CAPÍTULO PRIMERO
1 6 LAS ESCUELAS.
In order to compare health costs consistently across countries, our base line assumption was that health care was provided free at the point of demand, regardless of means, in return for taxes, health levies or social security contributions already covered in Chapter 3. Only health insurance premiums that are required to match this assumption and any costs that families have to pay for a standard packet of health care were included in the matrix. In order to compare like with like, national informants were asked to cost a standard health package consisting of the following:
• No inpatient episodes.
• Each member of the family visits the dentist for a check-up twice per year and has a cavity filled on one of these visits.
• Each member of the family visits the general practitioner once per year and receives a prescription for a standard antibiotic.
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The assumption underlying this is that the quality of this package of care is the same in each country. This is unlikely to be the case. For example in Greece, there is currently no system of general practitioners, although a free system is expected to be implemented by 2006.
Charges payable after any rebates or deductions or refunds were estimated and expressed as a monthly sum for each family. Table 6.1 summarises the extent of charges and exemptions for different services for children. Denmark, Germany, the Netherlands and the UK have no charges for children. Finland only has hospital charges for children, Italy only has dentist charges and Austria and Sweden, only prescription charges. Belgium, France, Greece, Ireland, Japan, Luxembourg, Portugal and USA charge children for all types of available health care.
Of those who charge for health care, all except Belgium, Finland, Israel, Luxembourg and Spain have some kind of exemption for children. Six countries have age-related exemptions. Australia (New South Wales) exempts children in grades 2, 4, 6 and 8 and children up to year 8 in high school from dental treatment if needed. Children under six are exempt from all charges in Italy, from GP charges in New Zealand and from prescription charges direct from the GP in Japan. In Japan, there are also local arrangements for children under three. Norway exempts under sevens and Portugal under 13s from all health care. Austria, Canada, France, Ireland and Italy have income-related or means-tested exemptions. In Sweden, there is a limit to annual charges for prescriptions and in the USA, health care is free for Medicaid recipients.
Table 6.1
Health costs for children
Charges for children
Country Hosp GP Dent Prec. Exemptions
Australia no no yes yes Varies. NSW: risk assessment for all children in kindergarten and grades 2, 4, 6 and 8 and free dental care. Up to year 8s free dentist if got toothache.
Austria no no no yes Income-related
Belgium yes yes yes yes no
Canada no no yes yes Low income in some provinces
Denmark no no no no -
Finland yes no no no no
France yes yes yes yes Income-related
Germany no no no no -
Greece yes - yes yes No charges for emergency hospital treatment or dental treatment in Greek NHS hospital. All medical expenses are tax deductible Ireland yes yes yes yes Means tested
Israel no no yes yes no
Italy no no yes no For children under 6 income-related
Japan yes yes yes yes Under 6 exempt from charges for prescriptions direct from GP. Local exemptions for under 3s
Luxembourg yes yes yes yes no
Netherlands no no no no -
New Zealand no yes no yes Under 6s free visit to GP.
Norway no yes yes yes Free for under 7s limit to annual charges Portugal yes yes yes yes Free for under 13s
Spain no no yes yes no
Sweden no no no yes Over yearly maximum costs prescriptions free
UK no no no no -
USA yes yes yes yes Free for medicaid.
Health costs
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Table 6.2 shows the charges and exemptions from charges for adults. All except Canada, Denmark, Greece, Israel and the Netherlands have some kind of exemption from health care for adults. Of those with an exemption, Japan, Spain and Sweden are the only countries that do not have some kind of income-related exemption for which adults with dependent children would be eligible. Indeed, these could be more generous for adults responsible for dependent children.
Table 6.2
Health costs for adults
Charges for children
Country Hosp GP Dent Prec. Exemptions
Australia no no yes yes Health card/pensioners concession card (income support recipients) Austria no yes yes yes Income-related
Belgium yes yes yes yes Reimbursement from sickness fund which is higher for some patients eg. long-term unemployed - does not cover total charge
Canada no no yes yes No
Denmark no no no yes No
Finland yes no yes no (Those born after 1946 using private dentists: 60% exemption)
France yes yes yes yes Income-related
Germany yes no no yes Income-related (contributory)
Greece yes - yes yes (No charges for emergency hospital treatment)
Ireland yes yes yes yes Means tested medical card. treatment benefit: dental, optical, hearing aids: PRSI conditions apply.
Israel no no yes yes No
Italy no no yes no For singles – income-related. Japan yes yes yes yes Elderly with low income.
Luxembourg yes yes yes yes Limit to annual charges for hospitalisation.
Netherlands no no yes no No
New Zealand no yes yes yes Community services card reduces gp and prescription charges (low- income people, pensioners and students).
Norway no yes yes yes Limit to annual charges
Portugal yes yes yes yes Low-income pensioners, low-income working people, pregnant women and women giving birth.
Spain no no yes yes Pensioners.
Sweden yes yes yes yes Pensioners.
UK no no yes yes Means tested
USA yes yes yes yes Free for medicaid.
6.4
Matrix analysis
Table 6.3 presents what a couple with two children has to pay in charges each month for the standard package of health. This is the total charge – not what has to be paid for a child. That is presented in Tables 6.4 for a one earner on average male earnings. What Table 6.3 shows is the variation in the total charge by income. It can be seen that there are no health charges of any kind in Finland and in many countries health charges are reduced or exempted for low-income families. This is the case in Australia, Austria, France, Germany, Italy, the Netherlands, New Zealand, the UK and the USA. In Belgium, Canada, Denmark, Greece, Ireland, Israel, Luxembourg, Norway, Portugal, Spain and Sweden health charges do not vary by earnings. In most countries health charges are only a small amount. However they are relatively large in the Netherlands and the USA.
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Table 6.3
Actual total health costs, couple plus two children £ per
month ppp
Country Case 2 Case 4 Case 6
Australia -0.6 -31.5 -31.5 Austria 0.0 -2.2 -2.2 Belgium -3.7 -3.7 -3.7 Canada -45.2 -45.2 -45.2 Denmark -5.5 -5.5 -5.5 Finland 0.0 0.0 0.0 France 0.0 -27.3 -27.3 Germany 0.0 -0.5 -0.5 Greece -6.6 -6.6 -6.6 Ireland -35.9 -35.9 -35.9 Israel -20.8 -20.8 -20.8 Italy 0.0 0.0 -9.2 Japan -6.2 -6.2 -5.7 Luxembourg -10.1 -10.1 -10.1 Netherlands -44.8 -232.8 -168.5 New Zealand -18.4 -22.8 -22.8 Norway -10.3 -10.3 -10.3 Portugal -2.5 -2.5 -2.5 Spain -25.7 -25.7 -25.7 Sweden -12.7 -12.7 -12.7 UK 0.0 -3.6 -3.6 USA -184.1 -368.3 -368.3
Case 2: One earner on half national average male earnings Case 4: One earner on national average male earnings
Case 6: Two earners on average male and half average female earnings
Table 6.4 presents the same data for a one-earner family on average male earnings. At this level of earnings families with children in more countries are expected to pay something towards their child health costs. However there are no charges at all in Finland, Germany, Israel, Sweden and the UK. Whereas in the Netherlands and the USA the charges are relatively high.
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Table 6.4
Health costs by family type and size. One earner average
male earnings (Case 4) £ per month ppp. [Negative amounts
are how much more families with children need to pay for a
standard health care package and positive sums are how
much less they have to pay than a childless couple or single
person.]
Lone parent Lone parent Couple +1 Couple +2 Couple +3 Country +1 aged 7 +2 aged 7 and 14 aged 7 aged 7 and 14 aged 7,14,17
Australia -7.8 -15.6 -7.8 -15.6 -23.0 Austria -0.3 -0.5 -0.3 -0.5 -0.7 Belgium -0.7 -1.7 -0.8 -1.7 -2.5 Canada -11.3 -22.6 -11.3 -22.6 -33.9 Denmark -0.2 -0.5 -0.2 -0.4 -0.6 Finland 0.0 0.0 0.0 0.0 0.0 France -7.5 -14.9 -2.5 -2.5 -2.5 Germany 0.0 0.0 0.0 0.0 0.0 Greece -1.6 -3.3 -1.6 -3.3 -4.9 Ireland -9.0 -17.9 -9.0 -17.9 -35.5 Israel 0.0 0.0 0.0 0.0 0.0 Italy -2.3 2.3 4.6 4.6 4.6 Japan -1.7 -3.4 -1.7 -3.4 -5.1 Luxembourg -2.5 -5.1 -2.5 -5.1 -7.6 Netherlands -54.3 -83.9 -27.8 -57.1 -86.8 New Zealand -1.8 -3.5 -1.8 -3.5 0.0 Norway -0.6 -1.1 -0.6 -1.1 -1.7 Portugal -0.2 -1.0 -0.2 -1.0 -1.8 Spain -6.4 -12.8 -6.4 -12.8 -19.2 Sweden 0.0 0.0 0.0 0.0 0.0 UK 0.0 0.0 0.0 0.0 0.0 USA -92.1 -184.1 -92.1 -184.1 -276.2
6.5
Future changes
Future changes in regards to health costs for children are planned in Belgium and Japan only. In Belgium, for children up to 15 years old there will be an extra protection (from 2002 onwards) via an individual maximum ceiling of 26.000 BEF per child (irrespective of household income). In Japan, the government has proposed the reform of health insurance which reduces the charge for children under three. Currently the charge for children is 30 per cent of medical costs (although many local authorities cover some proportion of the 30 per cent) and the rest (70 per cent) is covered by public health insurance. The reform will change this proportion to 20 per cent from 2004. After this change, combined with local authorities’ own measure, children under three will effectively receive health care free of charge. In New Zealand no plans have yet been implemented but there is some pressure to develop free health care for dependent children.
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6.6
Conclusion
Most countries have either free health care for children or they mitigate charges at low earnings levels. There are only two countries in which health charges represent a substantial drain on the child benefit package – the USA and the Netherlands. In Australia, Canada and Ireland they represent a lesser yet significant drain on the child benefit package.
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7 Maternity leave,
paternity leave, parental
leave and leave to care
for sick children
7.1
Introduction
Policies which enable parents to reconcile paid work with care include provision of childcare, as described in Chapter 5 and leave entitlement from work specifically for the purpose of caring for children. Leave from paid work encourages a balance between paid employment and unpaid care. Also, leave from paid work for both parents can specifically address gender equity both in the labour market but also in relation to unpaid care work by actively encouraging men’s role in childcare which, in turn, potentially enables women to participate in the labour market and to compete on equal terms as men. However, the right to time off work is not adequate by itself. Rather, it is the quality of leave and the extent of financial assistance that can serve to put the right to care for children into practice. Unpaid (or partially paid) leave disadvantages one-earner families and leave which is restricted to a narrow group of people, does not guarantee a job at the end of it or does not cover social insurance contributions, will not fully reconcile paid work with the caring of children. In this chapter we investigate four kinds of statutory leave to care for children: maternity leave, which is leave put aside for the mother only; paternity leave, which is leave only for the father; parental leave that can be taken by either parent but sometimes specifies a certain number of days or weeks to be taken by the mother or the father and leave to care for sick children. First we explore the changes that have taken place since 1996.