Building the welfare state and developing a universal system of health protection have been among the main social achievements of the 20th century. In Belgium the system of statutory health insurance - as we know it today - was established by the Compulsory Sickness and Disability Insurance Act of 9 August 1963. Over a period of fifty years the constant focus has been on organizing and extending social solidarity – both horizontally and vertically – while at the same time ensuring responsibility and accountability of all actors involved. This has been achieved through various mechanisms, such as a convention-based system for purchasing health care, a gradual move towards universal coverage, a budgetary system for cost containment, a risk-adjusted allocation system and the systematic application of co-insurance with special financial protection mechanisms for vulnerable groups. While all this has made the health system increasingly complex, the context has also changed. The ageing of society, medical and technological progress, various financial and economic crises, the European integration process as well as the decentralization of powers to subnational levels have all had their impact on the way statutory health insurance operates.
With solidarity as its beating heart, the Belgian system is a typical social health insurance system, characterised by a plurality of actors involved in management and implementation as well as a large degree of therapeutic freedom and consumer choice. The question is where this social health insurance model stands today and how it will evolve in the next 50 years? What challenges will it have to face and how will this affect its approaches to solidarity and the incentives given to encourage accountability? Whereas statutory health insurance was conceived at a time when curative care was booming; chronic, mental and long-term care will be the major types of healthcare provision in the future. This will increase the need for a better integration of health services as well as the need to address unhealthy lifestyles and other health determinants. In addition to these developments, the context of contracting financial resources and expanding expensive technological innovations may also have significant implications for the organizational model of health insurance, the manner in which healthcare is purchased and reimbursed, but also for insurance coverage, the public/private mix and the use of competition and market mechanisms to stimulate efficiency. This gives rise not only to technical questions about effectiveness and performance but also to a political and ethical debate about the right balance between citizens’ choice and responsibility of the actors, on the one hand, and societal goals and solidarity, on the other hand.