25 Coups de Plume

25 Coups de Plume 25 Coups de Plume 25 Coups de Plume By Mark Nichol What, precisely, is an overthrow, and what number of sorts of upsets are there? This post depicts an assortment of expressions utilizing the word, in addition to a variety of related terms. Upset, a word for an abrupt striking and additionally splendid act it likewise fills in as a truncation of â€Å"coup d’ã ©tat† originates from the French word overthrow, which means â€Å"stroke† or â€Å"blow†; at last, it’s from the Greek expression kolaphos by method of the Latin acquiring colaphos. Not many of the accompanying articulations have been broadly received into English, yet they’re all accessible for strict as well as informal use: 1. Upset la porte (â€Å"knock on the door†): a sign or calling 2. Upset bas (â€Å"low blow†): a shameful move 3. Upset d’archet (â€Å"stroke of the bow†): contact of the bow with at least one strings on a violin or a comparative instrument 4. Upset d’chance (â€Å"stroke of luck†): a blessed occasion 5. Upset d’eclat (â€Å"stroke of glory†): a sublime accomplishment 6. Upset d’ã ©tat (â€Å"stroke of state†): the topple of a national government by an administration group as a rule, components of the nation’s military 7. Overthrow d’oeil (â€Å"stroke of the eye†): an overview taken initially 8. Overthrow de coeur (â€Å"blow to the heart†): an extraordinary yet brief enthusiasm 9. Overthrow de pastel (â€Å"stroke of the pencil†): an outflow of aesthetic inventiveness 10. Overthrow de destin (â€Å"blow of fate†): a shocking occasion 11. Overthrow de foudre (â€Å"stroke of lightning†): an unforeseen unexpected occasion; additionally, all consuming, instant adoration 12. Overthrow de glotte (â€Å"stroke of the glottis†): a strategy in singing and talking method in which the glottis, the space between the vocal folds, is out of nowhere controlled by strong compression 13. Upset de grã ¢ce (â€Å"stroke of mercy†): a blow or shot to end the enduring of a mortally injured individual or creature; a metaphorically comparable act; or an unequivocal demonstration, occasion, or stroke 14. Upset de l’amitiã © (â€Å"stroke of friendship†): one (drink) for the street 15. Upset de principle (â€Å"stroke of the hand†): an unexpected, full-scale assault, or help 16. Upset de tuft (â€Å"stroke of the pen†): a clever or unbelievable manner of expression 17. Upset de poing (â€Å"stroke of the fist†): a punch, or a stun 18. Upset de pouce (â€Å"stroke of the thumb†): some assistance, or a poke 19. Upset de repos (â€Å"stroke of rest†): a chess move in which a player gets ready for a blow against the player’s adversary 20. Upset de sang (â€Å"stroke of blood†): outrageous indignation 21. Upset de th㠩ã ¢tre (â€Å"stroke of theater)†: an abrupt curve in a phase play’s content, or, when all is said in done, an unexpected unforeseen development or an unexpected impact; additionally, a fruitful stage creation 22. Overthrow du ciel (â€Å"stroke from heaven†): abrupt favorable luck 23. Overthrow dur (â€Å"stroke of trouble): an intense blow, or something hard to acknowledge 24. Overthrow en traã ®tre (â€Å"stroke of treachery†): a betray 25. Overthrow montã © (â€Å"stroke of fitting†): an edge up or con Numerous different expressions and articulations incorporate the word overthrow; those recorded above are only the vast majority of them that start with it. Among the others are upset pour overthrow (â€Å"blow for blow,† or â€Å"tit for tat†) and upset sur upset (â€Å"in speedy succession,† or â€Å"time after time†). Overthrow shows up in different utilizations, and related terms proliferate. An overthrow injury is one in which the head strikes an article, making injury the mind; the going with countercoup injury to the cerebrum happens when the head strikes a fixed item, making the mind sway against the skull too. Tallying upset is the demonstration of ruling or overcoming a rival in single battle without causing injury; in some Native American societies, a warrior won such eminence by striking an adversary or a foe position with a hand, a weapon, or an overthrow stick, or by taking an opponent’s weapon or his pony. Achievement in tallying overthrow, which required the honoree to pull back without injury, was recognized by indents trim in the upset stick or hawk quills worn in the honoree’s hair. Coupage has four particular implications: mixing two kinds of wine to adjust flavor, blending drugs in with different substances, expelling hair from a stow away, and tapping on the chest to help oust emissions, for example, in treatment for tuberculosis. Decoupage, irrelevant to any of these faculties, portrays improvement of an item with paper patterns and different materials. Different terms with the root word overthrow incorporate recover, which initially implied â€Å"to deduct,† however now the general sense is of remuneration for a misfortune, and beaucoup, a French expression meaning â€Å"many, an extraordinary number.† The last entered general utilization in American English by method of military faculty who had served in Vietnam, which had up to this point been a piece of French Indochina. Coupã ©, the word for a sort of carriage and, later, a style of vehicle, is connected; the sense is of something cut (with a stroke) down to a littler size. In this way, as well, is coupon, from the French word for â€Å"piece.† They are related with the action word adapt, much of the time found in the expression â€Å"cope with† and meaning â€Å"deal with challenges† and, less regularly, â€Å"prevail in battle or competition.† An adapting saw, in the interim, is a device with a little, slim, saw edge set in a U-molded edge, and a coppice (additionally rendered hedge) is a shrubbery of trees developed for cutting. Need to improve your English quickly a day? Get a membership and begin accepting our composing tips and activities day by day! Continue learning! Peruse the Vocabulary classification, check our mainstream posts, or pick a related post below:4 Types of Gerunds and Gerund PhrasesDifference among Squeezing and IroningHonorary versus Honourary

An Overview of the Top Awards and Honors for Economists

An Overview of the Top Awards and Honors for Economists As anyone might expect, the most esteemed honor that a living market analyst can get is the Nobel Prize in Economics, granted by the Royal Swedish Academy of Sciences. The Nobel Prize is, from numerous points of view, a lifetime accomplishment grant, notwithstanding the way that its frequently granted to financial analysts a long time before they resign. Since 2001, the prize itself has been 10 million Swedish kronor, which is identical to between $1 million and $2 million, contingent upon the conversion standard. The Nobel Prize can be part among various people, and prizes in financial aspects have been shared by up to three individuals in a given year. (At the point when a prize is shared, it is commonly the situation that the champs fields of study share a typical topic.) Winners of the Nobel Prize are called Nobel Laureates, since in old Greece shrub wreaths were utilized as an indication of triumph and respect. In fact talking, the Nobel Prize in Economics is anything but a genuine Nobel Prize. The Nobel Prizes were set up in 1895 by Alfred Nobel (upon his demise) in the classes of material science, science, writing, medication and harmony. The financial aspects prize is really named the Sveriges Riksbank Prize in Economic Sciences in Memory of Alfred Nobel and was built up and enriched by Sveriges Riksbank, Swedens national bank, in 1968 on the banks 300th commemoration. This qualification is generally unimportant from a down to earth viewpoint, since the prize sums and the designation and determination forms are the equivalent for the Economics prize with respect to the first Nobel Prizes. The primary Nobel Prize in Economics was granted in 1969 to the Dutch and Norwegian financial analysts Jan Tinbergen and Ragnar Frisch. Numerous financial experts have been granted from that point forward. Just a single lady, Elinor Ostrom in 2009, has won a Nobel Prize in Economics. The most renowned prize granted explicitly to an American market analyst (or a least a financial expert working in the United States at that point) is the John Bates Clark Medal. The John Bates Clark Medal is granted by the American Economic Association to whom it considers to be the most cultivated as well as promising financial specialist younger than forty. The main John Bates Clark Medal was granted in 1947 to Paul Samuelson, and, though the decoration used to be granted each other year, it has been granted in April of consistently since 2009. Due to the age limitation and the lofty idea of the honor, its lone characteristic that numerous financial analysts who win the John Bates Clark Medal later proceed to win the Nobel Prize in Economics. Truth be told, around 40 percent of John Bates Clark Medal champs have proceeded to win the Nobel Prize, regardless of the way that the main Nobel Prize in Economics wasnt granted until 1969. (Paul Samuelson, the main John Bates Clark Medal beneficiary, won only the subsequent Nobel Prize in Economics, granted in 1970.) One other honor that conveys a ton of weight in the financial matters world is the MacArthur Fellowship, otherwise called a virtuoso award. This honor is conceded by the John D. also, Catherine T. MacArthur Foundation, which reports by and large somewhere in the range of 20 and 30 beneficiaries every year. 850 champs have been picked between June 1981 and September 2011, and every victor gets a no surprises partnership of $500,000, paid out quarterly over a five-year time span. The MacArthur Fellowship is one of a kind in various manners. To start with, the selecting advisory group searches out individuals in a wide assortment of fields as opposed to concentrating on a specific region of study or mastery. Second, the cooperation is granted to people who display an ability to do imaginative and important work and is hence an interest in future outcomes as opposed to just a prize for past accomplishment. Third, the designating procedure is exceptionally cryptic and victors are uninformed that they are considerably getting looked at until they get a call disclosing to them that theyve won. As per the establishment, over twelve business analysts (or financial matters related social researchers) have won MacArthur Fellowships, starting with Michael Woodford in the debut year. Strikingly, six MacArthur Fellows (starting at 2015) - Esther Duflo, Kevin Murphy, Matthew Rabin, Emmanuel Saez, Raj Chetty, and Roland Fryer-have additionally won the John Bates Clark Medal. In spite of there being critical cover among the beneficiaries of these three honors, no business analyst has accomplished the triple crown of financial matters yet.

Changes in Official iBT Tests 2019 Editions

Changes in Official iBT Tests 2019 Editions Hey, I found library copies of the new editions of the Official iBT Tests books (Vol. 1, 3rd edition, Vol. 2, 2nd edition) to see what was new.The text seems to be 100% the same, except for a couple of references to online materials in the introduction. The old editions already had the reordered listening questions from the Official Guide (4th edition) and the varied Integrated writing prompts from the Official Guide (3rd Edition). Those are continued here, of course.The Tests books do NOT contain the longer independent writing prompts (with the warning about memorized examples) found in the Official Guide (4th Edition).The only difference I can see is that the tests are now delivered on DVD, rather than CD. I didnt examine every page, though, so let me know if there is something I can double check for you.For the record, these are 2019 publications. However, they will be somewhat obsolete when the TOEFL changes in August 1 of 2019. When that happens ETS will include an insert in fut ure printings of their books that describe the new version of the test. This does not mean they will update them! The insert will just be a piece of paper that describes the changes. ETS does not know when the actual text of the books will be updated.Update from 2020: ETS has hinted that new editions of some of their books will be published this year, but nothing has been made official.

Keeping The Minimum Drinking Age - 864 Words

Keeping the Minimum Drinking Age In 1984, the United States’ federal government passed the National Minimum Drinking Age Act. Under this act, the federal government gives highway funds to States that forbid people under the age of twenty-one years old from â€Å"purchasing or publicly possessing alcoholic beverages†(23 U.S.C.  § 158). The incentive created a sense of a standardized minimum drinking age when legally there cannot be a federal minimum drinking age. Even though this Act has been in effect for decades, there are many debates on whether or not the age should be changed. The minimum legal drinking age should stay the same because it prevents a large number of drinking and driving accidents; it reduces overall alcohol consumption; and it has very horrible health effects on youth. Reducing drinking and driving was a goal of having a minimum drinking age of twenty-one. Before 1984, all states had their own minimum drinking age. These ages ranged from eighteen to twenty-one. A majority of states selected their minimum age as eighteen years old. If one were not able to legally purchase alcohol in his or her state, the person would drive to another state to drink legally. Many people would get into fatal accidents on their way home because they would be drunk. This caught a great deal of attention by the public. The nickname blood-borders was given to the borders between states with two different minimum drinking ages since many people would die in these drinking andShow MoreRelatedKeeping The Minimum Drinking Age880 Words   |  4 Pages Keeping the Minimum Drinking Age In 1984, the United States’ federal government passed the National Minimum Drinking Age Act. Under this Act, the federal government gives highway funds to States that forbid people under the age of twenty-one years old from â€Å"purchasing or publicly possessing alcoholic beverages†(23 U.S.C.  § 158). The incentive created a sense of a standardized minimum drinking age despite the fact that legally there cannot be a federal minimum drinking age. Even though this ActRead MoreKeeping the Minimum Legal Drinking Age1283 Words   |  6 Pagesthe minimum legal drinking age in the United States or not. Many Americans forbid the idea of legalizing the drinking age so that it would be profitable to the businesses. Likewise, there have been many advantages and disadvantages of why should the government allow young adults drink under the age of 21. To prevent this issue, many Americans have provided reasoning that will support the idea of keeping the minimum legal drinking ag e where it is now. The government should maintain the minimum legalRead MoreKeeping The Minimum Legal Drinking Age2656 Words   |  11 Pagesstarting to drink at a younger age, and their drinking patterns are becoming more extreme.† Keeping the minimum legal drinking age (MLDA) at twenty-one or lowering it to the age of eighteen has been a continuous issue in the United States. People, mostly adolescent teenagers, say it should be lowered because if one is able to vote at the age of eighteen, they should also be allowed to drink. Sure, when a seventeen-year-old turns eighteen they are considered an adult, but age does not define maturity;Read MoreMinimum Legal Drinking Agre1173 Words   |  5 PagesThe legal age of adulthood in the United States for most purposes is 18. At the age of 18, a person enters the realm of adulthood and is assigned the rights and responsibilities associated with this legal status. For example, an 18 year old can legally sign a contract and is bou nd by the terms and conditions of the contract. An 18 year old can marry without parental consent, serve on a jury, and vote in state and federal elections. An 18 year old who is charged with a crime is not tried in theRead MoreShould The Minimum Drinking Age Be Lowered?1138 Words   |  5 Pagesquestion whether drinking should be lowered to eighteen or not? Citizens have gave details regarding the affirmative and negative views of the minimum drinking age be lowered to eighteen. Do you think that it is wise to lower the minimum age? Would you look at the negative and positive impacts? Is it more important to give our citizens these full rights? Currently, in the United States the legal drinking age is twenty-one. But as we all know many teenages are involved in underage drinking. But the mainRead MoreLowering the drinking age: Increasing their Lifespan1058 Words   |  5 PagesBefore the year of 1975, the minimum legal drinking age (MLDA) was set at eighteen. It wasn’t u ntil 1984 when the National Minimum Drinking Age Act was passed which required the States to set the MLDA at twenty-one causing no one under the age of twenty-one to be able to consume or purchase alcohol. States that did not comply faced a reduction in highway funds under the Federal Highway Aid Act. Many can argue that ever since the drinking age was set at a higher age limit, there have been less reportsRead MoreThe Legal Drinking Age Of The United States1479 Words   |  6 Pages The legal drinking age in the United States has been argued for many decades. The current minimal legal drinking age is twenty-one but some want to lower between eighteen and twenty. The main focus of the research conducted and opinions of people are based on the minimal legal drinking age of eighteen. The research is taken from the 1970s, when the twenty-sixth Amendment was passed in the Constitution (Wagenaar, 206). It was stated that eighteen is the â€Å"age of majority†, so thirty-nine of theRead MoreLegal Drinking Age : Should It Be Altered?1408 Words   |  6 Pages Legal Drinking Age: Should It Be Altered? The legal drinking age has been an ongoing controversy for decades, consisting of people who are for lowering, raising, or keeping the age with multiple reasons behind each side. It is commonly known that consuming alcohol can have life-threatening effects on the human body, but these effects can be much harsher at a younger age. Reducing the age for eighteen year olds may result in senseless acts from the drug. Statistics prove that maintainingRead MoreLowering The Minimum Drinking Age1429 Words   |  6 PagesKorea and Thailand are others – with a minimum drinking age over 18† (Griggs, 1). When Ronald Reagan signed the National Minimum Drinking Age Act in 1984, its goal was to reduce less-mature adults from consuming alcohol and performing reckless acts (Cary, 1). However, despite the current drinking age, 17.5 percent of consumer spending for alcohol in 2013 was under the age of 21. It is estimated that â€Å"90 percent of underage drinking is consumed via binge drinking†¦with alcohol abuse becoming more prevalentRead MoreEssay about Drinking Age Controversy1076 Words   |  5 PagesDrinking Age Controversy In the United States, a citizen is considered an â€Å"adult† at the age of 18, and with that new title comes many responsibilities, such as the right to vote and to join the army. However, the legal drinking age in America is twenty-one. This issue has been a major controversy for some time now that faces both national and state governments. Should the drinking age be lowered to the age when legally a person becomes an adult and assumes all other adult responsibilities,

Video Games Cause Violence Essay - 546 Words

Video Games Cause Violence Video games have become a major occupation of majority of the youth these days. They spend hours on end concentrating on video games, some of which are apparently very violent, yet this is actually the whole idea. Coming from the horses mouth is an argument in support of video games coined from a video programmers point of view, stating that violent video games allow people to do what they can not do in reality- virtual reality. ( http://www.theroc.org/roc-mag/textarch/roc-15/roc15-08.htm ) For instance, someone said to be having a bad day could use a violent video game to release stress by shooting down a couple hundred bad men than actually taking an AK-47 and spilling down a few brains down the†¦show more content†¦The focus on these games is not only to kill, but also to torture and maim in the process. (http://archive.abcnews.go.com/sections/tech/DailyNews/internetgames981201.html) The story line behind some violent video games includes games in which players earn points by carjacking taxis, scoring drugs from cursing thugs, and mowing down pedestrians.(see http://www.feedmag.com/vgs/duncan.html) Some cartoonish tag lines in some sadistic video games include : -- As easy as killing babies with axes and More fun than killing your neighbours cats. This kind of themes definitely influence the players, especially the younger ones, and inflict violent tendencies on them. It is no wonder, that this killing mania in violent games was seen to seep out into the actual world when a high school junior opened fire in his school cafetaria in Littleton, Colorado, killing two of his classmates. The gunman was reported to be an ardent fan of Quake and Doom, some rather violent video games. More proof of the relationship between video games and violence is revealed by a study which clearly reveals how this kind of entertainment affects our lives. Greater details of the hi story of how high school students turned gunmen in Columbine High School are given, which shows that the effect of video games in their lives was a major source of influence in doing what they did best. In the light of all these, it is very clear that virtual reality asShow MoreRelatedViolent Video Games Cause Increased Violence Essay1855 Words   |  8 Pagesobjective of video games is to entertain people by surprising them with new experiences.† (Shigeru Miyamoto) Shigeru Miyamoto is the creator of some of gaming’s most iconic video game characters, Mario Jumpman Mario, Link and Donkey Kong; while also, serving as co-Representative Director of the game company, Nintendo and is highly respected. Miyamoto, based on the quote provided, feels that video games are meant to entertain people and nothing more. However, many people feel as though video games only causeRead MoreViolent Video Games Cause Violence : Cause Of Violence And Video Games1377 Words   |  6 PagesLit. 27 November 2017 The Blame Game Statistically, 2017 has become the year with second lowest crimes rates since 1990, assuming there isn’t a big resurgence in violent crime between now and the end of the year (Bump). However, violent crimes continue to be a problem in modern-day America. Many have sought out to find out the root of these crimes and what causes them, and as a result, many different things have been cited as a cause for violence. Violent video games are said to be a possible sourceRead MoreVideo Games Cause Violence1931 Words   |  8 PagesVideo Games Cause Violence Video game violence is an increasing problem in today’s youth with violence as one of the most popular themes. Games such as Grand Theft Auto and Call of Duty are among the most popular games and have been scientifically proven to have a major effect on teens. Many people try to argue that there is a difference in the effects between genders, however it has been proven wrong. Video games have the same effects as other forms of entertainment but do not get attacked likeRead MoreVideo Game Violence : The Cause Of Violent Video Games1000 Words   |  4 Pagesmentioned that the cause of violent video games became an issue for public debate after teenagers and the main cause of this is the parallel effect. Based on the Studies done for violent video games correspond with individuals having violent acts. Also, young adolescents reveal that those who play a lot of violent video games become more aggressive and see the world as more hostile. The article also revealed that this acts would be a coincidence or a cause from playing violent videos. Additionally, researchersRead MoreDo Video Games Cause Violence?752 Words   |  3 Pageswith, video games are something kids, teens, and even adults enjoy playing every day. Video games have provided people endless hours of entertainment to people across the globe, yet people seemingly want to get rid of video games altogether. Whenever any sort of crime occurs and a report comes out that the individual plays video games, video games take the blame rather than the person who committed the crime. Video games tend to be a very common scapegoat for causing violence. However, video gamesRead MoreViolent Video Games Cause Violence843 Words   |  4 PagesVideo games have been around for half a century when, the first simple tennis game was designed by William Higinbotham in 1958. Since then, video games have gotten more in depth, with better graphics and more options which include violent video games. Violent videos have g otten more popular with a better amount of variety including the franchise of Call of Duty, Battlefield, and Grand Theft Auto. These are the most common and popular video games and because of the violence in them debate has startedRead MoreVideo Games Do Not Cause Violence1619 Words   |  7 PagesVideo game violence has been a discussion dating back to games like Pac-Man and Space Invaders to current games like Call of Duty and Mario. Many people are lead to believe that video games can cause children to act violent. However, video games do not cause violence in children. Video games can help in many ways either in society, people with certain disorders, or improve some mental issues. Video games help shape society in the way they bring people together. Video games are said to bring kindnessRead MoreVideo Games : Can It Cause Violence?1379 Words   |  6 PagesVictor Chau Professor Myers ENGL-1301 Video Games: Can it cause violence? Any action against violent video games should be met with more research and that any banning of violent video games should come under more significant scrutiny. For sometime, many people consider violent video games to be the cause of violent behavior in the younger generations. However there are also people who would refute such claims that violent video games are the causes of tragedies, and would point to another reasonRead MoreViolent Video Games Cause Violence1906 Words   |  8 PagesEver since he started playing video games, like Call of Duty. Violent video games have been a battle that my family has been fighting for a few years now. My brother, started out small, playing Nintendo games and simple games like Crash. However, m y brother has always had a slight anger management problem and even with easygoing games, he became furious when he lost. Because he has lofty dreams of winning every game possible, he will not stop. Now, with video games, like Call of Duty and God of WarRead MoreEssay on Violent Video Games Cause Violence? 1170 Words   |  5 Pagesand aggression is everywhere; in magazines, in the shops, on the TV, on websites like YouTube as well as in video games. Yet, why is it that those video games are assumed to be the biggest media source responsible for the violent outbursts of different individuals? Is this really the case? Every eight out of ten homes in the United Kingdom own a existing generation games console and video games have become a extraordinary source of education when helping kids to learn, such websites like educationcity

Analysis of Elizabeth Bishop’s “The Fish” Free Essays

Esther Zamora Jon Schneiderman ENC1102-09 03/12/2013 Analysis of Elizabeth Bishop’s â€Å"The Fish† All battered and scarred from many years of trials, Grandma always has a smile on her face. Grandpa died when she was still young, her three sons have also died, and only her two daughters remain. In spite of these difficulties in her life, she manages to be happy and accepting of what life has tossed her way. We will write a custom essay sample on Analysis of Elizabeth Bishop’s â€Å"The Fish† or any similar topic only for you Order Now An older person has scars from life and doesn’t have the strength to fight for it. The elderly have gone through many trials and afflictions that life has tossed at them. With age, they have gained wisdom and understanding through these hardships. Life has a tendency to cruelly throw darts at humanity without any kind of reservation or remorse. In Elisabeth Bishop’s â€Å"The Fish,† the narrator is the fisher woman. Upon catching a tremendous fish and analyzing it carefully, she is reminded of her life. She notices the fish is not fighting to stay alive. He just hung there, still, and ready to die. This reminds her of her own life. She is now faced with the memory of the many scars that life has brought her. She’s not willing to fight as she once did. Age has really taken a toll on her, demanding her once youthful strength. The author speaks of the fish saying, â€Å"He hung a grunting weight, battered and vulnerable and homely† (7-9). The fisher woman found a similarity with her life and the fish’s life. She made a distinct connection between her life and this small creature. Older and more experienced, the fisher woman is reminded of her past afflictions. Now old and gray which are signs of aging, as the fish’s lips that give away his age. The lips are an important sign because the hooks and lines they have in their mouth demonstrates their experience. The fish in the poem declares â€Å"hung five pieces of fish- line† (51), showing how many times the fish had previously been caught and released again. Each line represents the many endeavors the fish had accomplished by conquering those hooks. As with people who overcome adversity and scars inhabit their life, the fish also has scars that remain as an indication of previous struggles. Wisdom and understanding is gained as things in life happen. For the fish, he gains wisdom and understanding each time he escaped a net or a line which is shown by his scars. A person gains wisdom and understanding with the trials they are faced with and that age has brought them. These are reminders to people as well as for fish. A person may have loved ones who have passed away, or possibly experienced some kind of trauma. All these tribulations serve for gaining wisdom and understanding in life. In conclusion, the fisher woman, by looking and observing the fish closely, is reminded of all the previous trials she had in her life. The scars in his lips, the â€Å"five-haired beard of wisdom† (62) helps her think of herself. She notices the rainbow of colors reflecting from the oil on the boat, reminding her of the fish’s accomplishments. Even though the fish is small, it somehow provokes a sense of relation with herself. She relates these attributes of the fish with maturity, adversity, trials, wisdom, and understanding. She encounters a close identification with the fish. Filled by this emotional connection and compassion for the fish, she let him go. How to cite Analysis of Elizabeth Bishop’s â€Å"The Fish†, Essay examples

Strategies in the Healthcare Sector in France free essay sample

Der Open-Access-Publikationsserver der ZBW – Leibniz-Informationszentrum Wirtschaft The Open Access Publication Server of the ZBW – Leibniz Information Centre for Economics Henke, Klaus-Dirk; Schreyogg, Jonas Working Paper Towards sustainable health care systems: Strategies in health insurance schemes in France, Germany, Japan and the Netherlands ; a comparative study Diskussionspapiere // Technische Universitat Berlin, Fakultat Wirtschaft und Management, No. 2004/9 Provided in Cooperation with: Technische Universitat Berlin, School of Economics and Management Suggested Citation: Henke, Klaus-Dirk; Schreyogg, Jonas (2004) : Towards sustainable health care systems: Strategies in health insurance schemes in France, Germany, Japan and the Netherlands ; a comparative study, Diskussionspapiere // Technische Universitat Berlin, Fakultat Wirtschaft und Management, No. 2004/9, http://hdl. handle. net/10419/36410 Nutzungsbedingungen: Die ZBW raumt Ihnen als Nutzerin/Nutzer das unentgeltliche, raumlich unbeschrankte und zeitlich auf die Dauer des Schutzrechts beschrankte einfache Recht ein, das ausgewahlte Werk im Rahmen der unter http://www. econstor. eu/dspace/Nutzungsbedingungen nachzulesenden vollstandigen Nutzungsbedingungen zu vervielfaltigen, mit denen die Nutzerin/der Nutzer sich durch die erste Nutzung einverstanden erklart. We will write a custom essay sample on Strategies in the Healthcare Sector in France or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page zbw Leibniz-Informationszentrum Wirtschaft Leibniz Information Centre for Economics Terms of use: The ZBW grants you, the user, the non-exclusive right to use the selected work free of charge, territorially unrestricted and within the time limit of the term of the property rights according to the terms specified at http://www. econstor. u/dspace/Nutzungsbedingungen By the first use of the selected work the user agrees and declares to comply with these terms of use. Towards sustainable health care systems Strategies in health insurance schemes in France, Germany, Japan and the Netherlands – A comparative study – 23. March 2004 Klaus-Dirk Henke, Jonas Schreyogg1 Berlin, March 2004 1 Berlin Technical University, Faculty of Economics and Management, Department for Public Finance and Health Economics and Department for Health Care Management, E-mail: k. [emailprotected] ww. tu-berlin. e; jonas. [emailprotected] de,The authors would like to thank Mr. Tom Stargardt for excel lent research assistance. Abstract In all four countries health care expenditures grow while the revenue remains at the same level or even shrinks in many cases. Due to medical progress, ageing and many other factors the gap is widening over time. The pay-as-you-go approach is running against limits either with rising employer and employee contribution rates as is the case in the so-called BismarckSystems or with higher taxes in the so-called Beveridge-systems. There are differences regarding the solutions of each country to tackle the described challenge and they might be able to learn from each other if they are compared. Therefore the study compares the health care systems of France, Germany, Japan and the Netherlands. Due to the complexity of the different institutional settings it seems necessary to select certain criteria in order to make a comparison at all possible. The comparison is divided into three different sections. The institutional and organizational framework as first section compares the general organization of social health insurance in all four countries. It comprises the benefit structure, the enrolment, ownership issues and other criteria. The second section focuses on the funding of social health insurance comparing the different approaches according to criteria like contribution rates, contribution assessment bases, burden of contributions and others. The final section analyses different strategies in the provision and purchasing of health services in the four countries. Next to other hospital ownership infrastructure characteristics play an important role in this section. In the last part of the study certain lessons are drawn from the comparison of the four countries. Furthermore certain developments are described which can be anticipated for the future of social health insurance systems. Abstract (deutsch) Sowohl die demographische Entwicklung als auch vielfaltige medizinische und medizinischtechnische Fortschritte fuhrten in den letzten Jahren zu starken Ausgabensteigerungen in den sozialen Krankenversicherungssystemen. Neben Deutschland sind von dieser Entwicklung auch andere Lander mit sozialen Krankenversicherungssystemen betroffen. Die vorliegende Studie nimmt einen systematischen Vergleich zwischen verschiedenen Landern vor, deren Gesundheitssystem auf einer sozialen Krankenversicherung aufbaut: Deutschland, Frankreich, 2 Japan und die Niederlande. Anhand definierter Kriterien werden die unterschiedlichen Auspragungsformen im Hinblick auf den organisatorischen und institutionellen Rahmen, die Mittelaufbringung sowie die Leistungserbringung bzw. ie Mittelverwendung der einzelnen Lander verglichen. Anschlie? end werden mogliche Handlungsstrategien aus dem Vergleich abgeleitet, um den zukunftigen Herausforderungen zu begegnen und eine nachhaltige Entwicklung der sozialen Krankenversicherungssysteme sicherzustellen. Abschlie? end werden bestimmte Entwicklungen beschrieben, Krankenversicherungssysteme antizipiert werden konnen. 3 die fur die sozialen Contents in short Figures 1. Introduction .. 6 2 . Impacts on health care systems .. 14 2. 1 Trends in expenditures for health care .. 14 2. 2 Causes for expenditure trends 16 2. 2. Demographic characteristics . 16 2. 2. 2 Changes in disease structure . 20 2. 2. 3 Technological Progress 23 2. 2. 4 Economic situation 24 2. 2. 5 Changes in Preferences 7 2. 2. 6 Structural weaknesses of the systems .. 28 3. Comparison between the social health insurance systems of Japan, Germany, France and the Netherlands 30 3. 1 Institutional and organisational framework . 30 3. 2 Funding .. 42 3. Provision and Purchasing of health services .. 55 3. 3. 1 Health expenditures by type of services . 55 3. 3. 2 Hospital Care 57 3. 3. 3 Ambulatory Care. 66 3. 3. 4. Long Term Care . 3 4. Lessons to ensure sustainable social health insurance systems and future developments 76 4. 1 Lessons towards sustainable social health insurance . 76 4. 2 Further Developments 79 References . 5 Contents Figures 4 1. Introduction .. 6 Financial and other current problems 6 Risk management in theory 8 Health policy: goals and entitlements 10 Elements of health care reforms 11 2. Impacts on health care systems .. 14 2. Trends in expenditures for health care .. 14 2. 2 Causes for expenditure trends 16 2. 2. 1 Demographic characteristics . 16 2. 2. 2 Changes in disease structure . 20 2. 2. 3 Technological Progress 3 2. 2. 4 Economic situation 24 2. 2. 5 Changes in Preferences 27 2. 2. 6 Structural weaknesses of the systems .. 28 3. Comparison between the social health insurance systems of Japan, Germany, France and the Netherlands 0 3. 1 Institutional and organisational framework . 30 Membership, Enrolment, Coverage 30 Benefits 31 Ownership, number of sickness funds and freedom of choice 32 Competition and risk structure compensation 37 3. 2 Funding .. 42 Contribution rates, income ceiling and contribution assessment bases 42 Contribution of pensioners 44 Separation of health and long term care 44 Burden of contributions at different income levels 45 Burden sharing between employers and employees 48 3. 3 Provision and Purchasing of health services .. 55 3. 3. 1 Health expenditures by type of services . 55 3. 3. 2 Hospital Care 57 Ownership 57 Access to services 59 Hospital planning and contracting 60 Reimbursement and spending control 62 User charges 63 3. 3. Ambulatory Care. 66 Employment status and organisation 66 Dispensation of pharmaceuticals 66 Manpower planning 67 Contracting 70 Claiming fees 70 2 3. 3. 4. Long Term Care . 73 Planning 73 Benefits 73 Access 74 User charges 74 4. Lessons to ensure sustainable social health insurance systems and future developments 6 4. 1 Lessons towards sustainable social health insurance . 76 Competition vs. regulation of sickness funds 76 Separation of long term care and high cost medical care 77 Private Health Insurance 77 User charges 78 Reimbursing hospital care with DRG’s 79 4. 2 Further Developments 79 Functional approach and comprehensive all-round care 80 Setting priorities in health care 81 New ways of funding health care 82 The future of the European Welfare State and international comparisons 83 References . 85 3 Figures Figure 1. 1: Financing gaps in social health insurance systems .. 7 Figure 1. 2: The current situation of the four health care systems . 8 Figure 1. 3: Risk management and social welfare . 9 Figure 1. 4: Goals of social security 0 Figure 1. 5: Entitlements to Health Care .. 11 Figure 1. 6: Elements of a health care reform 12 Figure 2. 1: Total Health Expenditures per capita .. 14 Figure 2:2: Total Health Expenditures in % of GDP 16 Figure 2. 3: Ageing of population in the four countries 7 Figure 2. 5: Average Life expectancy at birth in the four countries .. 22 Figure 2. 6: Lost life years due to disease in the four countries 24 Figure 2. 7: Standardised unemployment rates in the four countries . 25 Figure 2. 8: Development of state budgets in the four countries . 26 Figure 2. 9: Maslow’s hierarchy of needs pyramid . 7 Figure 3. 1: Different Sources of funding as % of the total health expenditure 46 Figure 3. 2: Contributions at different income l evels according to contribution rates in the four countries 48 Figure 4. 1: Integration of providers in the care for elderly 80 Figure 4. 2: Setting priorities in health care 81 Figure 4. : Financing health care in the future 82 Figure 4. 4: The future of the European welfare state I 83 Figure 4. 5: The future of the European welfare state II .. 84 4 Tables Table 2. 1: Population and population density in 2001 and 2050 Table 2. 2: Body Mass Index in the four countries Table 2. 3: Healthy life expectancy (HALE) from WHO at birth and at age 60, estimates for 2000 and 2001 Table 3. : Membership in different sickness funds in % of total population Table 3. 2: Number of sickness funds according to different schemes Table 3. 3: Comparison of the institutional and organizational framework of social health insurance on the basis of selected criteria Table 3. 4: Change of funding sources as % of the total health expenditure Table 3. 5: Comparison of funding principles of social insurance systems according to selected criteria Table 3. 6: Health expenditures by type of services as % of total health expenditure Table 3. 7: Development of ownership in general hospitals in each country Table 3. 8: Access to inpatient services Table 3. 9: Hospital infrastructure and utilization Table 3. 10: Planning, contracting, reimbursement and user charges in hospital care Table 3. 12: Organisation, Employment status, planning and access of ambulatory care Table 3. 13: Purchasing and contracting of ambulatory care Table 3. 14: Infrastructure characteristics of long-term care Table 3. 15: Long term care: planning, coverage, access and user charges 5 19 21 22 35 36 40 47 53 56 58 60 61 65 69 72 73 75 1. Introduction Apart from differences in health care systems of France, Germany, Japan and the Netherlands the starting points for health care reforms are similar in each country. They refer to the financial gaps in health insurance systems and other current problems of the four countries (figures 1. 1 and 1. 2). The basis for providing and financing health care are the theoretical approaches of risk management and social welfare. Their basic forms and arrangements are basically the same for all countries (figure 1. 3). The goals of social security in general and the entitlements to health care in particular are often codified in social laws and provide the foundations for health policy (figures 1. 4 and 1. 5) and the lements of a health care reform which have to be analyzed (figures 1. 6). Financial and other current problems In figure 1. 1 the financial gaps are easily to be seen: health care expenditures grow while the revenue remains at the same level or even shrinks in many cases. Due to medical progress, ageing and many other factors the gap is widening over time. The overall answer to solve this situation is relatively easy and consists of three app roaches. The nations facing financial gaps may firstly cut back expenditures through budgets and/or exclusion of benefits and services. Secondly they can increase revenue by either higher contribution rates, by using a broader base for financing and/or through higher co-payments and out-of-pocket-expenditures. Thirdly major structural reforms could be the answer to close the financial gap. These reforms can be accomplished from an overall perspective on the basis of the ability-to-pay-principle or with the help of the benefit or insurance principle. These overall approaches occur in all nations at a time. They offer not much more than a simple structuring of the overall roblem that more or less all nations face. But there might be differences depending on how nations are financing health services. Tax-financed systems may perhaps run into heavier financial problems than social health insurance systems in France, Germany, Japan and the Netherlands 6 Figure 1. 1: Financing gaps in social health insurance systems revenue, expenditures expenditures Financial gap due to ageing, medical progress etc. revenue 2000 2050 More specific are other current problems that the four health care systems face in the short and in the long run. The technological change, the medical progress and the demographic development were already mentioned and without going into details one faces with the given demographic challenge an intergenerational equity problem which has to be solved. And in addition, as just mentioned, the pay-as-you-go-method is running against limits either with rising employer and employee contribution rates as is the case in the so-called BismarckSystems or with higher taxes in the so-called Beveridge-systems. None of the two ideal systems are able to regulate themselves quasi automatically. The number of political interventions increases more and more and patchwork repair is the reality everywhere. Major reforms are either too difficult in a more and more overcomplex area or are politically not manageable in a highly sensible area as health care is. This situation describes very shortly why in Europe and in Japan the public is calling for more substantial and longer lasting reforms. Sustainability in health care systems has become more than a mere phrase used by the media. Muddling through on a comparatively high level characterizes the situation we are facing in France, Germany, Japan and the Netherlands. 7 Figure 1. : The current situation of the four health care systems †¢ †¢ †¢ †¢ †¢ Demographic development, technological change, medical progress Pay-as-you-method running up against limits with rising employer and employee contribution rates Systems are no longer able to regulate themselves Spiral of political interventions and patchwork sol utions has not solved basic problems Europe’s and Japanese citizens are calling more and more emphatically for a basic, lasting reform, i. e. sustainability in health care systems. Risk management in theory The analytical background for the overall risk management in social welfare is the same for all countries. To provide the basic needs you may divide two general forms: a more private or a more public approach, each of which has different arrangements and ways of financing. In all systems the existence of social assistance for the unemployed and those who need support for other reasons is essential. These expenditures stem in all systems from general revenue, i. e. mainly taxes. Health expenditures in countries like the United Kingdom or the Scandinavian Countries with national welfare systems are financed mainly through taxes on the basis of the budgetary decisions taken year by year by their parliaments. Although nations with social insurance systems are mandatory social welfare systems as well they are financed differently. Their revenue stems from so-called payroll taxes, which are levied on the basis of wages and salaries as employer and employee contributions. The payroll-tax rates are perceived by the public as labour-costs and they are relevant in the context of international competition between nations. In addition to the parliamentary system some countries, e. g. Germany, have institutionalised so-called self-governmental structures trying to discuss and solve health policy issues outside the parliament and the market. Figure 1. 3: Risk management and social welfare provision of basic needs 1. Basic Forms voluntary individual protection mandatory social welfare options 2. Arrangement savings enrolment in free choice of enrolment in private mandatory insurances insurances 3. Financing out of pocket 4. Relationship between benefits and contributions national social insurance we lfare principle plans riskoriented premiums wage/salary oriented social insurance contributions general revenue i. e. mainly taxes marketoriented benefit principle between costoriented benefit rinciple and ability-to-pay principle social assistance ability-topay principle Source: Zimmermann and Henke (2001). Apart from the different options within mandatory social welfare many nations offer substitutional or in complementary individual protection against the risks of life. Thus the enrolment in private insurances may be mandatory for the total or part of the population. It could also be a free choice to enrol in mandatory insurances or in private ones which are in general more risk- and less income-related in regard to their financing mechanisms. Whilst the risk management on the basis of private insurances relates merely to the tasks of an insurance, the risk management in payroll- or tax-financed systems generally includes elements of income and family redistribution as well. Allocation and distribution is thus not separated from each other. This relationship between benefits and contributions may be described through the market-oriented benefit principle on the one hand and the ability-to- 9 pay-principle on the other hand. And many systems are between these two possible principles of risk management in social welfare. Health policy: goals and entitlements The goals of Social Security are to be seen in close relation with the more theoretical background in figure 1. 3. These goals are probably the most basic elements underlying all systems. They are comparatively general and thus being supported by all the four nations (figure 1. 4. ). But problems will definitely arise, when people or politicians have to decide how „equitable distributionâ€Å", „optimal prevention and rehabilitationâ€Å" or the scope and content of the „most important risks of lifeâ€Å" is interpreted. And even if this will work out the parliament or other bodies have to decide about the weight of the different goals respective criteria. Thus value judgements play a significant role in health care issues and in setting the health policy agenda. Figure 1. 4: Goals of social security †¢ †¢ †¢ †¢ †¢ †¢ †¢ †¢ Adequate coverage of the population against the most important risks to life No arbitrary discrimination As much transparency as possible Optimal prevention and rehabilitation Self-responsibility Equitable distribution of burdens Maximum efficiency and Minimization of administrative costs In the German Social Security Law the legislator wanted to be more precise and codified the six prerequisites in figure 1. 5 for health care in a German setting. Again everybody will probably like these postulates in figure 1. 5 and agree to them. But the problems arise when one tries to operationalize them. What is the „current state of medical scienceâ€Å" in a nation and what is it in a growing common market in Europe? Are patient`s needs everywhere the same? And are adequate services the same in France, Germany, Japan and the Netherlands? In which 10 moment do health services exceed what is necessary? More questions than answers. But nevertheless these goals are codified and the legal basis for claims of the insured population in general and the patients in particular. Thus the courts of justice play more than a minor role in these decisions. Figure 1. 5: Entitlements to Health Care †¢ †¢ †¢ †¢ †¢ †¢ Focus on patient’s needs Be equally accessible to all Correspond to the current state of medical science Provide adequate services Be appropriate, effective and humane Not exceed the necessary level of care Elements of health care reforms A last set of starting points refers to a health care reform from the onset. In all countries the health care sector is a labour intensive growth sector. About 10 % of the working population is employed in this part of the economy, where many new professions developed over the years. Good health, fitness, wellness and aging healthily are key concepts in an ageing society. The numbers also impressively demonstrate a desirable trend: the paradigm for the health care system is changing from a cost factor to a fast-growing service sector. While economic growth and increasing employment are generally seen as desirable goals for an economy, mounting health care expenditures are usually seen in a negative light and are always associated ith „cost explosionâ€Å" and undesired oversupply of services. 11 Figure 1. 6: Elements of a health care reform †¢ †¢ †¢ †¢ †¢ Labour-intensive service sector Interest-driven system Risk-structure-equalization Moral-hazard, adverse selection, asymmetric information Mobilisation of efficiency reserves Another point of departure for health care reforms is the fact that there is no overall rationality in a given or planned system. Health care reforms are driven by the interests of all the participants and other driving forces, e. g. the media. The ability to achieve acceptance for proposed reforms does not by any means depend solely on the diverse professional and personal interest of doctors, economists, lawyers and commission members. It is also critically influenced by the driving forces in the health care system – the health insurance associations and the bureaucracy of the ministries. In addition to the political atmosphere the pending elections have to be considered. Ultimately the „chemistryâ€Å" must be right among the few persons who ultimately must pull together under strong, statesmanlike leadership and achieve a politically acceptable, viable, sustainable solution. Finally there are three economic prerequisites for health care reforms. One of them is valid everywhere and at all times. And that is the mobilization of efficiency reserves. There is always structural change, medical progress and political pressure for reform, which means that permanent adjustments will take place in order to avoid an inefficient allocation of resources on the different micro, meso and macro levels. Thus the mobilisation of efficiency reserves is a permanent challenge and not the panacea for financing problems in health care. Furthermore there is agreement that everywhere and within all reforms moral hazard and adverse selection as two forms of misbehaviour should be avoided. Moral hazard ax ante takes place through an unhealthy lifestyle or a behaviour which provokes the event insured against. Ex-post moral hazard happens when a doctor does more out of income interest than is necessary. And the patient requires unnecessary services because he has paid his contributions and wants to make the best out of it. 12 Finally a risk structure equalization or compensation is necessary to avoid adverse selection and to allow fair competition within health care. In addition a mandatory minimum coverage for all is necessary and obligatory so that all sickness funds have to accept applicants without individual risk review. In chapter 2 impacts on health care systems are analyzed on the basis of expenditure trends in the different countries. This will be followed by a classical comparison of France, Germany, Japan and the Netherlands on the basis of financing health care, provision and purchasing health services in the different sectors with the help of selected criteria (chapter 3). The conclusion in the final chapter gives hints for the future development of the four systems compared and of course for other systems as well (chapter 4). 13 2. Challenges for health care systems 2. 1 Trends in expenditures for health care Basically health care expenditures have risen considerably in the past ten years in all four compared countries. However, there are significant differences regarding the scope and the structure of changes. While Japan, Germany and France experienced an average yearly increase in total health expenditures between 1992 and 2001 of 3. 8%, 3. 75% and 3. 98%, health care expenditures in the Netherlands have risen with an average of 6. 18% per year in this period. 1 Nevertheless, expenditures per inhabitant in the Netherlands have still not reached the spending level dedicated to health care in Japan or Germany as shown in figure 2. 1. Figure 2. 1: Total Health Expenditures per capita 2800 2600 in â‚ ¬ 2400 2200 2000 1800 1600 1400 1992 1993 1994 19 95 1996 1997 1998 1999 2000 years Japan Germany Source: OECD Health Data (2003). 1 Based on OECD Health Data 2003 and own calculations. 14 France Netherlands 2001 It has to be pointed out that the increase in health care expenditures in each of the four systems is due to different reasons. Between 1992 and 2000 total spending for out-patient care remained nearly the same in Japan (+2%) while at the same time it drastically increased in Germany (+37%), France (+27%) and the Netherlands (+62%). During the same period pharmaceutical expenditures, for instance, even decreased in Japan (-5%), but increased considerably in the three European states (Germany: +25%, France + 60%, Netherlands +50%). All four countries experienced increased expenditure for in-patient care between 1992 and 2000. In Japan it increased by 52%, followed by the Netherlands (+39%), Germany (+37%) and France (27%)2 (see also figure 2. 1. above). Although the differences might be due to a different design of institutional provision or due to different priority setting in health care policy they might also give evidence whether certain actions taken by the governments or the sickness funds have been successful in containing health care expenditures. As revealed in figure 2. 2 the percentage of GDP spent on health care services is increasing in all four countries while Japan experienced the highest rise from 6. % in 1992 to 7. 6% in 2000. Therefore health care is obviously gaining in more importance. Nevertheless a slight tendency in reducing the public share of total health care expenditures is observable. The public health expenditures of the Netherlands, which include sickness funds expenditures as a percentage of total health expenditures, dropped by 9. 5% from 72. 8% to 63. 3% between the years 1992 and 2000. The German government reduced its public share by 2% while the Japanese and the French public share remained at the same level. 2 Based on OECD Health Data 2003 and own calculations. 5 Figure 2. 2: Total Health Expenditures in % of GDP 12 % of GDP 11 10 9 8 7 6 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 years Japan Germany France Netherlands Source: OECD Health Data (2003). 2. 2 Causes for expenditure trends There are many factors which definitely contribute to rising health expenditures although due to the complexity of the health care systems it is hardly possible to identify their impact. 2. 2. 1 Demographic characteristics One major reason for recent expenditures growth in all four countries can be attributed to changes in demographic characteristics. A higher life expectancy combined with lower birth rates led to an ageing population in most industrialized countries. In Japan, the share of people above the age of 65 years has risen from 5. 7% as percentage of the total population in 1960 to 17. 4% in the year 2000. At the same time, the share of young people between 0 and 19 years has decreased from 40. 1% to 20. 1% of the total population. The changes in the three European countries have not been that drastic, but nevertheless the number of people above the age of 65 years has increased as well from 11. % to 16. 4% in Germany, from 11. 6% to 16 16. 1% in France and from 9. 0 % to 13. 6% in the Netherlands as percentage of the total population in 2000 while the number of young people between 0 and 19 years has decreased from 25. 3% to 21. 2% in Germany, from 32. 5% to 25. 5% in France and from 37. 9 to 24. 4% in the Netherlands as displayed in figure 2. 3. 3 Until today, the demographic development had only minor effects on the l abour markets, since the number of people in working age in the four countries stayed about the same. As further factors an increasing number of women in the work force and an increasing immigration are counter-balancing the shortfalls but are not able to fully compensate the development mentioned. Figure 2. 3: Ageing of population in the four countries 100 90 80 70 60 50 40 30 20 10 0 1960 2000 1960 * 2000 1960 0-19 Japan 1960 2000 20–64 54,2 62,1 France Germany gt; 65 5,7 17,4 0–19 25,3 21,2 20–64 63,1 62,3 1960 Netherlands France gt; 65 11,6 16,4 2000 gt; 65 Germany Japan 0–19 40,1 20,5 20-64 2000 0–19 32,5 25,5 20–64 55,9 58,4 Netherlands gt; 65 11,6 16,1 0–19 37,9 24,4 20–64 53,1 62,0 Source: OECD Health Data 2003, Federal Statistical Office of Germany, Stat. Yearbook 2002. *Germany 1960: 0-19, 19-65, gt;65 3 OECD Health Data 2003. 17 gt; 65 9,0 13,6 In the near future however, it can be predicted that the four pay-as-you-go based systems will face severe problems. Age groups of low birth rates are soon entering the labour market while age groups of high birth rates are going to retire from work. This development is going to continue over the next decades because births per women in all four countries are below 2. 00 (Germany 2001: 1. 29; Japan 2000: 1. 41; Netherlands 2001: 1. 69 and France 2001: 1. 0)4. As a consequence the proportion of the total population over 60 years of age is constantly growing and this population group is to a significant extent no longer part of the labour force. Since, however, the pay-as-you go approach is working on the theoretical basis of an intergenerational redistribution and the major part of the contributions is funded by those members of the population who are still employed, an increasing volume of health care services is to be funded in these systems by a decreasing number of employed people. A third factor combined with the demographic challenge is the development of the population. As presented in table 2. 1 the population for Germany and Japan is predicted to shrink until 2050 while the French and the Dutch populations are estimated to rise slightly. A shrinking population especially has implications on the provision of health care infrastructure. It means for instance for Japan, that much less hospitals will be needed if this development is not offset by a much higher demand for health care of the elderly. At the same time a shrinking population also leads to lower population density which could in the case Japan lower the risk of epidemics. 4 OECD Health Data (2003). 8 Table 2. 1: Population and population density in 2001 and 2050 Japan population in 1,000 (2001) estimated Population in 1,000 (2050) population density (per km? ) estimated population density in 2050 size of area (in km? ) Germany France Netherlands 127,130 82,350 59,188 16,046 100,496 64,973 64,032 18,000 336 230 109 386 265 182 118 433 377,835 357,026 543,965 41,526 Sources: OECD Health Data (2003), Federal Statistic Office of Germany (2000), National Institute of Population and Social Security research, Institut National de la Statistique et des Etudes Economiques (France). It is difficult to anticipate the impact for the health care system, as cost development especially for the elderly population is not reliably predictable. On the one side, crosssectional data show a clear correlation of health care costs with age as shown in figure 2. 4 in the case of Germany. 5 It can be seen that for instance in Germany the expenditures for people above 60 are almost 3 times as high as for those between 20 and 60. On the other much of this increase with age can be attributed to the larger percentages of persons in their final year(s) of life for whom health care is especially costly. If life expectancy is increasing, this portion of the costs will be shifted upwards. However, currently implicitly applied age limits for using certain diagnostic or therapeutic procedures will also be shifted upwards with increasing health (and life expectancy) of older people which increases costs. This effect can be seen by the so-called â€Å"steepening† of the age-cost curve over time. Finally it is very likely that in pay-as you-go systems the demographic development leads to the problem that the number of net-benefit-receivers is increasing while at the same time the number of net-payers is decreasing. This hypothesis is not undisputed in the literature. Some authors argue that rising costs do not primarily depend on age but on the time of death since they are reach the highest level in the period before death. Zweifel, Meier and Felder (1999). 19 Figure 2. 4: Standardized Expenditures in Germany according to age and gender e xpe ndit ur e pe r day in DM 40 35 30 25 20 men 15 women 10 5 85 gt;= 90 80 75 70 65 60 55 50 45 40 35 30 25 20 15 5 10 0 0 age Source: Bundesversicherungsamt (2002). 2. 2. 2 Changes in disease structure Changes in disease structure are partially linked to the demographic development having direct impact on the provision of health care and therefore on the health expenditures. First of all a shift to chronic diseases can be observed. Allergies, asthma and diabetes are becoming widespread. This is only partly due to ageing, but also due to changes in the environment. Environmental pollution in the past decades has decreased in general, but there is a time lag between the uptake of harmful substances and the effects on the health of an individual and the total health care system. For example, the long term effects of pollution in the 1960ies and 1970ies are affecting the health care systems today, while the effects of stronger ultraviolet radiation in 1980ies and 1990ies will be experienced in the future. Due to increased economic welfare excess of weight is becoming more and more a mass disease. Measured as body mass indexes the number of people considered to be overweight e. g. in France has risen from 5. 8% in 1990 to 9% in 2000. The Netherlands and Japan have similar problems as displayed in table 2. 2. This development is alarming since diseases in coherence with skeleton, muscles and circulatory diseases are expected to increase. 20 Table 2. 2: Body Mass Index in the four countries Japan 25lt; Germany 25lt; France 25lt; Netherlands 25lt; BMI BMI BMI BMI BMI BMI BMI 30 gt;30 gt;30 gt;30 gt;30 gt;30 gt;30 17. 5 18. 0 19. 7 19. 6 21. 0 2. 0 1. 9 2. 3 2. 6 2. 9 33. 0 18. 0 39. 4 29. 2 23. 9 26. 4 27. 2 5. 8 7. 0 9. 0 28. 0 28. 8 31. 0 34. 7 5. 0 6. 1 6. 9 9. 4 Source: OECD Health Data (2003); Bundesgesundheitssurvey 1998; Deutsche-HerzKreislauf-Praventionsstudie 1990. In spite of this development life expectancy and healthy life expectancy have increased in all four countries over the last forty years (figure 2. 5; table 2. 3). As revealed above in figure 2. 5 Japan has the highest average life expectancy at birth with 81. 3 (2000) years followed by France with 79. 0 (2000) years and the Netherlands with 78. 0 (2000) years. Germany had the lowest average life expectancy at birth of all four countries since more than 30 years, but has since 2000 a higher average life expectancy than the Netherlands with 78. 4 years. As far as healthy life expectancy (HALE) is concerned the situation changes as one may see from table 2. 3. The healthy life expectancy in citizens in Japan is even 2. 3 years higher than in France which has the second highest healthy life expectancy. This hypothesis is further supported by column 4 and 5 as Japan. Column 4 documents that Japan has the lowest expectation of lost healthy years at birth in 2001 while column 5 shows that is also has the lowest healthy life years lost as % of the total life expectancy. 21 Figure 2. 5: Average Life expectancy at birth in the four countries 82 80 expected life years 78 76 74 72 70 68 66 1960 1965 970 1975 1980 1985 1990 1995 2000 years Japan France Germany Netherlands Source: OECD Health Data (2003). Table 2. 3: Healthy life expectancy (HALE) from WHO at birth and at age 60, estimates for 2000 and 2001 Healthy life expectancy (HALE) Males Total 2001 population Females 2001 Japan (1) At At birth birth 2000 2001 73. 5 73. 6 (2) At At birth a ge 60 71. 4 17. 1 (3) At At birth age 60 75. 8 20. 7 Germany 70. 1 70. 2 68. 3 15. 0 72. 2 France 71. 1 71. 3 69. 0 16. 1 Netherlands 69. 7 69. 9 68. 7 15. 0 Country Expectation of lost healthy life years at birth in 2001 (years) (4) Healthy life years lost as % of the total life expectancy (5)