Preconditions for efficiency and affordability in competitive healthcare markets: Are they fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland? Ten years later.

From the mid-1990s several countries have introduced elements of the model of regulated competition in healthcare. In 2012 we assessed the extent to which in five countries ten important preconditions for achieving efficiency and affordability in competitive healthcare markets were fulfilled. In this paper we assess to what extent the fulfilment of these preconditions has changed ten years later. In 2022, as in 2012, in none of the five countries all preconditions are completely fulfilled. In the period 2012-2022 on balance there have been some improvements in the fulfillment of the preconditions, although to a different extent in the five countries. The only preconditions that were improved in most countries were 'consumer information and transparency' and 'cross-subsidies without incentives for risk selection'. On balance the Netherlands and Switzerland made most progress in the number of better fulfilled preconditions. For Belgium these preconditions no longer seem relevant because the idea of regulated competition has been completely abandoned. In Germany, Israel and Switzerland, the preconditions 'effective competition policy' and 'contestability of the markets' are not sufficiently fulfilled in 2022, just as in 2012. In Germany and Switzerland this also holds for the precondition 'freedom to contract and integrate'. Overall, the progress towards realizing the preconditions has been limited.