Health Economics, Policy and Law


Changing choices in health care: implications for equity, efficiency and cost1

Gwyn Bevana1 c1, Jan-Kees Heldermana2 and David Wilsforda3

a1 Professor of Management Sciences, Department of Management, London School of Economics and Political Science, London, UK

a2 Assistant professor, Department of Public Administration & Political Science, Radboud University, Nijmegen, The Netherlands

a3 Professor of Political Science, Department of Public and International Affairs, George Mason University, Fairfax Virginia, USA


Although choice may be seen as an end in itself, the papers included in this special issue of Health Economics, Policy and Law, examine choice policies in European systems of health care, which aim to be effective instruments for ameliorating the systemic pressures from the iron triangle of equity, efficiency, and cost. Three papers consider the nature of differences between and within countries following the Beveridge and Bismarck models of financing and organising the delivery of care, and how choices are changing within different systems. Within countries following the Beveridge model, current policies in England, Denmark and Sweden emphasise increasing patient choice of provider. Within countries following the Bismarck model, current policies in France and Germany seek to restrict choice of specialists by introducing ‘soft’ gatekeeping; and in the Netherlands there is a system of managed competition with choice of insurer that, in principle, allows insurers to contract selectively with providers. A fourth paper considers how government policies that seek to restrict choice within systems of universal coverage have been subject to challenges in the courts. A commentary explores the implications of the fraught and complex nature of choices between insurers and providers of health care for designing effective choice policies.


c1 Correspondence to: Gwyn Bevan, Department of Management, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK. Email:


1 Three of the papers included in this Special Issue of Health, Economics, Policy and Law, on choice in European systems of health care, were presented at a series meetings of the European Health Policy Group (EHPG) between 2006 and 2008 at the Instituto Superior de Economia e Gestao in Lisbon, the Bertelsmann Foundation in Berlin, the Economic and Social Research Institute in Dublin, and the London School of Economics and Political Science (LSE). Gwyn Bevan organised the selection and discussion of papers at these meetings. We are grateful to Carolyn Tuohy for giving an overview of these papers and the editorial, and commenting on each when these were discussed at a meeting focused on this special issue at the LSE in September 2008. In addition, we invited Mark Schlesinger to contribute a commentary and included a fourth paper presented at the EHPG meeting at LSE in September 2009 organised by Adam Oliver. The three editors agreed on papers to be selected for this special issue. David Wilsford prepared a first draft of this editorial to lay out the principal argument. Gwyn Bevan revised this to offer a commentary on the papers included in this special issue, and all three of us contributed to the redrafting.