Recent Changes in Dutch Health Insurance: Individual Mandate or Social Insurance?

Abstract

This paper describes and analyzes the new insurance model of 2006 and its origins in the earlier reform efforts of the 1980s and 1990s. The paper starts with some of the particular characteristics of social policy-making in the Netherlands and the core features of the 2006 health insurance reform. The paper looks at the (only partially implemented) reform proposals of the 1980s and early 1990s. As in other industrialized countries, the oil crises and economic stagnation in the late 1970s triggered extensive debate on the future of the welfare state. The health reform proposals of the 1980s reflected a shift in ideological thinking as well. After decades of consensual policy-making where the major stakeholders shared the responsibility for social policy with government, the focus shifted in the 1980s to reform models of individualized and decentralized decision-making. While those earlier health reforms did not succeed directly, they helped to change the political climate and opened the way for new forms of private care that did not previously have much public support.Next, the paper looks at the changing positions of the main stakeholders in Dutch health care, including managers and organized patient groups. Managers of health insurance and health care services alike adjusted their attitudes and behavior in reaction to - and in anticipation of - announced health reforms, even when some of that policy was not implemented. And, once such changed behavior became visible and generally accepted, it encouraged governments to change course and to take up reform proposals that were rejected a decade before. Dutch patients and consumers also faced new options and have reacted in quite divergent ways, sometimes initiating and supporting change, sometimes forcing government to reverse its course. The paper concludes that rather than a dramatic break with the past, the 2006 health insurance reform represents much continuity in the role of government and other actors in Dutch health care. For example, since the abolition of mandatory contracting in 1991, Dutch health insurers no longer have to contract with every health care provider. Insurers, however, have shown themselves reluctant to break off long-standing contractual relations (and face angry reactions from their insured). New providers - in contrast to health insurers, where there have been few newcomers to the market-have entered the market offering substitutes for traditional health services, but thus far they have had limited success. Dutch citizens have shown limited interest for individual consumer choice in health insurance, and the government is quick to act when facing popular dissatisfaction about the consequences of policy change.