The boundaries of the Dutch health care system

Summary Although (inter)national law concerning the right to health care describes that everyone should have equal access to good quality health care without discrimination and without unexplained delay (UN CESCR, 2000), this is not always the case. Homeless persons, who form a vulnerable group at the bottom of society, sometimes have difficulties to access health care facilities. By analyzing health care provision concerning homeless persons it is possible to explore the boundaries of the health care system with regard to the sufficiency to which it can foresee in necessary health care. The boundaries of the health care system are shown in the lack of reimbursement of necessary health care expenses. When there is no (sufficient) financial reimbursement, the health care won’t be accessible for homeless persons as a result of their financial problems. The consequences of the Dutch health care acts, rules and regulations for the financial accessibility of care for homeless persons are analyzed in this study using a case study. By looking at the case of Havenzicht, a shelter for homeless persons in the Netherlands where medical care is provided to homeless persons, it could be explored how well the Dutch health care system is able to provide necessary health care for this vulnerable group. Havenzicht has a very low threshold to enter their nursing ward and additionally has no access restrictions concerning the patients. The care process is often started before it is clear how Havenzicht will be reimbursed. By comparing the overall care reimbursements as well as the overall provided amount of care over one year in the nursing ward of Havenzicht, one can conclude whether the reimbursements were enough to cover the costs. Additionally, because the data are gathered on patient level, analysis can be made concerning patient characteristics that determine the use of care as well. In order to check whether the overall provided amount of care could in theory be provided to the patients, the salaried hours are analyzed as well. The comparison of costs and reimbursements shows a financial gap of 696.981,76 euro. Since care intensity packages assigned by the Care Assessment Centre (CIZ) are conform the somatic health condition of a patient, the extra hours of care necessary can be explained by the characteristics of the homeless persons other than his health status. The fact that homeless persons have more and more severe health conditions at earlier age is an explanatory factor, as well as substance use. However, the extra hours necessary are best explained by the fact that most homeless persons have a complex mixture of interrelated problems concerning different areas. In addition to their somatic conditions, the homeless persons often have psychological problems and one or multiple addictions as well. On top of this, homeless persons are known to be persistent care avoiders. The combination of these problems makes the regular health care setting unsuited for the care concerning homeless persons. Overall it can be concluded that the contemporary health care system doesn’t take into account a complex mix of problems such as associated with homeless persons. The division in the current health care system between psychological and somatic health care problems makes that the system is not sufficient when there is a combination of multiple problems. Additionally, the current assessment of the health care need doesn’t take the full scope of problems of a person into account while different problems are often interrelated. Especially psychosocial problems that impact the health of homeless persons are not sufficiently taken into account. Based on the financial gap identified in the case study and the shortcomings of the health care policy that explain this gap, it can be concluded that the current financial coverage in the Dutch health care system is insufficient to foresee in medical necessary care for homeless persons in the intramural setting. Since the accessibility and availability of care for homeless persons is directly influenced by the financial coverage of care, it can be concluded that the outcome of the current health care policy is not in line with the international law concerning the right to health care. The future developments, especially the extramuralisation of care intensity packages and the increase of the own contribution will decrease the sufficiency even more.