1 Paper to be presented at the 6th Annual ESPAnet Conference “Cross-border Influences in Social Policy” in Helsinki (Finland), September 18–20, 2008, Stream 13: Changing ideas and consequences of reforms in healthcare THE ROLE OF PROBLEM PRESSURE AND IDEAS IN HEALTHCARE SYSTEM CHANGE --Preliminary version, please do not cite without permission-- Achim Schmid, Ralf Götze, Mirella Cacace and Heinz Rothgang Achim Schmid, University of Bremen, Collaborative Research Center 597 “Transformations of the State” Linzer Str. 9a, 28359 Bremen (Germany), +49 (421) 218-8730, achim.schmid@sfb597.uni-bremen.de Ralf Götze, University of Bremen, Collaborative Research Center 597 “Transformations of the State” Linzer Str. 9a, 28359 Bremen (Germany), +49 (421) 218-8729, ralf.goetze@sfb597.uni-bremen.de Mirella Cacace, University of Bremen, Collaborative Research Center 597 “Transformations of the State” Linzer Str. 9a, 28359 Bremen (Germany), +49 (421) 218-8731, mirella.cacace@sfb597.uni-bremen.de Heinz Rothgang, University of Bremen, Collaborative Research Center 597 “Transformations of the State” Linzer Str. 9a, 28359 Bremen (Germany), +49 (421) 218-4132, heinz.rothgang @sfb597.uni-bremen.de Abstract The paper attempts to explain the changing role of the state in OECD healthcare systems. The analysis of 23 OECD countries has revealed broad trends with respect to financing, service provision and regulatory structures. We identified increasing similarities between the three system types National Health Service, social health insurance and private health insurance. The public financing share tends to converge over time and the funding mix has grown in- creasingly similar. At the same time service delivery shows a common privatization trend. With respect to regulatory structures, we observe convergence as healthcare systems have integrated non-system-specific elements of regulation. Our broad explanatory model starts with the identification of driving forces in the form of globalization, demographic change and medical-technological progress which cumulatively create problem pressure on healthcare systems as they raise healthcare expenditure while eco- nomic resources are limited. While the direction and the timing of system transformation may be influenced by various intervening variables, such as actors, their interests and perceptions, we argue that the healthcare system type is an essential factor to explain the increasing simi- larities seen amongst systems over time. As healthcare systems vary, so do their adaptive re- sponses to problem pressure. Healthcare systems tend to develop specific deficiencies which can not be solved by routine mechanism. As a consequence non-system-specific elements are implemented which lead to the emergence of mixed types. However, this model based upon problem pressure and system type fails to address the mechanisms of change and convergence. Therefore we aim to combine the rather functional model with interpretative approaches which include policy learning and diffusion, both broadly captured under the heading of ideas. We do this by describing the diffusion of regula- tory mechanisms (DRGs and Reference Pricing) across healthcare system types.