Health care is in danger of becoming unaffordable. For an increasing number of citizens, this is no longer an abstract, macroeconomic vision of the future. More and more insured persons are struggling with payment arrears. That is why the promise to abolish the mandatory excess paid off in the recent general election. The result was a parliamentary debate that once again ignored the crux of the problem.
Opinion by Martin Buijsen, professor of Health Law at Erasmus School of Law and Erasmus School of Health Policy & Management.
The legally mandatory excess
Around 6% of health care spending reimbursed through the basic health insurance package under the Health Insurance Act (Zvw) comes from the legally mandatory excess (€385). Full abolition would cost around €3.7 billion. If it went ahead, health insurers would be forced to increase the nominal premium for every person aged 18 and over insured under the Health Insurance Act, by an estimated €260 a year.
This prospect led the government to not abolish the excess, but instead reduce it to €165 from 2027. Since this would still result in a considerable increase in premiums – even for insured persons whose claims always exceed the full amount of the excess – on 24 October, Wieke Paulusma, a Member of the House of Representatives for the D66 party, along with other Members, called upon the government to reduce the excess by €220 for chronically ill and disabled people only.
Sympathetic but misguided
The legally mandatory excess applies for people aged 18 years and older who are obliged to have health insurance under the Health Insurance Act. Those under the age of 18 who are obliged to have health insurance are not subject to the legally mandatory excess, and certain forms of health care (such as GP care, obstetric care and district nursing) are also excluded from the excess. The Act draws sharp boundaries.
However, it is not clear who counts as chronically ill. There is no exhaustive list of chronic conditions. If we apply the usual definition of ‘chronic condition’ (any condition for which there is generally no prospect of full recovery), as many as 10.4 million people in the Netherlands (59% of the population) appear to have at least one chronic condition that has been recorded by their GP. If the excess is reduced to €165 for all of these people, as called for in the motion, it would still lead to a hefty increase in all premiums. This is not likely to result in revenue that – as those who submitted the motion intend – could be used for tax relief 'that ensures, among other things, that health care worker capacity will increase if they work for three days or more, to reduce rather than increase waiting lists'.
And if no such scheme will be applied to this entire group, which chronically ill people will be covered and which will not? This leads to endless discussions. If 96% of people aged 75 and above have at least one chronic condition, why not opt for a clear age limit too? The motion also ignores the fact that, under current laws and regulations, so-called ‘integrated care’, on which, for example, patients with Type 2 diabetes mellitus and COPD depend, is already excluded from the legally mandatory excess. What will the proposal by Paulusma et al. mean for insured persons suffering from these common conditions?
'Reducing the basic package is a no-go area. Yet it will have to'
Prof.dr. Martin Buijsen
Professor of Health Law
'Rough justice'
There are only two ways to mitigate the rise in health insurance expenditure. There is a clear reluctance to pursue the first option (higher personal contributions). Reducing the basic package – the second option – is a no-go area. The Netherlands lacks the structures to even discuss it. Yet it will have to. Mature political decision-making will have to be made possible. ‘Rough justice’ is simply the highest achievable form of distributive justice in a country with collectively funded health care.
- Researcher
- More information
More science stories? Check out our online magazine Erasmus Extra.
- Related content
