Socialized Medicine. Part 3: Belgium

Belgium, like Germany (covered in our first installment) and Israel (covered in our second installment), has a hybrid system that is basically state-regulated rather than state-run.

Belgium has six authorized HMO federations, called “ziekenfondsen” (sick funds) in Dutch and “mutualités” (mutual aid associations) in French. Three of these have always been affiliated with the three major political parties, as part of the peculiarly Belgian and (historically) Dutch phenomenon known as “pillarization” or “vertical pluralism” — where you voted for one major political party, belonged to the trade union affiliated with it, joined the sick fund associated with that,…

Of the two biggies: (1) The Christian Mutualities (CM) belong to the “pillar” of what used to be called the Catholic Party, later the Christian-Democratic party (a Catholic, socio-economically center to center-left, socially somewhat conservative party). (2) The Socialist Mutualities (SM) were always connected to the Belgian Workers Party, later the Socialist Party.

The smaller Liberal Mutualities (LM) are within the ambitus of Belgium’s pro-market party, which (confusingly for Americans) has been called the Liberal Party for most of its existence — the Dutch-speaking branch used to be called the Party for Freedom and Progress.

Desire for a “mutualité” not affiliated with a major party eventually led to the Neutral Mutuality, while self-employed people and professionals are catered to by the Professional Mutuality. There is also a small niche player restricted to railroad employees.

Much like Israel, people pay a social security tax, and the part set aside for healthcare goes to the State Institute for Health and Disability Insurance (Dutch acronym: RIZIV; French acronym INAMI), which manages a joint risk pool for the HMO federations.

Unlike Israel, healthcare at HMO polyclinics is the exception and care by private physicians the norm. Part of the reason is a longtime glut of doctors in Belgium: according to this table, Belgium has nearly twice as many physicians pro capita as the USA. The absence of admission exams to medical school until quite recently, as well as lack of incentives for the universities to weed out the unfit, led to serious quality control problems: while some Belgian doctors are as good as any you will find in the USA or Israel, I would not entrust my worst enemy to the “care” of some others. One has very limited opportunities for redress in  case of malpractice (which is distressingly common): in theory the Board of Medicine may suspend or cancel medical licenses, but in practice this step is rarely taken.

Access to physicians and procedures is not a major problem in Belgium: the real problem is locating competent ones. As these tend to build up clientele by word-of-mouth, particularly well-regarded specialists may have long waiting lists.

Dentistry in Belgium is cheap, and generally worth what you pay for it.

At least until recently, the HMOs had only limited incentives for cost containment, as they generally had no connection at all with GPs and specialists, and generally do not operate their own hospitals (which are either governmental, affiliated with various Catholic Church organizations, or university hospitals).

An “inverted population pyramid” (aging population, low childbirth) and Belgium’s traditionally ultra-liberal policy concerning immigrants have led to a situation where  the system in its current form is basically unsustainable.

A number of proposed measures in the USA have been given the controversial sobriquet “death panels”. Belgium, in fact, shares with The Netherlands the dubious distinction of having the most radical pro-euthanasia legislation (both passive and active) in the world. And in fact, there is serious evidence that the majority of such euthanasia takes place without patient’s consent.

When talking to medical professionals and others in Belgium, it is very hard to escape the conclusion that the enthusiasm of many Belgian politicians for legalizing euthanasia (except for a rearguard battle fought mainly by the Christian-Democrats)  is at least in part motivated by cost containment considerations — no matter how wide the rivers of mealy-mouthed, patronizing, condescending cant about “quality of life” and “dying with dignity”.

I cannot believe for even one moment that this is a road the USA would like to go down.