The Story of the Estonian Health Insurance Fund. 20 Years of Treatment and Insurance. Grupi autoridЧитать онлайн книгу.
visit to the doctor himself or he had to apply for special permission from representatives to request such an appointment. Whoever was not a member of the health insurance fund or a person of equivalent status also had to pay a fee for his visit, which was two kroons in the 1930’s. Any procedures performed also had to be paid for in addition.
The occupation of the Republic of Estonia by the Soviet Union in 1940 cut off the health care system’s path of development and the Soviet Semaško system was adopted, according to which health care was financed under the direction of the government from the state budget through centralised planning.
Rapid changes had far-reaching consequences. A large number of health care employees left Estonia during the Second World War and this had a severe effect on its manpower structure. The concentration of all attention on normative objectives led to an excessively large number of hospital beds.
There was no private sector in the health care system during the Soviet era. All citizens seemingly had unrestricted access to health care services, which were provided by salaried state employees. The preparation of medi cal employees and the quality and availability of health care services were evaluated in general terms.
Publication commemorating 25 years of activity of the Tallinn Municipal Enterprises Health Insurance Fund.
The search for innovative solutions for reshaping the social sphere began in the course of political changes in the 1980’s. The Association of Estonian Physicians (EAL) was re-founded on 11 June 1988. The establishment of an umbrella organisation made it possible to bring interest groups together and to start seeking and working through ideas for reorganising the health care system and its financing. Health care reform was initially not spoken of. Only the transformation of the existing system and putting that system in order was under consideration. Even though the idea existed to combine the health care and social welfare systems and to form joint social assistance funds at the local government level, these ideas did not yet emerge in the forefront.
The conviction that it would be appropriate for Estonia to apply the principles of insurance medicine was arrived at through the initiative of Dr. Laur Karu, the first president of the re-established Association of Estonian Physicians. The authors of the first drafts of sickness insurance legislation were Laur Karu, Enn Õunpuu and Georg Männik. These legislative drafts incorporated the principles of solidarity in health insurance. Regardless of intense work in developing this legislation, the insurance ideas that this trio shaped did not spread beyond a narrow circle of interested parties. Developments reached the stage in 1989 that the ESSR Council of Ministers Presidium decided to form a broad-based commission to work out proposals for reorganising the health care and social assistance of ESSR residents. For the first time, the understanding was arrived at that the new system should be based on social funds and health funds.
In short, it was felt that the correct approach would be to switch completely from state financing of health care and the social assistance system to insurance medicine founded on insurance taxes, including health tax. In the health care system, the decision was arrived at that further development must be based on the preferential development of ambulatory specialised medical care and that the transition to the family physician principle is advisable. Since the political trend was decentralisation, the increased inclusion of local governments in resolving social issues was seen as being necessary.
Examples of health insurance fund membership cards.
Vello Kuuse, who at that time still worked at Eesti Kindlustus (Estonian Insurance), participated in working out the concept of insurance medicine. Several working groups were created with the task of thoroughly studying the principles of health care and the insurance system. Knowledge was gathered from examples from other countries and several choices were discussed. Primarily doctors participated in the working groups. Arguments and misunderstandings emerged concerning terminology because the legislation of other countries was taken as the basis and the lack of terminology or its inadequacy in the model of society that had been in effect until then was frequently encountered in the course of translating that legislation. The ideas of that time were far from considering the health insurance fund as an organisational form because the structure of the system was seen primarily as structures of the ministry. At the same time, there were already ideas based on business where an association of health and social assistance insurance funds would be created as a public limited company in the ministry’s administrative field. One idea was to hand insurance operations over to Eesti Kindlustus. The possibility of the partial voluntary insurance of disability days was discussed in terms of benefits and the condition of being insured. There was also an idea to combine all the different funds, including the medical care fund that could possibly be created.
This preceding work culminated on 28 May 1990 when the Government of the Republic of Estonia made the decision to implement insurance medicine. The Ministry of Health Care was assigned the task of submitting an all-encompassing conception of insurance medicine by 25 September 1990. Health insurance was thought of as a fundamentally new, economically self-regulating health care system, where a person’s interest in preserving and strengthening his own health is central.
The results of the work of specialists and experts at the Ministry of Health Care led to the position that health insurance in Estonia should be founded on the following principles:
• The national budget would cover only the capital expenditures of medical institutions.
• Health care institutions will begin operations as autonomous commercial enterprises and their status would be equal to that of all other enterprises.
• Health care institutions will be transferred from national ownership to municipal ownership and opportunities for their privatisation will be created.
• Health insurance funds will be created for the administrative territory of each county and municipal government. The health insurance fund is a division of the independent insurance company that is to be created with the rights of a legal person.
• The insurance company is the umbrella organisation for the health funds. It is practical to create the insurance company as a public limited company.
• The compulsory health insurance tax rate will be established at 13 %.
• Voluntary health insurance is prescribed. The voluntary insurance contribution rate is 3–5 % of wages. The duration of the insurance agreement is five years.
• Voluntary health insurance contributions are tax free in calculating income.
Since discussions had lasted for several years and little time remained, draft legislation was submitted to the Government of the Republic instead of a conception. The legislation combined the ideas that had been discussed during the preceding years. There was still no concept yet of what the health insurance fund should be – the concept of toetuskassa (relief fund in Estonian) was used because according to the opinion of many people, the term haigekassa (literally sickness fund in Estonian) places too great an emphasis on illness and on being ill and thus this term was unsuitable. Another important clause stipulated that the legislation also covers people who have concluded voluntary insurance agreements.
Legislation concerning compulsory health insurance tax came next. It contained an interesting provision that stated that the health insurance tax rate is 13 %, of which 2/3 will go to local governments and 1/3 will be used to cover nationwide expenditures. All important draft legislation was completed by August of 1990 and was thereafter sent for broad-based consultation in order to arrive at a consensus, meaning that agencies, offices and county governments were included in consultations. It took several months to work through the proposals.
The next deadline in starting up insurance medicine was projected in the latest drafts of legislation as 1 July 1991 already. The most important key words that remained in use regardless of what version of draft legislation is considered were as