According to the European Health Consumer Index, the Netherlands has had the best-run healthcare system in the world for the best part of a decade, ahead of Switzerland and Norway. So it might seem surprising that health is likely to be one of the most contentious issues in the election campaign. But as the EHCI acknowledges, the Dutch also have the highest per capita spending on health in Europe, and the spiralling cost of health insurance is a major concern for voters.

A decade ago the Netherlands introduced competitive health insurance, replacing the universal ziekenfonds dating from the 1940s. As the scope of health cover increased with medical advances, administrators warned that the system was becoming unaffordable and producing long waiting lists. The current system was designed to keep costs down by letting insurers compete for patients’ custom, and also by giving them more bargaining power with hospitals and other care providers.

But instead spending has increased steadily over the last 10 years, and with it the cost of health cover. In last November’s budget the government anticipated that the premium for basic health insurance would go up by 3.5% in 2017; in fact the average increase was nearly 10%. In addition, the excess charge (eigen risico) – the amount patients must pay from their own pockets before insurance cover kicks in – has risen sharply since 2011 to €385.

Two tiers

The 2006 reform also created two tiers of healthcare: the basisverzekering, or basic insurance scheme, which is compulsory for everyone (and which insurers cannot refuse to patients), and various forms of additional cover (aanvullende verzekering). What types of care should be included in the basic package is a recurring subject of debate in Dutch politics. Left-wing parties tend to call for a comprehensive basic package that gives everyone access to good quality treatment, while those on the right argue it should be pared back to ensure the system remains affordable.

The Socialist Party (SP) has made abolishing the competitive system the main campaigning issue of its election programme. The SP argues that market forces have driven up the cost of care, partly because the biggest four insurers have an 88% market share, giving them enormous power in negotiations to set budgets and decide when and where patients are treated.

National scheme

The SP proposes replacing the current array of around 50 insurers with a single national scheme for the universal basic package. Commercial insurers would only be able to offer additional cover plans. The basic package would be also extended to include treatments such as physiotherapy and dental care. Finally, the SP wants to scrap the excess charge, making care free at the point of delivery. Several other parties, including 50Plus and the Animal Rights Party (PvdD), have backed the Socialists’ plan. Others, such as the (PVV), Labour (PvdA) and GreenLeft share the idea of scrapping the excess charge, while the Christian Democrats (CDA), the SGP and the ChristenUnie want to bring it back down significantly. The government’s statistics service estimates the cost of total abolition to be €4.5bn, while Geert Wilders’s party believes it would cost €3.7bn. The Socialists claim the figure is €3.2bn, since insurers would no longer need to spend millions on advertising in the December ‘transfer window’, when patients are allowed to change their insurance provider for the following year.

Status quo

As the main party of government, the VVD are the defenders of the status quo, including the recent reform that allows people to reduce their annual premium by increasing their excess charge. Similarly, D66 oppose reducing the eigen risico charge on the grounds that it push insurance premiums up even higher. D66 argues the better way to reduce costs is to introduce efficiencies in the system, such as encouraging hospitals and clinics to work together in networks. A similar idea is proposed by the ChristenUnie. Several parties, including Labour, GreenLeft and 50Plus, call for district nurses (wijkverpleegkundigen) to be brought back to liaise between patients and care providers. They argue this would ensure patients receive made-to-measure care and make insurers more accountable. Most parties want to restrict or reform the range of insurance policies. The VVD says contracts between insurers and care providers should run for several years to allow long-term planning and improvements.

Multi-year

The SGP argues that insurers should be allowed to offer multi-year policies, which would encourage long-term investment and give patients better value. On the other hand, GroenLinks says insurers should only be allowed to compete on quality of care rather than price and call for the abolition of ‘budget policies’ which in practice, they say, mean the poor receive a lower standard of care. Labour, like the Socialists, want to impose a uniform basic insurance package and ban insurers from competing on essential healthcare. The party also want patients to be given a more active say in what care they receive, a vision largely shared by D66.

Labour wants to create more acute care facilities for the elderly, which they say would benefit both patients, by providing more appropriate care, and the system, by relieving pressure on emergency wards. 50Plus also says elderly care facilities should be protected by the government, but also wants to ensure that elderly people can live independently for as long as possible.

The party would introduce a universal basic care package covering home care, support for volunteer carers (such as friends and relatives) and daycare facilities. The Christian Democrats plan to invest in personnel in long-term care institutions, arguing that as people live longer and stay at home until a later age, those in nursing homes need more specialist care.

The free-market VoorNederland (VNL) party stands alone in seeing far-reaching further privatisation as the way to bring down healthcare costs. VNL believes excessive bureaucracy is to blame for the rising cost of care and says it will tackle ‘waste’ in the system – a sentiment echoed in milder form by the VVD. VNL also says individuals should be able to create their own tailored basic insurance plan, the exact opposite of the universal care plans put forward by the left-wing parties.

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