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Chapter 8 | The impact of the crisis on the health system and health in the Netherlands
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definition, 1.9% of the population defaulted in 2011 and 2.1% in 2012 (Statistics
Netherlands, 2013b). The number of uninsured has also likely increased but no
data are available to quantify this trend. According to Statistics Netherlands,
0.1% of the population was uninsured in 2012 (Statistics Netherlands, 2013a).
There has also been an increase in cost-related access problems. A study by
the Commonwealth Fund among 1000 Dutch citizens revealed that 22% of
respondents experienced cost-related access problems and 9% experienced
problems with paying their medical bills in 2013 (Schoen et al., 2013). In 2012,
a survey among 854 Dutch respondents revealed that 9% of this population
sample stated that they did not go to the GP because of the high deductible,
even though the deductible does not apply to GP care (Reitsma-van Rooijen,
Brabers & De Jong, 2012). Since 2012, a decrease in the volume of hospital care
has been observed. This is an important break in the trend, since the volume
has been increasing for decades. The decrease might have been caused by the
economic crisis, but this is not yet fully clear or explained (Heijn, 2013). 14
In 2013, a survey among 8500 Dutch GPs showed that 94% were consulted
by patients who had difficulties paying for non-refundable medications and
other medical aids (24% dealt with such patients on a daily basis); 77% of the
surveyed GPs said that they sought alternative solutions for their patients, such
as additional consultations, before referring them to care that was subject to the
compulsory deductible (National Association of General Practitioners, 2013).
Reduction of referrals is also in line with the 2013 agreement with the Ministry
of Health (see section 3.1), but it is not clear what influenced the behaviour of
doctors: the crisis, the 2013 agreement or both.
The financial vulnerability of health insurers has grown through the increase
in risk bearing as a result of the abolition of financial safety nets, such as the
retrospective compensation for large deviations from the budget set by the
government. Increased competition on premiums might also have contributed
to this. Recently, a Dutch newspaper (De Telegraaf) reported that in 2013
patients increasingly had trouble paying the compulsory deductible and that
health insurers were frequently asked by their clients to come to an insolvency
arrangement (Boon & Navis, 2013). If this trend continues, the financial
vulnerability of health care providers and even access to health care may be
affected in the future.
As noted above, in 2013 health insurers were for the first time able to lower
premiums for the basic package. This might have happened at the expense of
reducing the choice of provider and increasing the level of deductibles, but
14 The International Health Policy surveys conducted by the Commonwealth Fund show that, in 2010, 4% of Dutch
respondents "did not see a doctor when sick or did not get recommended care because of cost"; this figure was 20% in
2013. In other countries, the percentage of respondents that agreed with this statement remained stable or decreased
(e.g. from 23% in 2010 to 10% in 2013 in Germany; Schoen et al., 2013).