**5.1 Complementary health insurance in economic crisis**

Slovenia was hit by an economic crisis a little bit later than some EU countries, at the end of 2008, when the business orders from abroad began to decline and consequently, the unemployment started to increase. As 98% of all incomes for compulsory health insurance are represented by contributions paid from wages and other incomes by the population, these changes had a big impact on the health insurance income. To assure that compulsory health insurance can still cover all its expenditures, numerous measures had to be passed. Among these measures, CHI played an important role. Compared to 2010, in 2015 expenditure on compulsory health insurance increased by € 49.17 M or 2.3%, while expenditure on CHI increased by € 66.31 M or 16.3% (**Figure 3**).

The average annual growth rate of compulsory health insurance expenditure in this period was 0.46%, while CHI expenditure was 3.07%. The growth rate of CHI expenditure was, hence, seven times higher than the growth rate of compulsory health insurance.

Despite stricter business conditions and the same contribution rate and equal (or at least not lower) access of insured persons to health services, the HIIS must comply with the commitment of the Stability and Growth Pact adopted by the EU in 1998 and subsequently upgraded several times. The Stability and Growth Pact is a set of rules that ensure that countries in the European Union maintain sound public finances and coordinate fiscal policies. According to the rules, HIIS must ensure the balance of revenues and expenditures without borrowing. As this was simply not possible in times of economic crisis, HIIS adopted and implemented innovative measures in 2009 to ensure its stable business operation. In determining the measures, the focus was on finding reserves in the compulsory health insurance system, without compromising the access of insured persons to services and without changing the rights from compulsory health insurance. The measures were primarily aimed at lowering the prices

#### **Figure 3.**

*Expenditures of compulsory and complementary health insurance, in M€, 2010–2015. Source: Health Insurance Institute of Slovenia, Annual report for years 2013 and 2015 [13, 14]; Slovenian Insurance Association, Statistical insurance report 2016 [15].*

of health services and reducing the share of the price covered by compulsory health insurance and increasing the share of the price covered by CHI for medicines, medical devices, services, sickness benefits. The changes in the coverage shares happened at two levels.

The first transfer of financial obligations from compulsory onto CHI happened when HIIS passed the Decision on determining the percentage of the value of health services provided in compulsory health insurance, on 18 July 2009, namely for a spa treatment that does not represent the continuation of hospital treatment and for medicines from the interim list. The validity of the amendment to the resolution on determining the percentage of the value of health services provided in compulsory health insurance was extended to the whole of 2010. On 15 February 2010, HIIS additionally extended the reduction of the share of services at the expense of compulsory health insurance to the field of non-emergency ambulances, spa treatment other than hospital treatment, dental prosthetic services, and eye accessories for adults.

The second package of changes was brought about by the Fiscal Balance Act (2012) with the following measures:

Reduction of the share of the value of health services covered by compulsory health insurance (from 1 January 2013 onwards), meaning the transfer of the financial burden to CHI, namely:


The increase in complementary health insurance is evident also from the increase of the share of complementary health insurance expenditure in GDP between 2010 and 2015: while this share increased by 0.10 percentage points, the share of compulsory health insurance decreased by 0.22 percentage points.
