Netherlands and Sweden

In both countries, the majority of the population buys supplemental policies, often purchased from the insurer providing basic coverage. Insurers providing supplemental coverage are subject to fewer (Netherlands) or no (Switzerland) risk-rating restrictions. This has had complex effects on competition and mobility of the insured in the supplemental insurance market.

An additional 1.5 percent is insured but behind on premium payments—a policy concern in both countries. Both countries subsidize premiums for low-income households, with about 40 percent receiving such premium assistance.[1]

Netherlands

• Compulsory social insurance for people earning an income below a certain income level
• Private insurance available for people earning above a certain income level

Sweden

Sweden attaches high priority to the provision of health services to the entire population paid for through

• National taxes
• Regional taxes.[2]

Netherlands – The Health Insurance Act of 2006

The Health Insurance Act of 2006 was the culmination of several years of Dutch legislation and policy aimed at achieving universal health care coverage. It requires all people who legally live or work in the Netherlands to buy health insurance from a private insurance company. Insurers are required to accept each applicant at a community-rated premium regardless of preexisting conditions.

As discussed, insurance companies are required to accept each applicant for basic insurance coverage. Individuals can choose from among 14 private insurance companies and several related subsidiaries. The Dutch government has set up a Web site where consumers can compare all insurers with respect to price, services, consumer satisfaction, and supplemental insurance, and compare hospitals on different sets of performance indicators.

The plan is financed with individuals’ annual income-based contributions to the tax collector. Employers are required to compensate their employees for these contributions.

• In addition, all adults are required to pay premiums directly to the selected insurer, which sets its own community-rated premium. It is estimated that 1.5% are uninsured[3]

In the Netherlands, the government is not in charge of the day-to-day management of the healthcare system.

• Private health suppliers are responsible for the provision of services in this area.
• The government is responsible for the accessibility and quality of the healthcare.

Since January 1^st 2006 there is a new healthcare insurance system in the Netherlands and you should be aware of the requirements before you leave for the Netherlands.

If you are living in the Netherlands or you are paying income-tax in the Netherlands you are required to purchase a health insurance at a Dutch insurance company. In the past there was a difference between public and private healthcare in the Netherlands. This however has been changed and everybody is now required to purchase basic health insurance.

Fees of the basic package

The fees for the basic health insurance package are annually determined by the health insurance companies and are normally approximately €95 per month. Although the Ministry of Health ( Ministerie van Volksgezondheid, Welzijn en Sport) determines a standard premium, the insurance companies determine the additions fee you will have to pay in the end by charging a certain rate and a no-claim charge. It is with these additional fees that the insurance companies compete with each other. There are various health insurance companies and a new law will make it easier to change between health insurance companies.

If you are required to purchase health insurance and are earning a salary, you will also pay a supplementary contribution from your income (rated 6.5% up to the first €30,000 of earnings; 4.4% for self-employed individuals). [4]

In the Netherlands, for example, people must buy supplementaryinsurance for health care such as cosmetic surgery, non-rehabilitative physiotherapy, or more comprehensive dentistry. Costs have been cut, quality driven up, and fees are far from prohibitive; infact 93% of the population have bought some form of supplementaryinsurance.[5]

“Have you recently moved to the Netherlands? “Remember to take out health insurance. Obligatory health insurance Health insurance covers the costs of medical care. Residents in the Netherlands are obliged by law to take out health insurance, for themselves and for their partners and children. Even if you already have a health insurance policy, you are still obliged to take out a new policy in the Netherlands.[6]

The Netherlands operates a national insurance market for its 16 million residents. Plans may operate on a for-profit or nonprofit basis.

Plans typically offer coverage in all areas of the country and include all providers, although selective contracting is allowed. Children are covered in full through public funds. Premiums charged for adults represent 50 percent of the expected annual costs. Netherlands has notably low cost-sharing, with additional protections for the chronically ill. [7]

The right to health care in the Netherlands

As for the waiting lists, their existence is as such acceptable, but only depending on the required treatment. And in this respect, it must be said that waiting lists in the Netherlands are sometimes unacceptably long. For example, there are huge shortfalls in appropriate care for children with mental and behavioural disorders, which is a growing problem in the Netherlands.

On occasion, the length of the waiting list has led to a situation where people have died because they could not get the treatment they needed on time.

The waiting lists are partly caused by shortfalls in personnel. There is a particular shortage of general medical practitioners, GPs in short. Although in the Netherlands everyone is supposed to have access to a GP, which is a worthwhile objective, a fair amount of people are still without recourse to this type of general medical care. The shortage is most visible in areas where it is less attractive for GPs to set up their practice.

As a result of the waiting lists, people are increasingly seeking medical care across the border, especially in Germany and Belgium. Although this takes the pressure off, the government fears that this practice will endanger the return on its investments in the national health care sector.

The following groups are vulnerable to exclusion from health care services: immigrants, the elderly, women in certain cases, people with chronic diseases, including HIV/AIDS, and people with physical or mental disorders.

There is, however, one group in the Netherlands that is particularly susceptible to exclusion from medical services and they are illegally residing immigrants. Due to the so-called ‘Matching Act’, only people with legal status are covered by the sickness fund. This means that illegal aliens are excluded from access to the health care package provided under the fund. In order to prevent inhumane situations from arising, the Matching Act provides that people without legal status may claim subsidised medical help in cases of ‘medical necessity’. This means that they have access to a limited health care package. What should be provided under this package has been heavily debated in the Netherlands. As part of the discussion, before the term ‘ medical necessity’ was introduced, the term ‘ emergency medical care’ was applied, which is stricter than ‘ medical necessity’.  A practical implication of the system is that, in practice, people without legal status do not have access to treatment for HIV/AIDS.

Switzerland

The Swiss health care system has gained a reputation of being one of the best in the world. There is an extensive network of hospitals and doctors, waiting lists for treatment are rare and medical facilities have the latest technology. However, as with most things in Switzerland, there is a price tag attached to this quality!

Hospitals ( Krankenhaus, Spital/hôpital) can be recognized by a white “H” on a blue background and are listed in the yellow pages under Spitäler or hôpitaux. Except for emergencies, you usually have to be referred to a hospital by a doctor. You normally have to visit a hospital in the canton where you are residing, although there are exceptions to this.

Depending on your insurance scheme, you will either be put in a

1. Standard cover – general ward with two to four beds
2. A two-bed room (half private)
3. A single room (private)

Note that standard cover does not give you the right to choose your doctor, this may be important as not all doctors may speak your language.

Hospitals in Switzerland aren’t cheap! All hospital fees have to be paid for either by you or your insurance company. There is no such thing as ‘free treatment’ in Switzerland (even in the case of emergencies). If the decision is up to you whether or not to go into the hospital, you should first talk to your insurance company.

After visiting a hospital or doctor, you will receive a bill which you should pay within the specified period (usually around 30 days). You then send a copy to your insurance company, which will reimburse the percentage covered by your insurance scheme. If you are not resident in Switzerland and don’t have any sufficient health insurance, hospitals can require a deposit upon your admittance, which may range from CHF 2000 to 10,000.

Health insurance – Public and private health insurance in Switzerland

According to the Health Insurance Act ( Krankenversicherungsgesetz – KVG) every person living in Switzerland is obliged to take out a basic health insurance policy ( Grundversicherung). Note that in Switzerland, sickness insurance will normally not be arranged by your employer. You have the responsibility of contacting providers and arranging the insurance yourself. Only if your employer has an agreement with a specific insurer and pays part of your premiums (which rarely happens), will you be forced to choose a specific provider.

Health insurance premiums in Switzerland are:

1. Not dependent on income
   
2. Calculated based on your personal risk profile 
3. Swiss Confederation subsidizes premiums for low-income individuals/families

Swiss insurance schemes only cover individuals, not families as in some other European social security schemes. You will therefore have to insure each household member, including children.

If you only have a compulsory basic insurance scheme, you are obliged to make a contribution towards your total annual medical cost, up to a certain limit per year. This ‘franchise’ is calculated as a percentage of your total annual medical costs and capped at a yearly limit.

About 40% of the Swiss population chose to top-up their insurance cover. This is commonly in order to have more comfortable accommodation during a hospital stay or wider choice of treatments.[8]

The Swiss have operated with a mandate since 1996. Uninsured rates are low (estimated at below 1 percent in Switzerland). An additional 1.5 percent is insured but behind on premium payments.

Switzerland imposes much higher cost-sharing, including deductibles and coinsurance than the Netherlands.

The Swiss insurance system (7.5 million people) is highly decentralized, with plans operating and setting premiums at the canton level (26 divisions). In Switzerland, only nonprofit insurers may participate. The 10 largest of some 85 carriers insure 80 percent of the population. Swiss insurance risk equalization efforts adjust only for age and sex factors at the moment. Currently, Swiss premiums vary widely by health risks of insured pools across the country and within regions.

Switzerland, 12 percent of the population is enrolled in HMOs or other managed care plans. However, savings have been limited because most of these enrollees are in the least integrated plans, and plans have no ability to negotiate prices with providers. Outside such plans, Swiss patients have open access to physicians and can self-refer to specialists. Swiss provider fees are generally set by negotiations between provider associations and insurance associations.

Hospitals are mostly paid per diem rates, although a large fraction has already changed to prospective reimbursement.

Aside from emergency care health care or care that can not be acquired, you must be use providers that are located in your resident Canton.

A nationwide diagnosis-related group (DRG) system (SwissDRG) will be introduced in 2012. Cantons finance more than 50 percent of hospital costs either directly or through DRGs.[9]

[2] http://content.healthaffairs.org/cgi/reprint/13/5/106.pdf

[3] http://www.commonwealthfund.org/Content/Publications/In-the-Literature/2008/May/Universal-Mandatory-Health-Insurance-in-The-Netherlands–A-Model-for-the-United-States.aspx

[4] http://www.justlanded.com/english/Netherlands/Netherlands-Guide/Health/Healthcare

[5] http://www.bmj.com/cgi/content/full/bmj.39563.453183.AD

[6] http://www.minvws.nl/en/folders/z/2008/obligatory-health-insurance1.asp

[7] http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2009/Jan/The-Swiss-and-Dutch-Health-Insurance-Systems–Universal-Coverage-and-Regulated-Competitive-Insurance.aspx

[8] http://www.justlanded.com/english/Switzerland/Switzerland-Guide/Health/Introduction

[9] http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2009/Jan/The-Swiss-and-Dutch-Health-Insurance-Systems–Universal-Coverage-and-Regulated-Competitive-Insurance.aspx

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