There’s a wealth of economic evidence demonstrating that cost-sharing requirements for medical care, alongside protections for the vulnerable, can temper demand for outpatient care without resulting in adverse consequences.

A recent study documents how Canada stands among a small minority of only six universal health-care countries (out of 28) that have not acted on this evidence and, generally, do not expect patients to share the cost of care. This blog post is part of a series of posts that documents how eight high-performing universal health-care systems utilize cost-sharing mechanisms (deductibles, coinsurance payments and copayments) while protecting vulnerable patient populations. While previous posts in this series have outlined how Australia, Belgium and France accomplish this, this post will focus on the Netherlands.

The Netherlands ensures universal coverage through a compulsory social health insurance scheme. Residents must purchase a standard insurance package from one of several private insurers, in a regulated but competitive market. Coverage definitions for the basic insurance package are broad, but must include core services provided by general practitioners, specialists and hospitals. The purchase of voluntary insurance is also common (83.9 per cent in 2021) in the Netherlands, which often covers costs of dental care, physiotherapy, glasses and co-payments for medications that exceed the reimbursement rate.

The universal system is primarily financed through income dependent contributions (50 per cent) and “community rated” premiums (50 per cent). While premiums can vary between insurance companies, each insurer must determine a flat premium for adults that applies uniformly across the country regardless of individual health status or other factors. And insurers must accept all applicants for coverage.

Deductibles are the major form of cost-sharing for core services. In 2020, Dutch residents were expected to pay an annual deductible of €385 (C$589.37) for most types of care including access to specialist consultations and hospital care. Patients may also choose higher deductibles (up to €500 or C$765.40) in exchange for discounts on their monthly premiums. Patients are covered for all the cost of care once this deductible is met. Pharmaceuticals are also covered by the basic insurance plan in the Netherlands, but are also subject to the same deductible cost-sharing requirements. However, patients may have to pay an additional “personal contribution” for medications that exceed the maximum reimbursement amount (for which there’s an annual €250 or C$382.7 cap).

Dutch patients may also choose to expose themselves to other forms of cost-sharing depending on their choice of policy. “In-kind” policies allow patients to see contracted providers and receive no bill, with care from non-contracted providers being partially reimbursed (with patients responsible for the balance). In contrast, “restitution policies” allow for free choice of provider in exchange for paying for the bill out-of-pocket and receiving reimbursement afterwards.

Safety nets in the Netherlands include deductible exemptions for general practitioner visits, dental care for those < 18 years of age, obstetric/maternity care, and care for specific chronic illnesses.

The Dutch government also provides financial assistance as another form of protection. Low-income Dutch patients (individuals and families) may qualify for an “allowance” for their health-care premiums, based on the income of the individual and their “allowance partner” alongside the average premium price and compulsory deductible. In 2020, the income threshold to receive the smallest allowance was below €30,500 (C$46,690) or €39,000 (C$59,702) with a partner. In addition to this premium allowance, patients who’ve incurred “structural care expenses over time” due to chronic illness or disability are also able to receive financial compensation.

This fourth contribution to this blog series has provided a general overview of the Dutch health-care system, its cost-sharing arrangements and related protections. The next post in this series will examine the same topics for the universal system in New Zealand.