Healthcare in the Netherlands. The Health Insurance Act.

There are 231,000 uninsured citizens and 241,000 defaulters in the Netherlands according to the most recent statistical method that has been supplied by the Central Bureau Of Statistics on the 1st of May in 2007. Multiple reasons may cause these problems. These problems are causally related (people with a low-income reluctant to pay) or multi causal (suffering from other (social) problems). Uninsured citizens and defaulters are considered to be a problem by politicians, governments, healthcare insurers, healthcare providers and citizens. Uninsured citizens and defaulters present two different groups with their own specific problems. The problems are researched to find solutions at the hand of institutional theory and international benchmarking. Other factors that may influence the problems are not researched. The instrument settings (= changes in the healthcare system), the policy instruments (= instruments of policy makers to affect the situation) and the overarching goals (= changes in value and norms) are the indicators to illustrate solutions for the institutional context. Solutions that are expected to be found in the policy freedom of actors are indicated through the degree of regulation, organisational structure and nature of labour. Solutions within international benchmarking are indicated through the comparison of several institutional features. From the institutional context flows forth that changes within the context possibly lead to solutions of the problems. As for the change in the instrument settings counts that uninsured citizens are now only traceable when they apply for medical treatment. It is only possible to track down uninsured citizens on a passive basis. However, this is about to change. The government is going to actively seek uninsured citizens. New law, from the 1st of January 2010, allows the government to compare personal files in databases, without trespassing privacy law. The current law forbids this comparison. From the 1st of January 2010 there shouldn’t be any uninsured citizens left, because they have been traced so that they will be insured mandatory. A study of the policy instruments make clear that these instruments provide solutions. At present, uninsured citizens are mostly citizens who cannot afford insurance and they will become most likely defaulters after the 1st of January 2010. Therefore, the group of defaulters will grow. All concentration should be focused on this group. Without interference of the government, defaulters were allowed to switch insurers. These policy instruments are that the government has changed the policy towards defaulters. Defaulters are not allowed to switch from health care insurance companies. Moreover, defaulters are punished with a fine that is deducted from the source of income or the care allowance on the 1st of January 2009. All these measures are based on fines, but the problem group consists largely of low-income citizens. The measures are not affecting their behaviour (one cannot earn from a penniless person) and the problems will therefore not vanish. The ‘good-willing’ citizens must still pay for the costs. But, the instrument of group insurance options can be enhanced. Local governments can offer group insurance options (lower premium rates for the standard package) to low income citizens. If the local authorities would cooperate, a better or a more discounted deal could be managed towards the healthcare insurers. The low income citizens profit, by paying less money for the same package. As an effect, the group could decline. It is proposed that the Association of Netherlands Municipalities (Vereniging Nederlandse Gemeenten, VNG) may act as a spokesman. Or else, the central government could make one Jeroen Schönberger – Healthcare in the Netherlands – the health insurance act - 5 - centrally organised group insurance option. Also local governments can, with help of interest groups, guide (potential) defaulters in the process of paying their premiums. This success ratio of this measure is present, since the policy freedom of the local governments is very wide. But despite all efforts, the problems of defaulters is expected to grow. Overarching goals are also solution-makers. Possible solutions to decline the group of defaulters are that for the ones who can afford to pay but are not (yet) willing to pay, the government can shrink the size of the group by threatening these defaulters with all sorts of punishments. It is up to the norms and values as well as the cleverness of those citizens if the size of the group can be affected. Healthcare insurers can help to decline the group by acting firm (to press) on the behaviour of default. Just as local governments, health insurers have a lot of policy freedom. Overarching goals are also problem-makers. Excavation of insurance policy should be kept an eye on. The content of the standard premium has been excavating since 2006. As a consequence citizens need additional insurance. Additional insurance is up for free competition. This implies that prices are variable and that healthcare insurers are able to refuse high risk citizens. It is probably expected that the costs of the additional premiums will rise, due to the increase of health expenses. It leads to an increase of defaulters and to growing number of under-insured citizens, where no governmental support is yet made for. It is important for the government and other players, to keep an eye on this group. An international comparison shows that the Dutch problems with uninsured citizens and defaulters are not unique. Other healthcare systems face problems with uninsured citizens and defaulters as well. However, the solutions of other countries do not fit in the Dutch system. First, in literature, it is pointed out that comparison of the different existing international healthcare systems is not possible. It is the difference in the institutional framework of the systems, as researched, like for example the obligation to insure or to accept, the lack of premium differentiation and the omission of a regulated market. Second (not researched) it is expected or assumed that the difference in national state systems (a federal healthcare system as in Switzerland cannot be applied in a decentralized unitary state as in the Netherlands) or culture (non universal healthcare as in the USA cannot be applied in the universal healthcare system of the Netherlands). The research that has been done unfortunately complemented the theory of non comparability. But happily for the Dutch situation, governments of foreign countries are really interested in the way the Dutch manage their health care system and want to implement (parts of) the Dutch system in their own nation. To put the problems in context it seems that, although uninsured citizens and defaulters are considered to present a problem, it is not seen as an urgent one by many actors. The group is relatively small and the problems are relatively new (as for as long as statistics have kept track of the records). All non governmental policymaking actors do not really care, since they are reimbursed by the government. Healthcare insurers receive money from the Health Insurance Fund and healthcare providers are reimbursed by healthcare insurers or the loss of income is only marginal. Governmental actors do not give a red alert yet. I conclude to say that the current solutions will deplete the group of uninsured citizens, but the solutions will not deplete the group of defaulters. In the end, the group of defaulting citizens will still face problems. Jeroen Schönberger – Healthcare in the Netherlands – the health insurance act - 6 - Solutions / recommendations to solve the problems are that I disapprove on the current institutional settings of regulation of uninsured citizens and defaulters. The current situation creates a downward vicious circle of uninsured citizens. I also disapprove on higher taxation and the creation of a trust fund, because these are in conflict with overarching goals (solidarity). I approve the new law of 2010. I partly approve on the new law for defaulters. I disapprove on the law, because it is only based on fines. I recommend to put more pressure on the rich group of defaulters, by making collection trajectories more firm. I recommend to implement a non-context sensitive definition of ‘medical necessary care’ to avoid cherry picking and to drop the healthcare allowances, because it does not fulfil its purpose and leads to bureaucracy and in return lower nominal premiums. As for policy instruments I recommend that local governments should actively subscribe low-income citizens with group insurance options to reduce the group of uninsured citizens and to drop the own-risk option, because it (could) conflict with overarching goals (solidarity and equality) and leads to bureaucracy. The overarching goals must allow the government to intervene when citizens are not capable of handling themselves. It is disapproved to lead away from solidarity, because it breaks with tradition and can lead to American situations. I recommend that healthcare providers use their policy freedom and form alliances to compete with healthcare insurers for better group insurance options. I also recommend that healthcare providers adapt the best policy to prevent default of behaviour and that healthcare insurers stop to excavate healthcare insurance policies. The Dutch Health Care Authority has to ring the alarm bell as it is its task to do now. It is only a matter of time that American situations in additional insurances are business as usual. The authority has to be active (foreseeing) and must not act on a passive basis. Finally, I recommend to keep an eye on the trials at the European Court, because one verdict could make an end to the much discussed Dutch healthcare system.