universal manadatory health system a model for the united states

8/3/2019 Universal Manadatory Health System a Model for the United States

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N E T H E R L A N D S

Insurance In The Netherlands:A Model For The United States?The Dutch are leaving supply-side regulation beh ind in favor of amanaged co mpetit ion schem e that requires everyone to purchaseprivate coverage, w ith subsidies to make coverage afford ab le.by Wynand P.fVil.fVi. van de Ven and Frederik T. SchuHABSTRACT: Policy analysts consider the Netherlands health system a possible model forthe United States. Since 2006 all Dutch citizens have to buy standardized individual healthinsurance coverage from a private insurer. Consumers have an annua l choice am ong insur-ers, and insurers can selectively con tract or integrate with health care providers. Subsidiesmake health insurance affordable for everyone. A Risk Equalization Fund compensates in-surers for enrollees with predictably high medical expenses. The reform is a work in prog-ress. So far the emphasis has been on the health insurance market. The challenge is nowto successfully reform the market for the provision of health care. [Health Affairs 27, no. 3(2008): 771-781; 10.1377/hlthaff.27.3.771]

DROPosALS FOR HEALTH CARE REFORM in the United States regularly re-fer to the recently reformed Netherlands health care system. Highlighted_ L features are the individual mandate to buy private health insurance; an an-nual choice of insurers by consumers; individual-based instead of employer-basedinsurance; community-rated premiums and income-related subsidies to buyhealth insurance; risk-adjusted equalization paym ents to insurers for covering theelderly and chronically ill; a multiple-payer instead of a single-payer system; anddelivery of hea lth care by private providers.

In this paper we focus on the N etherlands health care reforms. We discuss thethree major waves of reform in the N etherlands during the pas t century, and we fo-cus on the national Health Insurance A ct that w as impleniented in 2006.TDncee W a v e s if IHleail4lh Caire Reffoirm

Historically, the D utch health care system has been cha racterized by much pri-vate initiative in bo th funding and provision of care. Until 1941 there w as no gov-


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G L O B A L I N N O V A T I O N S

ernment regulation with respect to health insurance. Doctors were free to estab-lish practices and to set prices. Around 1940 there were several hundred localcommunity health insurance organizations. These local insurers paid generalpractitioners (GPs) by capitation and often had their own facilities, so they couldbe considered early health maintenance organizations (HM Os). Since the first un-successful a ttem pt to enact universal health insurance in 1904, it took more than acentu ry to implement mandatory comprehensive coverage for all. In this process,three major waves of health care reforms can be discerned .'

D First wave: toward universal coverage (about 19 40 -1 970 ). Until the 1970sthe primary focus of the Dutch government was to promote pubhc health, guaranteea minimum level of quality (for exam ple, by professional hcensure), and ensure uni-versal access to basic health services. After decades of political debate, a mandatoryhealth insurance scheme for low- and middle-income groups was introduced in1941. In 2005 this scheme covered 68 percent of the Dutch population. Coverage in-cluded physician services, prescription drugs, hospitaUzation (365 days), maternitycare, dental care for children, some paramedical care, and some medical devices.People with incomes above a certain threshold were excluded. Most of them volun-tarily bought insurance from a private insurer. In 2005 only about 1.5 percent of thepopulation did not have any health insurance, except for "exceptional" medical ex-penses that were covered by the Exceptional Medical Expenses Act. This act waspassed in 1968 and constituted a mandatory national health insurance scheme w ithan income-related premium, covering long-term care, care for the mentally andphysically disabled, and hospitalization for longer than one year.

D Second w ave: cost containment by government (about 1 97 0 -2 00 0 ). Bythe end of the 1960s the Dutch government became worried about the seemingly un-controllable grow th of health care spending. The reason for this was twofold. F irst,rising health care spending could jeopardize the goal of universal access to basiccare. Second, the government feared that rising health care costs would result inhigher labor costs, which would raise Unemployment and harm the Dutch openeconomy, which relies heavily on exports. The growing pressure to contain medicalspending led to increasing supply and price regulation beginning in the mid-1970s.In 1983 the government decided to replace the open-ended hosp ital reimburse-men t system w ith a budgeting system, which in 1984 was expanded to all other in-pa tient care institu tions. The Health CarejPrices Act (1982) enabled governmentto contro l physicians ' fees and, in a later stage, also their total revenues. Tradition-ally, medical specialists received a fee for each item of service. Using the threat ofsubstantial fee cuts, government forced them to give up their fee-for-service (FFS)payment system. By the mid-1990s the FFS system was largely replaced by a


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sequence, demand-side constraints have played a restricted role in containingcosts, as compared to supply-side constraints. Third wave: efficieincy through managed com petition (from about 2000).From the early 1980s top-down rationing policies were subjected to growing criti-cism, focused particularly on the lack of incentives for efficiency and innovationwithin the prevailing system of health care finance and dehvery This led to broadsupport for incentive-based reforms and a reconsideration of the role of competition.In 1987 the government-appointed Dekker Committee advised a market-orientedhealth care reform and a national health insurance system. The Health Insurance Act(2006) and the current regulatory regime are based on these proposals.The act was the culmination of a series of market-oriented reforms that weregradually implemented beginning in the early 1990s. A number of complicatedpreconditions had to be fulfilled to combine competition with universal accessand to create the appropriate incentives for consumers, providers, and insurers.First, an adequate system of risk equalization had to be developed (see below).Next, an adequate system of prod uct classification and medical pricing had to bedeveloped, to give providers appropriate incentives for efficiency and to preventstinting on the delivery of services. Third, an adequate system of outcome andquality measurement was necessary to enable specified contracts between insur-ers and health care providers and to prevent competition focusing only on price.Fourth, an adequate system of consumer information about the price and qualityof insurers and care providers had to be developed to enable effective consumerchoice. Finally, an adequate governance s tructu re, including an effective com peti-tion policy, had to be devised.

Since none of these precond itions was fulfilled in 1987, a "radical" reform clearlywas not feasible. During the twenty years following the D ekker plan, health carepolitics can be described as an ongoing process of competing policy programs;however, successive governments have consistently worked on the realization ofthe preconditions for managed com petition.^ After decades of central price and ca-pacity control by government, the Dutch health care system is now in transitionfrom supply-side regulation tow ard managed competition. The center-left coah-tion government that in February 2007 replaced the previous center-right coali-tion continues in this policy direction.

TBue Pirovate SectorSince 1 January 2006, the Health Insurance Act has obliged each person who le-gally lives or works in the Netherlands to buy individual private health insurance,


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national contex t, the Du tch health system reform is unique: this is the first coun-try that is consistently implementing Alain Enthoven's model of national healthinsurance based on managed competition in the private sector.^ Financing. All individuals have to pay an income-related contribution (7.2percent of the first 31,200 of armual income in 2008) to the tax collector, who trans-fers these contributions to a Risk Equalization Fund (REE).'' Employers are legallyobliged to compensate their employees for these income-related contributions.These compensations are the same regardless of the chosen insurer and are taxableincome for employees. In addition, all adults have to pay a premium directly to thechosen insurer. Each insurer sets its own community-rated premium. Eor high-riskinsured people, insurers receive a high risk-adjusted equalization payment from the

REE. Eor low-risk insured people, insurers have to pay an equalization payment tothe REE. According to the Health Insurance Act, the sum of the income-related con-tributions equals 50 percent of the total insurers' revenues for the mandatory basicinsurance. In 2008 the average premium equals about 1,100 (about US$1,600) peradult (age eighteen and older) per year.About two-thirds of Dutch households receive an income-related subsidy

("care allowance") from the governm ent, which is at most 1,464 (in 2008; abou tUS$2,200) per household per year.^ Because the allowance is independen t of thechoice of insurers, consumers are fully price-sensitive at the margin. No premiumis required for coverage of children (under age eighteen); government compen-sates the REE for their health care costs.People are free to buy voluntary supplementary health insurance for benefitsthat are not included in the mandatory basic insurance, such as dental care foradults, physiotherapy, eyeglasses, alternative medicine, and cosmetic surgery. Eorsuch insurance, insurers may risk-rate premiums and refuse applicants. More than90 percent of the population buys supplementary health insurance, almost alwaysfrom the same insurer tha t provides their basic coverage.Since 2006 health care is primarily financed th rough tw o mandatory universalschemes with different regulatory regimes: a scheme for curative health care ser-vices under a regime of managed competition (Health Insurance Act) and ascheme for long-term care services under a regime of price and supply regulation(Exceptional Medical Expenses Act). The rationale for this distinction is based ondifferences betw een the typ es of risks and the feasibility of risk equalization, andbetween types of care for which the managed com petition model is considered tobe (in)appropriate.* In this paper we focus on the H ealth Insurance Act.

Entitlements. In the Health Insurance Act, the basic benefit package is de-scribed in terms of functions of care and not, as before, in terms of providers. Eor ex-


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Pharmaceuticals, or procedural conditions. Consumers can be entitled to receive"care in kind" or reimbursement of medical expenses. Insurers are free to selec-tively con tract w ith providers and to use financial incentives to motivate consum -ers to use preferred providers. Alternatively, insurers may offer con trac ts w ith fullreimbursement of all providers. In sum, although the standardized basic benefitpackage is prescribed in the Health Insurance Act, there can be substantial varia-tion in the insured person's en titlemen ts.

D Consumer choice of health insurance. For each type of insurance contract,an insurer is obhged to accept each applicant at any dme ("guaranteed issue") for thesame premium ("community rating per product") in each province. Insurers wathfew^er than 850,000 enroUees are allowed to restrict their activities to one or severalof the twelve provinces. The contract period is at most one year. According to theact, consumers have at least one option per year (on 1 January) to switch to anotherinsurer or basic insurance contract. Insurers are legally required to pubhsh nextyear's basic insurance contracts by November 15. There are about fourteen insurers,and some of them have several subsidiaries operating under different labels. Thelargest four insurers (including subsidiaries) have about 90 percent ofthe market. Inanticipation of the new national health insurance scheme in 2006, price competitionin the insurance market strongly increased. As the result of a "premium war," thehealth insurers incurred a total loss of 563 miUinn (2 percent of revenues) in 2006.''The introduction of the new health insurance scheme prompted many people to re-consider their choice of insurers, resulting in an all-time high switching rate of 18percent of the total population. In 2007, price competition resulted in similar losses.^

The Health Insurance Act provides the option of "group discounts." Insurers areallowed to give a premium discoun t of up to 10 percent to insured people who be-long to a "group," which can be any legal entity. In 2007, about 57 percent of thepopulation obtained such a group discount, with an average discount of 7 per-cent.' Tw o-thirds of them had a group discount via their employer. But there aremany other types of groups, such as patien t organ izations, sport associations, la-bor unions, cooperative banks (for their clients/members), and independent en-trepreneurs who organize groups (for example, via the In terne t). In principle, theentitlements for the basic insurance, including the consumer's choice of providers,are identical for those with a group discount and those witho ut such a discount.The only difference is the premium. For supplem entary insurance, however, theconditions may differ between group and individual con tracts. In practice, manygroups also negotiate about the conditions ofthe supplementary insurance, whichare often interrelated w ith the conditions of the basic insurance.According to the Health Insurance Act, every adult has a deductible of 150 per


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zens are legally obliged to buy basic health insurance coverage, in 2006 about 1.5percent failed to do so." Uninsured people are liable to a penalty of 130 percent of thepremium over the period of not being insured, with a maximum of five years. How-ever, the problem is that (1) government does not (yet) know who is uninsured, and(2) most uninsured people probably have such a low income that they cannot paythe penalty. If uninsured people need medical care, they can enroll with any insurer,because insurers are legally obliged to accept them. Alternatively, providers of carecan arrange the insurance enrollment of uninsured pa tients prior to treatment.

Government intends to actively enforce the mandate. As a first step, it is ac-tively tracking dow n the identity of the uninsured by matching the files of all in-surers wi th the files of civil registrations.'^ After identification, the uninsured willreceive a warning notice. If they persist in being uninsured, a last-resort option isthat some public authority w ill enroll them as insured w ith some insurer.

A related problem is the large number of insured people who do not pay the pre-mium. About 1.5 percent of the insured have not paid any premium in the past sixmonths.'^ In default of payment, insurers are allowed to cancel the contract and torefuse enrollment du ring the next five years. However, all other insurers are legallyobliged to accept the expelled person. If the person again does not pay the pre-mium, the second insurer may also cancel the contract. And the person might go toa third insurer, and so on. So the insurers fear a "merry-go-round" of defaulters.Canceling the contracts of defaulters is therefore not in their collective interest.To increase the enforcement of premium paym ents, the Dutch government in-tends to create the legal option in case of default to d irectly w ithho ld a paymentfrom the defaulters' income or welfare payments, just as it does for payroll taxes.This withheld payment wHl be higher than the h ighest premium in the market.'"*The government holds the view tha t each adult can afford the premium because indetermining the level of the welfare paym ents and the legal minimum wage, thepayment of the premium was taken into account. Therefore, according to govern-ment, nobody should withd raw from the responsibility to pay their premium.

An alternative way to reduce the poten tial risk of default or not taking up insur-ance would be to replace the current 50:50 ratio between income-related contri-butions and d irect out-of-pocket-premium with, for example, an 85:15 ratio, as itwas in 2005. The average annual out-of-pocket-premium would then be about350 per person (the 2005 level) rather than 1,100 (the 2008 level), and the in-come-related contribution would increase. In addition, the adm inistratively com-plex and costly system of income-related care allowances th at w as introduced in2006 could be abolished witho ut influencing access.


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ciently compensated the insurers for the (extreme) high expenditures of high-riskinsured people, insurers also received some ex post compensations based on theiractual expenses. As a result, the insurer's average financial risk on medical expenseswas limited to 36 percent of gains and losses in 2000.Since 2002 the following risk factors have been added: Pharmacy-based CostGroups (PCGs) in 2002, and Diagnostic Cost Groups (DCGs) and being seff-employed (yes/no) in 2004.^^ PCGs and DCGs are indicators of health status, de-rived from prior prescription drugs and the diagnosis of prior hospitahzation.Based on these risk adjusters, all individuals are classified into subgroups of in-sured people who are more or less homogeneous in future predicted health ex-penses. Together with these improvem ents in the equalization formula, the D utchgovernment increased insurers' financial risk from 36 percent (in 2000) to 59 per-cent (in 2008). This is partly the result of a gradual increase ofthe threshold abovewhich insurers receive a 90 percent compensation for all expenses per insuredperson per year, from 4,545 (in 2000) to 20,000 (in 2008). Despite the sophisti-cated risk-equalization model, insurers can easily identify unprofitable subgroups(Exhibit 1). Risk-selection activities targeted at these groups can therefore beprofitable.

Risk seiection . Although the risk-equalization scheme appeared to be sophis-ticated enough to prevent risk selection in the former social health insurancescheme, this may change because in the current scheme, insurers have more incen-EXHIBIT 1Predictable Losses For Subgroups Of Consumers, GivenFornnula (2005) And Community Rating (Without The Ex

SubgroupGeneral health indicators (iast year)Perceived health status: poor/moderateLimitations in physical functioningLimitations in daily activities

Three or more diseasesAnxiety neurosisDepressioniViigraineHigh choiesterolUse of at ieast five medicines in 14 days

Previous years25% highest expenses in each of the 3 preceding yearsHighest expenses 4 years agoHospital admission 4 years ago

The Dutch RIsk-EquallzatlonPost Compensations)Estim ated size of Predic table losses perth e group (%) person per year (Euro)

20.18.53.17.03.52.36.81.53.3

10.65.56.8

5 408 701,5908 901,1001,0803 2 01,3001,650

1,5001,3009 60


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tdves and more tools for risk selection than they had before 2006. This has occurred because, first, the chronically ill have more incentives to switch plans if some insurers' provider networks are more attractive than others. Prior to 2006, selective co n'tracting rarely occurred. Second, insurance contracts are no longer sold only byDutch "social insurers" w ith a long history of social solidarity; they are also sold byprivate insurers, which have more experience with risk selection. Third, govern-ment intends to further increase insurers' financial risk by reducing the ex post cost-based compensation.

Insurers also have more tools for risk selection at their disposal than they hadbefore 2006. First, they have more tools for managing care, which can also be used; to select risks. Second, insurers have more room to define the precise entitlem ents: of their insured groups, which can be used to select favorable risks. Third , insure rsare allowed to sell mandatory health insurance together with any other type of; non-life insurance (such as supplem entary health insurance, sick leave insurance,:and car insurance), which p rior to 2006 was not allowed. In particular, supple-mentary health insurance can be an effective tool for risk selection, because insur-! ers are allowed to reject applicants based on their health status. Fourth, insurers; are free to give premium rebates to groups for the mandatory basic insurance,, which prior to 2006 was not allowed. A group can have any risk composition, andthe "organizer" of the group can selectively enroll preferred members only. Al-though the rebate for the basic insurance is at most 10 percent, insurers can givethese groups any rebate on supplementary health insurance or other insuranceproducts.

In the transition period of implementing the H ealth Insurance Act in 2006, "se-lection via supplementary insurance" was not an issue because, under pressure from Parliament, insurers collectively agreed not to refuse applicants for the stan-dard supplem entary insurance. Under public pressure, insurers extended this col-lective agreement for one year. Indeed, no evidence of risk selection via individualsupplem entary insurance was found in late 2006 and early 2007.'^

Given the increasing incentives and expanding tools for risk selection, furtherimprovements of the risk-equalization method are necessary to prevent insurersfrom engaging in risk selection, which occurs, for example, in Switzerland.'^ Thegovernment intends to further improve the risk-equalization formula by addingnew risk adjusters such as DCGs based on outpatien t care, indicators of men talillness, and indicators of disability and functional restrictions, by multiyear rathe r, than one-year DCGs and by m ore effective forms of ex post risk sharing that com-pensate insurers for high-risk people who have high expenses because of rare


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surance policies for diabetes patients. These special policies were developed inclose cooperation with the national diabetes patient organization. In addition,several insurers are now actively involved in setting u p disease management p ro-grams for diabetes patients. These activities appear to be the direct effect of theextension of the risk-equalization system w ith a risk adjuster for type 2 diabetessince January 2006.'^ (Type 1 diabetes was already included as a risk adjuster.) In2007, almost forty p atien t organizations representing people with various chronicconditions had obtained group con tracts wdth insurers. On the other hand, at leastsixteen patient organizations were not able to obtain such a group contract be-cause the risk-equalization paym ents for these groups were insufficient, accord-ing to insurers.-^" Hence, in due course, the ability for patients with specificchronic conditions to negotiate favorable group contracts may provide a goodindicator of the quality of the risk-equalization method.

Ideally, the risk-equalization formula should be refined to such an exten t tha tinsurers expect the costs of selection (including the cost of a bad reputation) toexceed its profits. By making the risk groups in the equalization more homoge-neous, the costs of selection increase, while, on average, profits fall. In addition,the government or patien t advocacy groups could also raise the cost of a bad repu-tation by frequently monitoring insurers' behavior and publishing relevant con-sumer information.n iVilanaged c are . Competing insurers are expected to become prudent buyersof care on behalf of their insured populations. Although the supply side is still quiteheavily regulated by the government, insurers and providers w ill gradually get morefreedom to negotiate about prices, service, and quality of care. Since 2005, for exam-ple, prices for physiotherapy are no longer regulated. Insurers and hospitals are al-lowed to freely negotiate prices and selectively contract for a range of products (Di-agnostic Treatment Combinations) accounting for about 20 percent (in 2008) ofhospital revenues. In 2009, hospitals wall be allowed to set prices for about 50 per-cent of hospital services under a government-determined price cap.

Insurers are allowed to integrate with health care providers and to provide carein their own facilities using their own staff (such as primary care centers andpharmacies). Each insured person has to register with a single GP, who is assumedto coordinate and preauthorize specialist care. Recently insurers have started toset up primary health care centers and pharmacies. Insurers may provide theirgatekeeping GPs wi th incentives to stimulate integrated and coordinated care, re-sulting in integrated care organizations that give a prime role to primary care.Most legal obstacles to tha t type of integrated care organization have been abol-


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So far it is an unanswered question to what extent an integration of financingand delivery of care will be acceptable to the D utch population. Consumer information. A few years ago, the Dutch government took the ini-tiative to set up a Web site where consumers can get information about insurers andproviders of care (http://www.kiesbeter.nl). Consumers can compare all insurerswith respect to price, services, consumer satisfaction, and supplementary insurance(premiums and benefits). They can also compare hospitals on different sets of per-formance indicators, which have been developed by the Health Care Inspectorate(IGZ) since 2004. The provision of adequate consumer information is also one themain priorities of the newly established Netherlands Health Care Authority (N Za).

Knowledge of the Dutch health system rriay contribu te to the broadening of U.S.policy debates. Americans may be interested in the Dutch system because it com-bines mandatory universal health insurance with competition among privatehealth insurers. It is not a single-payer system. Since the early 1990s the Dutchgovernment has been gradually implementing this model. In 2006 a major stepwas taken w ith the implementation of the H ealth Insurance Act. It is important toemphasize that the D utch health care reform is a work in progress. So far the em-phasis has been on the health insurance market. A major challenge now is to re-form the still heavily regulated m arket for the provision of health care and to im-prove the quality of care and lower its cost. Major questions are whether theinsurers in the Ne therlands are really able ,to function as good purchasers of care,wh ich forms of "managed care" will be acceptable to the public, and whether gov-ernment wHl be prepared to give up its traditional tools for cost containment byreducing supply-side regulation. So far the jury is still out.Looking at the health care systems of the Netherlands and the United States,complementary strengths and challenges can be observed. The Netherlands hasimplemented the institutional framework to combine universal access and con-sumer choice of insurers ; its challenge.is to, create integrated delivery systems th atprovide high-quality care in response to consumers' preferences. In the UnitedStates there are several examples of excellent integrated delivery systems, whilethe reform debate is dominated by the issue of the lack of universal access to basichealth insurance coverage. Whether the best elements of both systems can becombined in the coming decade is a major challenge for health policymakers inboth countries.This paper was presented at the workshop "Thc Structure ofHealth Plan Com petition" at Stanford University


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NOTES1. See R.B. Scotton, "National Health Insurance in Australia: New Concepts and New Applications," Work-ing Paper no . 11 (Melbourne: National Centre for Health Program Evaluation, 1991); and D. Cutler, "Equal-

ity, Efficiency, and Market Fundamentals: The Dynamics of International Medical-Care Reform," Journal ofEconomic Literature 60, no. 3 (2002): 881-906.

2. J.K. Helderman et al., "Market-Oriented Health Care Reforms and Policy Learning in the Netherlands,"Journal ofHealth Politics, Policy and Law 30, no. 1-2 (2005): 189-209.

3. A.C. Enthoven, "Consumer-Choice Health Plan: A National-Health-Insurance Proposal Based on Regu-lated Competition in the Private Sector," New Englandjoumal ofMedicine 298, no . 13 (1978): 709-720.4. Self-employed people and retirees pay 5.1 percent.5. For a one-person household, the annual care allowance is at most 552 (about US$814) in 2008. In 2006,4.9 miUion households received a care allowance. Statistics Netherlands (Centraal Bureau voor deStatistiek, or CBS), "More than One Third of Adults Received Care Allowance," CBS Web Magazine, 13March 2007, http://www.cbs.nl/en-GB/menu/themas/arbeid-sociale-zekerheid/publicaties/artikelen/

archief/2007/2007-2135-wm.htm (accessed 1 February 2008). In total, there are 72 million households inthe Netherlands. CBS, "More and Smaller Households in 2050," CBS Web Magazine, 19 April 2007, http://www.cbs.nl/en-GB/menu/themas/bevolking/publicaties/artikelen/archief/2007/2007-2175-wm.htm (ac-cessed 1 February 2008).6. See, for example, W.P. van de Ven and F.T Schut, "Should Catastrophic Risks Be Included in a RegulatedCompetitive Health Insurance Market?" Social Science and Medicine 39, no . 10 (1994): 1459-1472.7. De Nederlandsche Bank, Statistisch Bulletin (Amsterdam: De Nederlandsche Bank, December 2007); and R.Douven and F.T. Schut, "Health Plan Pricing Behaviour and Managed Competition," CPB Discussion Pa-per no . 61,2006, http://www.cpb.nl/nl/pub/cpbreeksen/discussie/61 (accessed 1 February 2008).8. De Nederlandsche Bank,Staiistisch Bulletin.9. Nederlandse Zorgautoriteit, "Monitor Zorgverzekeringsmarkt. De Balans 2007" (Utrecht: NZa May

2007).10. For a U.S.-based analysis, see S.A. Glied, J. Hartz, and G. Giorgi, "Consider It Done? The Ukely Efficacy ofMandates for Health Insurance," Health Affairs 26 , no . 6 (2007): 1612-1621.11. CBS, "Het aantal onverzekerden tegen ziektekosten 2006, nieuwe methode" (Voorburg/Heerlen- CBS2007).12. First Chamber of Parhament, "Proceedings, 2007-2008," no. 11,4 December 2007,397-405.13. Ministerie van Volksgezondheid, Welzijn en Sport, "Structurele aanpak wanbetalers," 23 May 2007,http://www.minvws.n1/kamerstukken/z/2007/structurele-aanpak-wanbetalers.asp (accessed 1 February2008).14. Second Chamber of Parliament, 2007-2008,29689, no . 166,12 November 200715. W.P. van de Ven, R.C. van Vhet, and L.M. Lamers, "Health-Adjusted Premium Subsidies in the Nether-lands," HealthAffairs 23, no . 3 (2004): 45-55.16. D. de Bruijn and F.T. Schut, "Evaluatie AanvuUende verzekeringen" (Rotterdam: Erasmus Universiteit Rot-terdam, 2007).17 W.P van de Ven et al., "Risk Adjustment and Risk Selection in Europe: Six Years Later " Health Policy 83 no2-3 (2007): 162-179.18. Regarding plans to improve the REF, see Second Chamber of Parliament 2005-2006, 29689, no. 99,11-16;Second Chamber of Parhament 2006-2007, 29689, no. 129, 9; and Second Chamber of Parliament 2007-2008, 29689, no . 164, 8, and no . 165,1-4. Regarding multiyear DCGs, see L.M. Lamers and R.C. van Vhet,"Multiyear Diagnostic Information from Prior Hospitahiations as a Risk-Adjuster for Capitation Pay-ments," Medical Care 34, no. 6 (1996): 549-561. Regarding ex post risk sharing, see E.M. van Barneveld et al.,

"Risk Sharing as a Supplement to Imperfect Capitation: A Tradeoff between Selection and Efficiency,"journalofHealth Economics 20, no. 2 (2001): 147-168.


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universal manadatory health system a model for the united states

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