results of the German health fund model with the Dutch model
(before and after 2006) and to Richters proposal, we see that important
differences remained.
Compared with the Dutch model, these differences primarily relate to
the continued existence of substitute private health insurance, the share of
health care expenditure financed by flat-rate premiums, and the organization of transfers to low-income individuals. Differences between the
first step of the Richter proposal and the GKV-WSG are less pronounced
(Richter 2007). These differences primarily concern the terminology
(Gesundheitsfonds versus Inkassostelle), the organization of transfers to
low-income individuals, and the administration of the flow of payments.
Finally, Richter also criticizes the option of social health insurers to calculate income-dependent contribution rates instead of flat-rate premiums
to cover the difference between health care expenditure and income from
the central fund.
Conclusion and Future Research
Perspectives

By analytically drawing on Kingdons approach of the three streams,

this article followed two main objectives. The first was to understand the
extent to which the German health reform was actually influenced by the
Dutch model. While the evolution of this reform has already been analyzed from the perspective of actors interests and party political conflict
lines, this question has not yet been systematically addressed beyond a
mere description of institutional similarities between the two health systems. Second, in theoretical terms, the case study aimed to inform us

Leiber, Gre, and Manouguian Dutch Model for German Reform 561

inductively about how ideas from abroad enter government agendas. In

particular, we wanted to use this example as a case in point for how ideas
can be used as political power resources.
To the first question, our answer is yes, the Dutch model influenced German health care reform but to a more limited degree than we might have
expected by simply comparing their institutional similarities, and only at
a certain phase. Looking through the analytic lens of the three streams
allowed us to show that it was above all a change in national politics that
brought the Dutch experiencewhich was rather neglected before the
electionback in. In addition, independently of the Dutch model, other
policy entrepreneursthat is, Richter and the scientific advisory board
of the finance ministrypointed in a similar direction.
When considering the second question, we found that the way the
involved ministerial units and politicians learned from the Netherlands
in this case sharply contrasts with an image of solving policy problems
either by lesson drawing or transnational deliberation. In respect to the
politically highly salient issue of financing health care, learning from
the Netherlands was first of all about solving problems in the realm of
politics, that is, finding a way to prove the grand coalition capable of acting. However, once the principal direction of a compromise was set, there
was also more room for lesson drawing on more technical issues such
as mechanisms for integrating private insurance into a health-based risk
equalization scheme (on the likely cross-national spread of very technical
instruments in health policy, see also Schmid and Gtze 2009). But even
these rather technical discussions seem to have been very much embedded
in a national interest background, not concerned about copying a consis
tent foreign model but selectively making use of certain experiences from
abroad to develop a national model amid strong political constraints.
We are aware that during the past decades of almost uninterrupted
reforms in both countries, Dutch and German policy makers have
exchanged experience before. In the late 1980s the German health ministry
even seconded a high-level official to the German embassy in The Hague
for four years to study the Dutch reforms associated with the Dekker
Commission.21 Since the mid-1990s there has been a regular exchange
between the health ministries in a four-country conference, also including experts from Canada and the United States, and there is preliminary
evidence that the Dutch model was also important for the introduction of
the German Health Structure Act in 1992 (interview G 7). Thus the latest
21. We are very grateful to one of the anonymous referees for this information.

562 Journal of Health Politics, Policy and Law

German health reform may not be the only incidence of cross-national

policy transfer between the two countries. To avoid the premature conclusions on policy learning criticized above in the first section, however, each
incidence needs a thorough, in-depth qualitative analysis. In this article
we started by analyzing the circumstances of policy transfer from the
Netherlands to Germany in the 2007 German health reform that made the
Dutch and German health systems more similar to each other than ever
before. In our future research we seek to show whether what we observed
here applies to other crucial turning points of health reform as well.
In this article we also have not linked the streams approach to other
phases of the policy cycle to see whether cross-border learning plays out
differently (or is less pronounced) in policy formulation or implementation. Another challenging future task would be to reverse the perspective,
using the transfer of ideas not as an independent but as the dependent
variable, specifying for each stream under which conditions cross-national
policy transfer is considered most likely. In the stream of problem definition, the international orientation of policy entrepreneurs (on the importance of welfare elitesi.e., those involved in social policy making and
policy making for the welfare statefor policy change, see also Hassenteufel and Palier 2007; Hassenteufel et al. 2010), as well as comparative evidence showing that the home country is a poor performer and
the model country a good performer, might be relevant. In the stream
of policy proposals, a technical matter with a low degree of politicization might be more likely to be transferred, further enhanced by the
international orientation of policy entrepreneurs andin the stream of
politicsthe government administration. Finally, in theoretical terms, an
approach based on Kingdons streams bears the potential for combining
idea-based and interest-based analyses of welfare state change.

References
AFP. 2006. Gesundheitsreformohne Ulla Schmidt? [Health ReformWithout Ulla
Schmidt?] RP-Online, January 1. www.rp-online.de/public/article/politik/deutsch
land/170294/Gesundheitsreform-ohne-Ulla-Schmidt.html.
Agasi, S. 2008. Die Krankenversicherung in den Niederlanden zwei Jahre nach der
ReformFinanzentwicklungund Markttrends [The Dutch Health Insurance Two
Years after the ReformFinancial Development and Market Trends]. Zeitschrift
fr Sozialreform 54:279303.
Bandelow, N., and P. Hassenteufel. 2006. Mehrheitsdemokratische Politikblockaden

Leiber, Gre, and Manouguian Dutch Model for German Reform 563

und verhandlungsdemokratischer Reformeifer [Political Blockade in Majoritarian

Democracies, Eagerness for Reform in Consensual Democracies]. In Soziologie
der Gesundheit [Sociology of Health], ed. Claus Wendt and Christof Wolf, special
issue, Klner Zeitschrift fr Soziologie 46:320342.
Bandelow, N., and M. Schade. 2009. Konsens im Dissens? Konflikte in der Gesundheitsreform der groen Koalition [Consensus in Dissent? Conflicts in the Health
Reform of the Grand Coalition]. In Gesundheitsreform 2007: Nach der Reform
ist vor der Reform [Health Reform 2007: After the Reform Is before the Reform],
ed. W. Schrder and R. Paquet, 5876. Wiesbaden: VS Verlag fr Sozialwissenschaften.
Bland, D. 2005. Ideas and Social Policy: An Institutionalist Perspective. Social Policy
and Administration 39:118.
. 2010. Policy Change and Health Care Research. Journal of Health Politics,
Policy and Law 35:615641.
Bonoli, G., and B. Palier. 2000. How Do Welfare States Change? Institutions and
Their Impact on the Politics of Welfare State Reform in Western Europe. European
Review 8:333352.
Braun, D., and F. Gilardi. 2006. Taking Galtons Problem Seriously: Towards a Theory of Policy Diffusion. Journal of Theoretical Politics 18:298322.
Braun, D., F. Gilardi, K. Fglister, and S. Luyet. 2007. Ex Pluribus Unum: Integrating the Different Strands of Policy Diffusion Theory. In Transfer, Diffusion und
Konvergenz von Politiken [Transfer, Diffusion, and Convergence of Policies], ed.
K. Holzinger, H. Jrgens, and C. Knill, special issue, Politische Vierteljahresschrift
38:3955.
Brown, L. D. 1998. Exceptionalism as the Rule? U.S. Health Policy Innovation and
Cross-National Learning. Journal of Health Politics, Policy and Law 23:3551.
Cohen, M., J. March, and J. Olsen. 1972. A Garbage Can Model of Organizational
Choice. Administrative Science Quarterly 17:125.
Dobbin, F., B. Simmons, and G. Garrett. 2007. The Global Diffusion of Public Policies: Social Construction, Coercion, Competition, or Learning? Annual Review of
Sociology 33:449472.
Dhler, M., and P. Hassenteufel. 1995. Akteurkonstellationen in der Krankenversicherungspolitik: Ein deutsch-franzsischer Vergleich [Actor Constellations in the
Politics of Health Insurance: A Franco-German Comparison]. Zeitschrift fr Sozialreform 41:804822.
Dolowitz, D., and D. Marsh. 1996. Who Learns What from Whom: A Review of the
Policy Transfer Literature. Political Studies 44:343357.
. 2000. Learning from Abroad: The Role of Policy Transfer in Contemporary
Policy-Making. Governance: An International Journal of Policy and Administration 13:524.
Feldenkirchen, M. 2006. Eins plus eins = null [One Plus One = Zero]. Spiegel, September 18.
Fleckenstein, T. 2006. Europeanisation of German Labour Market Policy? The European Employment Strategy Scrutinised. German Politics 15:84301.
Freeman, R. 1999. Policy Transfer in the Health Sector. Unpublished working paper.

564 Journal of Health Politics, Policy and Law

. 2000. Health Policy and the Problem of Learning. Unpublished working

paper.
Gerlinger, T. 2004. PrivatisierungLiberalisierungRe-Regulierung: Konturen des
Umbaus des Gesundheitssystems [PrivatizationLiberalizationRe-regulation:
Contours of Health System Reform]. WSI-Mitteilungen 57:501506.
Gerlinger, T., K. Mosebach, and R. Schmucker. 2007. Wettbewerbssteuerung in der
Gesundheitspolitik: Die Auswirkungen des GKV-WSG auf das Akteurshandeln
im Gesundheitswesen [Governance by Competition in Health Policies: Effects
of the GKV-WSG in Actors Behavior in the Health System]. Discussion Paper 1,
Frankfurt/M.: Institut fr Medizinische Soziologie, Fachbereich Humanmedizin
der Johann Wolfgang Goethe-Universitt.
Giaimo, S., and P. Manow. 1997. Institutions and Ideas into Politics: Health Care
Reform in Britain and Germany. In Health Policy Reform, National Variations
and Globalization, ed. C. Altenstetter and J. W. Bjrkman, 175202. New York:
St. Martin.
. 1999. Adapting the Welfare State: The Case of Health Care Reform in Britain,
Germany, and the United States. Comparative Political Studies 32:9671000.
Gpffarth, D., S. Gre, K. Jakobs, and J. Wasem, eds. 2007. Jahrbuch Risikostrukturausgleich 2007G esundheitsfonds [Yearbook Risk Adjustment Fund
2007Health Fund]. St. Augustin: Asgard-Verlag.
Gtze, R., M. Cacace, and H. Rothgang. 2008. Von der Risiko-zur Anbieterselektion:
Eigendynamiken wettbewerblicher Reformen in Gesundheitssystemen des Sozialversicherungstyps [From Risk Selection to Selective Contracting: Market Reforms
in Social Health Insurance Systems]. Zeitschrift fr Sozialreform 55:149175.
Greener, I. 2002. Understanding NHS Reform: The Policy Transfer, Social Learning,
and Path-Dependency Perspectives. Governance 15:161183.
Gre, S. 2006. Regulated Competition in Social Health Insurance: A Three-Country
Comparison. International Social Security Review 59:2747.
. 2007. Private Health Insurance in Germany: Consequences of a Dual System.
Healthcare Policy 3:2937.
Gre, S., and M. Manouguian. 2007. Der Gesundheitsfonds vor dem Hintergrund der
Erfahrungen in den Niederlanden [The Health Fund against the Background of
Dutch Experience]. In Jahrbuch Risikostrukturausgleich 2007Gesundheitsfonds
[Yearbook Risk Adjustment Fund 2007Health Fund], ed. D. Gpffarth, S. Gre,
K. Jakobs, and J. Wasem, 231247. St. Augustin: Asgard.
Gre, S., M. Manougiuan, A. Walendzik, and J. Wasem. 2008. Gesundheitsfonds und
Finanzierungsreform im GKV-WSG [Health Care Funds and Finance Reform in
GKV-WSG]. Gesundheit und Gesellschaft Wissenschaft 8:1623.
Gre, S., M. Manouguian, and J. Wasem. 2006. Krankenversicherungsreform in den
Niederlanden: Vorbild fr einen Kompromiss zwischen Brgerversicherung und
Pauschalprmie in Deutschland? Studie im Auftrag der Hans-Bckler-Stiftung
[Health Insurance Reform in the Netherlands: Model for a Compromise between
Citizens Insurance and Flat Rate Premium in Germany? Study for the Hans Bckler Foundation, Duisburg-Essen]. Hans Bckler Foundation, Duisburg-Essen. www
.boeckler.de/pdf_fof/S-2006-812-4-1.pdf (accessed May 11, 2010).

Leiber, Gre, and Manouguian Dutch Model for German Reform 565

. 2007. Health Insurance Reform in the Netherlands. DICE ReportJournal

for Institutional Comparisons 5 (1): 6367.
Gre, S., A. B. Pfaff, and G. G. Wagner. 2005. Zwischen Kopfpauschale und Brgerprmie [Between Flat Rate Premium and Citizens Premium]. Dsseldorf: HansBckler-Stiftung.
Haarmann, A., T. Klenk, and P. Weyrauch. 2008. Beyond Policy Reforms: Governance
Reforms in the Health Insurance Sector: Germany, France, and the Netherlands
Compared. Working paper, University of Bath.
Hacker, J. S. 2004. Privatizing Risk without Privatizing the Welfare State: The Hidden Politics of Social Policy Retrenchment in the United States. American Political
Science Review 98:243260.
Hall, P. 1993. Paradigm, Social Learning, and the State: The Case of Economic Policy
in Britain. Comparative Politics 25:275296.
Hassenteufel, P. 1996. The Medical Profession and Health Insurance Policies: A
Franco-German Comparison. Journal of European Public Policy 3:461480.
Hassenteufel, P., and B. Palier. 2007. Towards Neo-Bismarckian Health Care States?
Comparing Health Insurance Reforms in Bismarckian Welfare Systems. Social
Policy and Administration 41:574596.
Hassenteufel, P., M. Smyrl, W. Genieys, and F. J. Moreno-Fuentes. 2010. Programmatic Actors and the Transformation of European Health Care States. Journal of
Health Politics, Policy and Law 35:517538.
Helderman, J.-K., F. T. Schut, T. E. D. van der Grinten, and W. P. M. M. van de Ven.
2005. Market-Oriented Health Care Reforms and Policy Learning in the Netherlands. Journal of Health Politics, Policy and Law 30:189209.
Holzinger, K., and C. Knill. 2005. Causes and Conditions of Cross-National Policy
Convergence. Journal of European Public Policy 12:775796.
Immergut, E. 1991. Institutions, Veto Points, and Policy Results: A Comparative
Analysis of Health Care. Journal of Public Policy 11:391416.
Kingdon, J. W. 1984. Agendas, Alternatives, and Public Policies. Boston: Little,
Brown.
. 1993. How Do Issues Get on Public Policy Agendas? In Sociology and the
Public Agenda, ed. W. J. Wilson, 4050. London: Sage.
. 2003. Agendas, Alternatives, and Public Policies. 2nd ed. New York: Longman.
Klein, R. 1997. Learning from Others: Shall the Last Be the First? Journal of Health
Politics, Policy and Law 22:12671278.
Knieps, F. 2007. Der Gesundheitsfonds aus Sicht der Politik [The Health Fund
from the Perspective of Politics]. In Jahrbuch Risikostrukturausgleich 2007
Gesundheitsfonds [Yearbook Risk Adjustment Fund 2007Health Fund], ed.
D. Gpffarth, S. Gre, K. Jakobs, and J. Wasem, 926. St. Augustin: Asgard.
Leiber, S. 2007. Paradigmatic Change in Social Insurance Countries? Assessing Recent
Health Care Reforms in Germany, the Netherlands, and Austria. Paper presented at
the ESPAnet Conference, Vienna, September 2022.
Leiber, S., and M. Manouguian. 2008. Between Competition and Solidarity: Changing
Ideas and Their Consequences in the German and Dutch Health Insurance Systems.
Paper presented at the ESPAnet Conference, Helsinki, September 1820.

566 Journal of Health Politics, Policy and Law

manager-magazin. 2006. Gesundheitsreform soll Chefsache werden [Health

Reform Is Given Top Priority]. www.manager-magazin.de/unternehmen/artikel/
0,2828,394115,00.html (accessed December 8, 2009).
Manouguian, M., S. Gre, and J. Wasem. 2006. Die niederlndische Krankenversicherungsreformein Vorbild fr das deutsche GKV-WSG? [The Dutch Health
ReformModel for the German GKV-WSG?] Gesundheits- und Sozialpolitik
60:3034.
Marmor, T., R. Freeman, and K. Okma. 2005. Comparative Perspectives and Policy
Learning in the World of Health Care. Journal of Comparative Policy Analysis
7:331348.
Marsh, D., and J. Sharman. 2009. Policy Diffusion and Policy Transfer. Policy Studies
30:269288.
Moran, M. 2000. Understanding the Welfare State: The Care of Health Care. British
Journal of Politics and International Relations 2:135160.
Niejahr, E. 2006. Erste Hilfe aus Den HaagDie Niederlnder haben eine Gesundheitsreform vollbracht, die allen gefllt. Hierzulande beginnt die Debatte erst
[First Aid from The HagueThe Dutch Have Carried Out a Health Reform That
Pleases Everyone]. Zeit online, March 30. www.zeit.de/2006/14/Erste_Hilfe_aus
_Den_Haag (accessed December 8, 2009).
Okma, K. G. H. 2008. Learning and Mislearning across Borders: What Can We (Not)
Learn from the 2006 Health Care Reform in the Netherlands? Commentary on
Rosenau and Lako. Journal of Health Politics, Policy and Law 33:10571071.
Palier, B., and C. Martin, eds. 2008. Reforming the Bismarckian Welfare Systems.
Oxford: Blackwell.
Paquet, R. 2009. Motor der Reform und Schaltzentrale: Die Rolle des Bundesministeriums fr Gesundheit in der Gesundheitsreform 2007 [The Motor of the Reform
and Control Center: The Role of the Federal Ministry of Health in the Health
Reform 2007]. In Gesundheitsreform 2007: Nach der Reform ist vor der Reform
[Health Reform 2007: After the Reform Is before the Reform], ed. W. Schrder and
R. Paquet, 3249. Wiesbaden: VS Verlag fr Sozialwissenschaften.
Polke-Majewski, K. 2006. Hollndische KopfversicherungIst eine gesundheitspolitische Einigung zwischen Schwarz und Rot mglich? Eine Analyse [Dutch Flat
Rate InsuranceIs a Compromise between the Black and the Red Possible? An
Analysis]. Zeit Online. www.zeit.de/online/2006/03/gesundheitsreform_holland
(accessed December 8, 2009).
Richter, W. F. 2005. Gesundheitsprmie oder Brgerversicherung? Ein Kompromiss
vorschlag [Health Premium or Citizens Insurance? Suggestion for a Compromise].
Wirtschaftsdienst 11:693697.
. 2007. Der Gesundheitsfonds als Kernstck einer Reform [The Health Fund as
Core of a Reform]. In Jahrbuch Risikostrukturausgleich 2007Gesundheitsfonds
[Yearbook Risk Adjustment 2007Health Fund], ed. D. Gpffarth, S. Gre,
K. Jakobs, and J. Wasem, 7195. St. Augustin: Asgard-Verlag.
Rose, R. 1991. What Is Lesson-Drawing? Journal of Public Policy 11:130.
Rosenau, P. V., and C. J. Lako. 2008. An Experiment with Regulated Competition and

Leiber, Gre, and Manouguian Dutch Model for German Reform 567

Individual Mandates for Universal Health Care: The New Dutch Health Insurance
System. Journal of Health Politics, Policy and Law 33:10311055.
Rosewitz, B., and D. Webber. 1990. Reformsuche und Reformblockaden im deutschen
Gesundheitswesen [Reform Search and Reform Blockade in the German Health
System]. Frankfurt: Campus Verlag.
Rrup-Kommission. 2003. Bericht fr die Nachhaltigkeit in der Finanzierung der
Sozialen Sicherungssysteme [Report for the Sustainability of Social Insurance
Financing]. Berlin: Bundesministerin fr Gesundheit und Soziale Sicher
ung. infomed.mds-ev.de/sindbad.nsf/de083cd4fce51312c12571e700442bef/
ed702a4fc25bb00200256d94003e84d7/$FILE/RUERUP_Bericht.pdf (accessed
December 8, 2009).
Schmid, A., and R. Gtze. 2009. Cross-national Policy Learning in Health System
Reform: The Case of Diagnosis-Related Groups. International Social Security
Review 62 (4): 2140.
Schroeder, W., and R. Paquet, eds. 2009. Gesundheitsreform 2007Nach der Reform
ist vor der Reform [Health Reform 2007After the Reform Is before the Reform].
Wiesbaden: VS Verlag.
Schut, F. T., and W. P. M. M. van de Ven. 2005. Rationing and Competition in the
Dutch Health Care System. Health Economics 14:5974.
Stern. 2006. Gesundheitsreform: Kinder-Versicherung aus Steuern [Health Reform:
Childrens Insurance Tax Financed]. April 11. www.stern.de/wirtschaft/finanzen
-versicherung/versicherung/:Gesundheitsreform-Kinder-Versicherung-Steuern/
559301.html (accessed December 8, 2009).
Streeck, W., and K. Thelen. 2005. Introduction: Institutional Change in Advanced
Political Economies. In Beyond Continuity: Institutional Change in Advanced
Political Economies, ed. W. Streeck and K. Thelen, 139. Oxford: Oxford University Press.
Taylor-Gooby, P., ed. 2005. Ideas and Welfare State Reform in Western Europe.
Houndmills, UK: Palgrave Macmillan.
van de Ven, W. P. M. M., and F. T. Schut. 2008. Universal Mandatory Health Insurance
in the Netherlands: A Model for the United States? Health Affairs 27:771781.
Walser, C. 2006. Brgerversicherung mit einer Kopfpauschale: Nach der Gesundheitsreform in den Niederlanden: Eine neue Krankenversicherung fr jeden [Citizens
Insurance with Flat Rate Premium: After the Dutch Health Reform: A New Health
Insurance for Everyone]. Soziale Sicherheit 55:8792.
Wasem, J. 2009. Wissenschaftliche Politikberatung und Gesundheitsreform 2007 [Scientific Policy Advice and Health Reform 2007]. In Gesundheitsreform 2007: Nach
der Reform ist vor der Reform [Health Reform 2007: After the Reform Is before
the Reform], ed. W. Schrder and R. Paquet, 247255. Wiesbaden: VS Verlag fr
Sozialwissenschaften.
Wilsford, D. 1994. Path Dependency, or Why History Makes It Difficult but Not
Impossible to Reform Health Care Systems in a Big Way. Journal of Public Policy
14:251283.
Wissenschaftlicher Beirat beim Bundesministerium der Finanzen. 2005. Zur Reform

568 Journal of Health Politics, Policy and Law

der Gesetzlichen Krankenversicherung: Ein Konsensmodell [On the Reform of the

Statutory Health Insurance: A Consensus Model]. www.bundesfinanzministerium
.de/nn_25412/DE/BMF__Startseite/Service/Downloads/Abt__I/0510171a3001
,templateId=raw,property=publicationFile.pdf (accessed December 8, 2009).
Zeitlin, J. 2005. The Open Method of Co-ordination in Action: Theoretical Promises,
Empirical Realities, Reform Strategy. In The Open Method of Co-ordination in
Action: The European Employment and Social Inclusion Strategies, ed. J. Zeitlin
and P. Pochet, 447503. Brussels: PIE-Peter Lang.