JANUARY

The Dutch Health Care System, 2015
Joost Wammes, Patrick Jeurissen, and Gert Westert
Radboud University Medical Center
What is the role of government?
In the Netherlands, the national government has overall responsibility for setting health care priorities,
introducing legislative changes when necessary, and monitoring access, quality, and costs. It also partly finances
social health insurance for the basic benefit package (through subsidies from general taxation and reallocation
of payroll levies among insurers through a risk adjustment system) and the compulsory social health insurance
system for long-term care. Prevention and social support are not part of social health insurance but are financed
through general taxation. The 2015 national reforms to long-term care made municipalities and health insurers
responsible for most outpatient long-term services and all youth care under a provision-based approach (with
a great level of freedom at the local level).
Who is covered and how is insurance financed?
Publicly financed health insurance: In 2013, the Netherlands spent 12 percent of GDP on health care, and
78 percent of curative health care services were publicly financed. All residents (and nonresidents who pay
Dutch income tax) are mandated to purchase statutory health insurance from private insurers. People who
conscientiously object to insurance, as well as active members of the armed forces (who are covered by the
Ministry of Defense), are exempt. Insurers are required to accept all applicants, and enrollees have the right
to change their insurer each year.
Apart from acute care, long-term care, and obstetric care, undocumented immigrants have to pay for most
health care themselves (they cannot take out health insurance). However, some mechanisms are in place to
reimburse costs that undocumented immigrants are unable to pay. For asylum seekers, a separate set of policies
has been developed. Permanent residents (for more than 3 months) are obliged to purchase private insurance
coverage. Visitors are required to purchase insurance for the duration of their visit if they are not covered
through their home country.
Statutory health insurance is financed under the Health Insurance Act, through a nationally defined, incomerelated
contribution, a government grant for the insured below age 18, and community-rated premiums set
by each insurer (everyone with the same insurer pays the same premium, regardless of age or health status).
Contributions are collected centrally and issued among insurers in accordance with a risk-adjusted capitation
formula that considers age, gender, labor force status, region, and health risk (based mostly on past drug and
hospital utilization).
Insurers are expected to engage in strategic purchasing, and contracted providers are expected to compete
on both quality and cost. The insurance market is dominated by the four largest insurer conglomerates, which
account for 90 percent of all enrollees. Currently, there is a ban on the distribution of profits to shareholders.
Private (voluntary) health insurance: In addition to statutory coverage, most of the population (84%)
purchases a mixture of complementary voluntary insurance covering benefits such as dental care, alternative
medicine, physiotherapy, spectacles and lenses, contraceptives, and the full cost of copayments for medicines
(excess costs above the limit for equivalent drugs—an incentive for using generics). Premiums for voluntary
insurance are not regulated; insurers are allowed to screen applicants based on risk factors and offer both
statutory and voluntary benefits. Nearly all of the insured purchase their voluntary benefits from the same
(mostly nonprofit) insurer that provides their statutory health insurance. People with voluntary coverage do not
International Profiles of Health Care Systems, 2015 115