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10 Economic crisis, health systems and health in Europe: country experience
the budget was allowed to grow by 4.5% per year in real terms. Importantly,
during the same period, actual spending grew more slowly and the gap between
the federal health budget and actual spending widened. Even in recent years
when a reduced growth cap has been imposed, actual spending has continued to
be less than the set budget.
Although the growth cap is the most important instrument in determining the
growth rate of the budget for the compulsory health insurance system, the annual
growth rate was in most years far above 4.5% (Table 1.2). 5 With a growth cap
of 2.5% in the period 1999–2004, extensive use was made of the possibility to
deviate from the cap for exceptional or specific expenses. After 2005, this budget
escape route was hardly used because of the rapid increase in the budget ceiling
to a more generous 4.5% (OECD, 2005). In more recent years (until 2012),
the difference between the growth cap of 4.5% and the budget increase mainly
reflects the way inflation is captured. To determine the health budget for the
next year, the expected increase in the health index (corrected consumer price
index) is applied to the total health budget, although in practice indexation does
not apply to all parts of the health budget since different indexation rules exist
depending on the spending item. Moreover, since the health index of a given year
is applied to the health budget of the previous year plus the growth cap of 4.5%,
there is a cumulative effect of both measures. Over the period 2005–2011, the
accumulated difference between the indexation budget based on the health index
and the budget based on applying the different indexation rules amounted to
€1265 million (Belgian Court of Audit, 2011).
Instead of reducing the real growth rate, the government decided to transfer
the budget surplus (the difference between the spending ceiling and actual
spending) to be used in the future or to other subsectors of social security
(Table 1.3). Normally, the health care budget included a mixture of new
initiatives and savings, with new initiatives having to be balanced by savings in
other sectors. For example, increased reimbursement of spectacles or hearing
aids could be financed by (increased) turnover taxes on pharmaceuticals. The
year 2012, however, was a special year. When new initiatives and savings for the
2012 budget had to be submitted, there was no government in situ. 6 Moreover,
in early 2012, the newly formed federal government had to impose a package
of austerity measures worth €11.3 billion on its public expenditure, of which
€2.3 billion was in the health sector. Structural savings accounted for about
€553 million. The largest part of savings in the health sector was realized by
not applying the growth cap. For the first time since the introduction of the
growth cap, the budget was aligned to the amount of estimated expenses and
5 The increase of 9.25% in 2008 can be partly explained by the integration of the small health risks of the self-employed
into the compulsory health insurance system.
6 Between the elections of June 2010 and December 2011 (541 days), Belgium had a federal caretaker government
meaning that, in line with Belgian political tradition, no new legal measures could be taken.