'We talk a lot about the macro costs of health care and the impact on the economy, but that is not the biggest challenge of rising health care costs. We talk far too little about another issue, which is ultimately going to be much more important for healthcare: the perpetuation of risk solidarity', said Frido Kraanen director at Gelre Ziekenhuizen and visiting practitioner at DRIFT.
Opinion by Frido Kraanen, director at Gelre Ziekenhuizen and visiting practitioner at DRIFT.
In healthcare, a big topic is costs. For 2025, the projected expenditure is over 110 billion euros. Twenty-five years ago, this was "only" about 30 billion euros. While, of course, the economy also grew during that period, healthcare costs almost quadrupled! The number of over-65s did increase, but not as fast, so we can by no means say that the growth is solely due to demographics. Technology, (justified) income enhancement of healthcare professionals and broader care also made a significant contribution to the well-filled bag.
But the totality of those costs are not the biggest challenge for healthcare as far as I am concerned. The biggest concern for healthcare? Risk solidarity - or the solidarity of people who pay insurance premiums and make little or no use of care in favour of the group that has quite a lot of care costs per person.
Paying more than you use
Some clarification. Healthcare, like a lot of other sectors in the economy, is not paid for by the user. If I decide to buy more of something, I naturally lose more. And if I don't buy it, I keep money. In healthcare, this is (thankfully) not the case. A very large proportion of people are net payers, in other words, they pay more than they use. And if you use only a little care, you still pay for it via a deductible. Around 90% of premium-paying adults thus contribute to the 10% of net recipients. For the record, this form of solidarity is an achievement!
Solidarity stands or falls with support, from the net payers to continue doing so without grumbling. Solidarity is therefore not infinite, because by definition this support base is never infinite. And where grumbling starts - especially when more and more healthcare costs can be traced to personal choices to smoke, play sports or not exercise - support crumbles. That this moment will come seems almost certain, because something else is going on. This solidarity is rising organically, as healthcare costs per user rise sharply, partly because more can be done. The best way to see this is because premiums are rising every year, and you will just see those costs rising as a (young) non-user of care, eating up an ever-increasing part of your purchasing power.
For most young people, an additional factor is that they have to make an assessment at the same time of whether this form of solidarity is still there when they might need it. It could well be that the answer to that is "no". That does no good to the willingness to pay a princely premium now.
Unrest
A good indicator is the unrest that arises when the new insurance premium is announced. I have not researched it, but it seems to get a bit more intense every year. This year, the premium rose over 10 euros a month and it will do the same next year. On top of that, because of the halving of the deductible (a measure that thus further increases risk solidarity), another 20 euros will be added! We will then be close to 200 euros per month, and I fear that this symbolic limit may well be a gamechanger for support.
Cost control is thus also not just a matter for insurers. But also of premium payers, of the government and of society as a whole. As a hospital man, I also think that this side of cost control should be given much more attention in healthcare itself; it is also in our interest to be frugal and efficient, not just because we are forced by the financiers. The prisoner's dilemma that we have to have a healthy revenue model on the one hand and try to control unit costs on the other is a false contradiction. Both is also in our interest. Indeed, paying attention to this now will delay or at best prevent difficult decisions later, when the turnaround in willingness to accept insurance premium increases starts to have consequences on our budgets.
In any case, my conclusion is: we hardly ever talk about it. And that is undesirable. Because take note: precisely to ensure risk solidarity, we need to talk about it much more. How do we shore up the support base when it is already increasing organically every year? If we don't explicitly enter into that conversation, I think we will pay the bill later! I join this necessary debate!’
About Frido Kraanen
Frido Kraanen is director at Gelre Ziekenhuizen, a top clinical hospital with locations in Apeldoorn and Zutphen. Frido is also a visiting practitioner at DRIFT, focusing on "transition pain"; the phenomenon of support for transition decreasing in people or organisations when loss and resistance (are perceived to) increase.
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