An International Comparison on Medical Savings Accounts: Applicable for the Netherlands?

Social Health Insurance schemes, as seen in many Western countries, cope with ever-increasing health expenditures as a result of rich benefits provided through comprehensive insurance coverage. Moreover, the Netherlands has introduced various cost-sharing methods including a compulsory and voluntary deductible which can add up to a total of €850 in 2013. The popularity of voluntary deductibles is small (only 6% have opted for voluntary deductibles) in the Netherlands despite the significant gains that can be acquired in terms of moral hazard reduction. The central research question of this thesis is therefore aimed at finding a solution in order to improve the participation rates among Dutch voluntary deductibles. The problem analysis propagates that the premium rebate and liquidity constraints faced under high financial risk have implications for the demand for voluntary deductibles. A regulated Dutch market shows that 1) premium rebates are effectively compromised for certain groups since the 2006 reforms because of risk-equalization and a community-rated premium and 2) the liquidity problem in the Netherlands is, in spite of an acclaimed savings culture, still significant. It is assumed that the regulations brought on by the 2006 health care reforms will not be changed on account of making voluntary deductibles more viable; therefore, the liquidity problem will be subjected to further study in this thesis. Moreover, this thesis will attempt to delineate a policy option that has the potential to increase participation rates among voluntary deductibles through minimizing of the liquidity problem. Literature has suggested Medical Savings Accounts (MSAs) as a way to increase participation rates among High Deductible Health Plans (HDHPs) by ‘softening’ the risk taken under a high deductible. This thesis shows that MSAs are both theoretically and empirically complex systems which possess many different design characteristics. Their complexity is visible in the two case studies performed on the United States and Singapore, where an attempt is made, to ascertain relevant experiences for the Netherlands. Both countries are acclaimed for their successful implementation of a savings mechanism next to (high) deductibles. Information drawn from the two case studies clearly show that it is difficult to ‘translate’ experiences to a potential Dutch variant on the count of all the differences in the three health care systems. Both the United States and Singapore have alternate motives for implementing MSAs, which do not or only partly coincide with the motives for a potential Dutch variant. Country-specific motives are naturally expressed in MSA-design, as well as country specific values on how to organize health care. This makes it so that neither of the two case studies is directly relevant and applicable to a Dutch situation. Nevertheless, their symbolization as two ‘extremes’ allows for a framework when analyzing an appropriate design for the Netherlands. Additionally, the analysis ultimately shows that MSAs can indeed be designed in such a way that they can render applicable to the Dutch health care system. Also, other ways are presented in which the liquidity problem can be counteracted. These simplified funding options seem less invasive in application; however MSAs continue to transcend these options with its potential for sustainability and potential for counteracting moral hazard.