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A public health insurance system can be managed by a state body, delegated to private bodies or be mixed. In the 19th century, the Industrial Revolution concentrated populations in towns where local solidarity could no longer operate, and the number of industrial accidents increased2. In addition, an intellectual and scientific movement is developing, which promotes individual foresight (at the origin of private insurance), mutual insurance companies which bring collective foresight and the notion of "sacred debt" brought by the French Revolution whose Article 21 of the Declaration of the Rights of Man and of the Citizen of 1793 recognizes for each citizen the right to social assistance and protection, giving rise to social security3. This insurance is in deficit of 634 million euros in 2004, in particular because of the aging of the population and the deterioration of the ratio “number of contributors” / “number of beneficiaries”. Sickness and invalidity insurance is a compulsory “health care” insurance managed by the National Institute for Sickness and Disability Insurance (INAMI).

It is one of the foundations of Belgian social security. Health insurance can take two different forms: In 1883, the law on health insurance established the establishment of compulsory insurance for workers in industry. Entered into force in 1914, this system remained the main legal basis for legislation on health insurance until the adoption in 1988 of the first law on the reform of the health system.

Health insurance can be a purely state (public) body, which can be only private insurers, or you can have a mixed system: the user has public insurance and can take out private insurance with a insurance company or mutual (called "complementary health" in France), which supplements the reimbursement or provides access to a network of complementary care. Based on the principles of occupational insurance within the framework of the company and social welfare, the German system has been undergoing a process of reform since the end of the 1980s, integrating a financial and organizational dimension. The Belgian federal government in agreement with the actors of the medical sector are looking for different solutions to this problem. The increased use of generic drugs, with equivalent efficacy to branded drugs but much less expensive, would, for example, make it possible to reduce the cost of drugs (at the expense of the pharmaceutical industry).

Reducing superfluous medical examinations is another avenue. Others plead for the regionalization of health insurance, arguing that the Flemings subsidize Walloons who overconsume health care. The German health insurance system is close to the French model in its philosophy and faces comparable difficulties10. Since December 21, 2012, a new law has come into force, eliminating the discrimination that could sometimes take place against women and sometimes against men: the unisex rate for insurance11. Until the end of 2012, insurance offered preferential rates for males and sometimes for females. Car insurance, for example, was much cheaper for women because the majority of accidents were due to male students12.

Price differentiation was present for many insurances until the European court, in a spirit of uniqueness towards other European countries, declared that these differences were no longer necessary. Henceforth, women thus pay more for their car insurance than before and men benefit from a lowering of these insurance costs to arrive at a unisex average. Health insurance has been changed very little but has nevertheless been unified between the two sexes (especially for cancer insurance). Basically, the measure did not have a significant budgetary impact, it was above all a question of reducing all forms of discrimination. The characteristics of the German system are as follows: We can have a coexistence of these two models.

Until the 18th century, protection against the risks of life was most often ensured by personal wealth, local solidarity (family, village) or professional (guilds, guilds) and charity. Nevertheless, we know of several cases of private companies which, in the 17th century in Spain, offered their employees reimbursement of medical expenses for them and their families1. The operation, like all other insurance, is based on the pooling of risk: each person contributes, and in exchange, they are reimbursed according to a fixed scale.

It can be seen that the countries that have adopted a purely private and competitive system are also those for which expenditure is the highest. Thus, while developed countries spend on average 10% of their GDP on their healthcare system, the United States spends 14% and Switzerland 13%. However, in a competitive insurance system, policyholders choose the level of expenditure they want in relation to the level of health coverage they want. The level of expenditure in a competing system therefore reveals the level of expenditure desired by consumers.

In a public system, the State sets the level of expenditure and rations the use of health services to limit them (for example, general practitioner in France). The comparison of expenditure levels between public systems and competing systems is therefore biased because the use of these systems is not comparable. These new conceptions are applied in Prussia where Otto von Bismarck, wishing for a strong state, develops the first system of compulsory social insurance with the draft laws on insurance against accidents at work and social health insurance adopted in 1883. and 18844.

For a public health insurance system, the insurance premium paid by the insured does not necessarily follow the rules of pure insurance, and it may not be based on risk alone. Indeed, the public system performs both a pure insurance function and a distribution function in which the wealthiest pay for the insurance of the most disadvantaged.