The influence of minimacontracts on the debt of health insurance defaulters in Dutch municipalities

In the Dutch health insurance market, collective insurances respond to risk factors of specific populations. A minimacontract is such a collective insurance focusing on people with low income and high healthcare costs, aiming to prevent indebtedness (Zorgwijzer, 2017b). This study is a first exploration of the effect of minimacontracts on the debt of defaulters and compares enrollees with non- enrollees. Due to minimacontracts varying in their composition, this study looks into four common elements, knowing: reinsurance of the deductible, municipality contribution, docket and income requirement for enrolment. This study used data from Dutch health insurer Achmea, consisting of 162.238 defaulters divided over 391 municipalities. The data has been analyzed based on the duration of indebtedness, with a focus on people indebted for 0-6 months, 7-12 months, 1-4 years, 4-8.5 years and 0-8.5 years.

The OLS analysis shows that defaulters enrolled in minimacontracts have an overall lower basic insurance debt of 53€ and deductible debt of 179€ than non-enrollees (p<0.005). However, the supplemental insurance debt is found to be 224€ higher for enrollees (p<0.005). In all three insurance components the effect is found to increase overtime, holding that the longer a defaulter is indebted, the bigger the difference between enrollees and non-enrollees. Zooming in on the effects of the four elements of minimacontracts was done with the Spearman correlation test, with a selection of the dataset, composing 4.861 enrollees divided over 68 municipalities. First, reinsurance has been found effective with a lower debt in all three health insurance components. Only the effect in the basic- and supplemental insurance are found to be statistically significant (p<.0001). Second, a higher municipality contribution has a lowering effect on the basic- and supplemental insurance debt. The deductible debt is found to be higher. All results are found to be significant (p<0.02). Third, a higher income requirement for enrolment shows a higher debt for the basic insurance and supplemental insurance, but a lower debt difference for the deductible. All three results are found to be highly insignificant (p>0.1) and hence the element is found not to be effective. Fourth, enrollees using docket are found to have a lower basic- and deductible debt, but a higher supplemental insurance debt (p<.0001). Docket is found to be effective.

Interpreting the results the following conclusions can be drawn: Minimacontracts are found to have a lowering effect on the median debt of defaulters, with reinsurance and docket as best practices. Although a higher contribution leads to a lower debt, it is not found to be an effective tool to prevent indebtedness. Next, income requirement is highly likely to affect the median debt of defaulters, but does not prevent indebtedness either. It can even disadvantage people who are as a consequence not eligible. Nevertheless, it is important to acknowledge that the role of minimacontracts is far from straightforward. Indebtedness can be a consequence of various life events and choices, not simply caused by (non) enrolment. If, based on the found effects, docket and reinsurance are widely implemented, it is expected that the median health insurance debt of defaulters decreases. The most important recommendations for health insurers, Dutch municipalities and government are the inclusion of docket and reinsurance in minimacontracts, enabling docket for income from labor and the redirection of care allowance to health insurers.