Economization and Marketization in the German Healthcare System: How Do Users Respond?(Essay‪)‬

1 Introduction From an historical perspective, the German corporatist healthcare system appeared for a long time reluctant to proceed with any far-reaching reforms. However, since the 1990s the German healthcare system has been targeted by several modernization processes, characterized by pundits as an "incremental reform" (see Gerlinger/Schmucker in this volume). This article scrutinizes two of its key drivers, economization and marketization, arguing that the two approaches restructure the healthcare system differently and have different consequences for healthcare users' behavior. They share, however, common ground: economization and marketization processes aim at the expert patient as a focal figure. For instance, state-driven agendas of user activation as well as market-based healthcare services emphasize individual responsibility, as well as financial stakes and participation of healthcare users. Simultaneously, there is a differentiation of users' identities, especially against the backdrop of mixed healthcare provision and the establishment of a complementary healthcare market. Users act in different contexts as citizens, patients, co-producers, consumers or community members. In order to do so, there is an increasing need for a specific health knowledge and competence; that means the development of a context-related "health literacy" (Nutbeam 2000).