Mandatory deductible in basic health insurance Country: Netherlands Partner Institute: University of Maastricht, Department of Health Organization, Policy and Economics (BEOZ) Survey no: (11)2008 Author(s): Maarse, Hans Health Policy Issues: Funding / Pooling Current Process Stages Idea Pilot Policy Paper Legislation Implementation Evaluation Change 1. Abstract A key element of the new basic health insurance (2006) was the introduction of a no-claim arrangement (NCA). After two years of experience the arrangement has been abolished. It proved to be an ineffective and administratively highly complex instrument. Furthermore it was considered an unfair arrangement. Since 2008 it has been replaced with a mandatory deductible (MD) of 150 euro (103 euro for persons with chronic illnesses) for insured aged 18 years or older. 2. Purpose of health policy or idea The main purpose of the mandatory deductible is to increase individual responsibility of consumers/patients in health care and increase efficiency by avoiding unnecessary medical consumption. Another purpose of the instrument is to bring about a shift from public to private financing in health care. Furthermore, the mandatory deductible is intended to resolve the perceiced unfairness of the no-claim arrangement (see HPM report "The no-claim arrangement in health insurance"). Main objectives The mandatory deductible applies to all insured aged 18 or older. It is set at 150 euro, except for persons who are registered as chronically ill - for them it is set at 103 euro. The latter amount is based on the expectation that the average deductible will be 103 euro per person. All insured can opt for a higher voluntary deductible up to 500 euro in exchange for a lower premium rate. The costs of GP care, maternity care and assistance at a delivery are excluded from the mandatory deductible (these costs are fully covered by the new health insurance scheme). Type of incentives The mandatory deductible can be classified as a financial instrument. Groups affected patients (patients aged 18 and older must copay 150 euro a year for all care covered by the new health insurance scheme; the costs of GP care, maternity care and assistance at delivery excluded), insurers (must implement the arrangement.), providers - 1 -
3. Characteristics of this policy Degree of Innovation traditional innovative Degree of Controversy consensual highly controversial Structural or Systemic Impact marginal fundamental Public Visibility very low very high Transferability strongly system-dependent system-neutral 4. Political and economic background The main reason of the mandatory deductible was the failure of the no-claim arrangement. The NCA was problematic for at least three reasons: 1. It was a highly complex arrangement from an administrative point of view. 2. It was considered an ineffective instrument. It did not reduce medical consumption because of the time lag between medical consumption and experiencing the financial consequences of that consumption (the 255 euro for the NCA was paid back one year later, after the costs of medical care in the previous year had been subtracted) 3. It was considered unfair because persons who needed frequent medical care could not benefit from the arrangement. The mandatory deductible is assumed to resolve the second and the third problem. Because of the direct link between utilisation of medical care and financial consequences, the MD is assumed to be more effective than the NCA. The MD is also viewed as a solution to the unfairness of the NCA because the rate for individuals with chronic conditions is set 47 euro lower than the standard MD of 150 euro. 5. Purpose and process analysis Idea Pilot Policy Paper Legislation Implementation Evaluation Change Origins of health policy idea The idea was developed by the Ministry of Health. It is a good example of 'reforming the reform'. Interestingly, the noclaim arrangement was introduced in 2006 (in 2005 already for subscribers of the sickness funds), because at that time there was no political majority for a mandatory deductible. The no-claim arrangement was a political compromise. Now that it has proven to be ineffective and unfair, a mandatory deductible has become politically acceptable. The mandatory deductible is not new in Dutch health insurance. An earlier version of it was introduced in 1997 but - 2 -
cancelled after two years because of administrative complexity, lack of effectiveness and social/political resistance. To increase the effectiveness of the mandatory deductible now, there are plans to set up the current version differently. According to these plans insurers will be allowed to cancel the mandatory deductible if the patient visits a preferred provider. So the mandatory deductible is converted into a financial instrument to steer patients. This is not yet possible under the current new health insurance legislation, but a proposal to change the legislation has been sent to the Parliament. Initiators of idea/main actors Government Providers Payers Patients, Consumers Media Approach of idea The approach of the idea is described as: renewed: The MD is not new in Dutch health insurance. An earlier version of it was introduced in 1997 but cancelled after two years because of administrative complexity, lack of effectiveness and social/political resistance. Stakeholder positions The introduction of the mandatory deductible was strongly opposed by the Socialist Party. The Labour Party, taking part in the government coalition, supported the arrangement. Insurers see the mandatory deductible as an instrument to reduce utilisation of medical care and thus costs. Furthermore, one should not forget that all insurers additionally give their subscribers the opportunity to take out a policy with a voluntary deductible, ranging from 100-500 euro (a person who opts for a 100 euro deductible, must pay 150 (mandatory) + 100 (voluntary) = 250 euro out-of-pocket). I believe that the appreciation of the mandatory deductible has significantly changed over the last few years. Patients and doctors always protest against these measures because they are considered unfair (they hit the sick) and may reduce access to health care. Doctors also believe that a deductible may interfere in the patient-physician relationship. This is all a cultural aspect of health care in the Netherlands. Actors and positions Description of actors and their positions Government Ministry of Health very supportive strongly opposed Ministry of Finance very supportive strongly opposed Providers Association of general practitioners very supportive strongly opposed Payers Health insurers very supportive strongly opposed Patients, Consumers Patient organizations very supportive strongly opposed Media - 3 -
Newspapers very supportive strongly opposed Influences in policy making and legislation The introduction of the mandatory deductible required a change in the 2006 Health Insurance Law. Legislative outcome success Actors and influence Description of actors and their influence Government Ministry of Health very strong none Ministry of Finance very strong none Providers Association of general practitioners very strong none Payers Health insurers very strong none Patients, Consumers Patient organizations very strong none Media Newspapers very strong none Positions and Influences at a glance - 4 -
Adoption and implementation Health insurers, patients and providers are involved in the implementation process. To appease opponents, it was decided again that the costs of GP care, maternity care and assistance at delivery were excluded. It is still not accepted in the Netherlands that patients co-pay for a visit to a GP. Monitoring and evaluation No evaluation planned as yet. Review mechanisms Mid-term review or evaluation Dimensions of evaluation Outcome Results of evaluation The NCA has been reviewed and did not prove to be effective. 6. Expected outcome The mandatory deductible will only lead to a short-term decline of medical consumption. It will have no long-term effect on it. The only long-term effect will be that the private fraction in health care financing/spending will increase (which is very much appreciated by the Ministry of Finance). I also expect that the MD will be set at a higher level every year. The current level of the mandatory deductible will turn out to be what political scientists call a 'camel's nose'. Quality of Health Care Services marginal fundamental Level of Equity system less equitable system more equitable Cost Efficiency very low very high Author/s and/or contributors to this survey Maarse, Hans Suggested citation for this online article Maarse, Hans. "Mandatory deductible in basic health insurance". Health Policy Monitor, April 2008. Available at http://www.hpm.org/survey/nl/a11/3-5 -