The issue: new healthcare system
text Caroline van der Schaaf photography Ronald van den Heerik
Exactly two years ago the Dutch healthcare system underwent drastic changes aimed at limiting the costs of healthcare and increasing freedom of choice. What have been the results so far? It is starting to look as if premiums continue to rise, while insurance packages are shrinking. Moreover, health insurance companies are increasingly deciding where and by whom their customers are treated by setting up insurer-financed healthcare centres.
New healthcare system, new problems
Two years ago a new Medical Expenses Act was adopted. Has it resulted in the envisioned cost savings? Or is the Dutch public in a worse position than before? Professor Roland Bal of the Institute of Health Policy and Management draws up the balance.
Why did the old healthcare system need to be reformed? “The old system was a system of budgeting and came with a number of serious problems. If you keep a budget intact while demand grows, all sorts of frictions arise, especially waiting lists. A few years ago there were waiting lists of many months, for some treatments there were waiting lists of even more than a year. That budgeting system also had perverse effects: doctors could spend September to December at the golf course because their budget was up and operation theatres just sat empty. The payment on procedure basis also meant that doctors were paid for the mistakes they made: if someone had to return for more treatment after an operation went wrong it was simply considered a new procedure. There were all sorts of incentives in that system that didn’t work well.”
So it was high time for a new system? “Yes, because another problem was that we had a very odd insurance system, in which you had national health insurance patients and privately insured patients. That created all sorts of absurd inequalities. The market structure should make the current health insurance system into a system more characterised by solidarity. Everyone has the same basic insurance now and you can buy extra private insurance on top of that.”
How does liberalisation of the market actually work in healthcare? “What it actually means is that healthcare providers make agreements with insurance companies about the specific care products they will supply. They agree on how much of that service they will supply and at what price. In doing this they create a kind of market. The health insurers have a certain number of customers for whom they buy in care from the healthcare providers, hospitals for instance. These care providers can achieve competitive advantages by organising things in a smarter way, so that they can work at lower costs. Or they can choose to work more efficiently or more patient-friendly or offer higher quality.”
Does the new system mean an end to the problems? “No, it doesn’t. We see, for example, discussions now about those who are uninsured. Everyone is required to have insurance, but the number of uninsured continues to rise. There are between 250,000 and 300,000 people currently uninsured. That is starting to become a growing problem.”
What are the consequences for all those uninsured individuals? “They are only really treated for life-threatening conditions, serious accidents and that sort of thing. Some hospitals are very strict about his, since they have to foot the bill otherwise. And that can result in serious public health problems.”
Are we heading for a situation like the one in the US? “But then on a much smaller scale. There are 47 million people uninsured in the US. That is a much more serious problem. But you do see that the numbers have been growing over the past years here as well.”
Is there a solution for that? “That depends on the cause of the problem. We do not have a good idea of why these people are not insured. Politicians often say that these people simply don’t want to pay. That is why politicians are looking for a solution in a coercive measure. At the same time, I think that it is very possible that people just don’t have the money to pay or that they are unable to handle the administrative side of it for some reason. These people therefore simply need more support. On the other hand, it is not really an option either to provide funds so that these people can be treated. Because then you are actually saying to the Dutch population: ‘You don’t have to be insured.’ And that is not the message you want to send either.”
Do you see other negative effects of the new system? “What I consider a dangerous development are all these discussions now about people with a high-risk lifestyle. People who participate in sports on the weekends and suffer injuries, people who smoke and people who engage in all sorts of dangerous activities in their personal life would have to pay more for their health insurance. I don’t think we should be heading in that direction. Because it will ultimately lead to people paying for their own individual healthcare needs. The whole solidarity of the system gets lost then. And that’s precisely what is so important.”
Is the problem of waiting lists solved now? “Largely, yes. You cannot just get treatment anywhere now for every ailment, though. There are still access times for some treatments and some specialisms but overall the problem has largely been worked away.”
But what does this all mean in concrete terms for the Dutch public? “They will still have to pay more and more for care. That is inevitable. The demand for care will only continue to rise in the coming decades, and that means that we either have to pay more for it or have less covered by insurance companies, which in the end also means paying more.”
What do you think has to change in the current system? “In any event much more attention must be focused on the quality of care. The ministry now feels that the sector should take care of that itself. The government sets all sorts of requirements on the field and then sends outs the inspectorate. But if the government feels it is so important, it should also invest a great deal in it. One of the major risks of liberalisation is that more and more focus comes to lie on costs. Of course it is possible to reduce costs, but that comes at a price, namely that you sacrifice quality. The one-sided incentive focused on costs at the moment, also doesn’t motivate the people who work in healthcare. And, ultimately, I also think that quality simply comes at a price.”
And the consumer pays? “Yes, in the end the consumer will have to foot the bill in one way or other. Either via tax, or via insurance.”
Every week in 'the issue' an academic from Erasmus University Rotterdam responds to a current topic in the media. 'The issue' is brought to you in cooperation with Erasmus Magazine, the opinion and information magazine of Erasmus University Rotterdam.