Holland, pay-or-play and the WSJ Opinion page making sense?

Don’t worry, the WSJ Opinion only makes sense because they let Zeke Emmanuel and Ron Wyden write an op-ed. The article is called Why Tie Health Insurance to a Job? and it’s impossible to argue with the logic about why we ought to move away from employer-based insurance.

There is of course an argument amongst those of us who both want to move to a social insurance system and want to have universal insurance as to whether this should be done in the voucher-type model that Emmanuel & Vic Fuchs have proposed (which looks a little like how the Dutch now do it) or whether we need to go to a modified single/multiple payer system like the French/Japanese/Brits/Australians.

I gave a talk in Canada the other night suggesting that there was some potential for convergence, and I used the very recent Commonwealth Fund data looking at the experiences of the chronically ill in seven nations. What is very interesting to me is that in terms of access to primary care and in terms of disease management, the Canadians and Americans look roughly similar—and not too good. As for specialty care, well as we know the Canadians & Brits ration by time and the Americans ration by money (or socio-economic status).

What was fascinating to me is that the data appears to show that the
Dutch have not only figured out access to primary care, but also to
specialty care, better than anyone else. And they have the least
pissed-off population, in terms of those who want the system completely
rebuilt. Only 9% of Dutch say that, compared to 12% of Brits, 16% of
Canadians, 23% of the French and 33% of Americans.

But are we going to end up with a Dutch-type system of highly
regulated insurers competing a la Enthoven (or a la
Fuchs/Emmanuel/Wyden) within a social insurance system? It certainly
doesn’t look like it—or not immediately.

Despite Wyden’s plan having a decent amount of bi-partisan support,
instead it looks like we’re going to a half-assed expansion of pay or
play—which, as Brian Klepper pointed out on THCB a few weeks back,
will still leave big problems and large swathes of uninsured as usually
small firms and those with contract or casual work-forces are left out.
Which probably means that the expansion of Medicare and Medicaid will
be the real result. I guess at least we know what to expect from
that—love ‘em or loathe ‘em.

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WitheheldLucien EngelenMaarten den BrabersonomacaDavid MD Recent comment authors
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For a balanced image of the Dutch Medical system, please spend some time reading these comments under the article on this page:-

Lucien Engelen

For those of you wanting to read a little bit more about the Dutch Healthcare migration :
It basically covers the system “as is” ult 2004 and the reforms which by now mostly are implemented. Keep in mind -as Maarten denBraber told earlier. the exchange-rates US$/Euro

Maarten den Braber

I’m from the Netherlands so for maybe I can shed *some* light on the issues raised here (although I’m no healthcare financy or policy expert – rather more organization oriented) Peter — A comment about the conversion figures in your comment: 1EU =~ 1.35 USD, so an amount of 95EU is approx. 128USD (so more than the double of what you calculated). I don’t think your comment about the insurance companies making money is accurate. It is completely true that there has been consolodation leaving us with 4-5 big players. These companies are mostly part of bigger insurance conglomerates offering… Read more »


The poor young saps who voted for Obama will soon discover that they’re paying for a super-luxury health insurance plan when, in the past, they happily existed without any insurance at all. Of course, what they really need is inexpensive catastrophic coverage, but the premiums associated with that wouldn’t be enough to subsidize all those older and sicker people who currently have no coverage. When, inevitably, the Dem’s plan creates an absolute cost explosion, and Congressionally-mandated reimbursement cuts and rationing begin to kick-in, we will see the best medical personnel depart the system altogether for concierge practices. Corporate executives, highly-paid… Read more »

David MD
David MD

From the WSJ Opinion: “Why, then, do millions of Americans get their health care through an employer-based system from the 1940s?” “Why does the country run on a constitution that was originally written in 1789?” Their comment was a silly one. A great reason for having employer run health plans / insurance is competitive advantage in that it gives employers an ability to attract employees with better plans. If one has one unified system there is no inducement to improve quality. Competition is the best way to deal with that. Now, if one is worried about costs one needs to… Read more »

bev M.D.
bev M.D.

I agree with Deron generally, and have steadily been commenting since I started reading this blog, that health care financing/insurance reform is doomed to failure (by breaking the bank) unless health care DELIVERY reform is accomplished either first or simultaneously. It seems that only the people inside the system understand how entirely screwed up the delivery system is; patients and other outsiders only get a glimpse.
As far as tying insurance to employment, we are seeing the inevitable result when lots and lots of people lose their jobs as is happening now. A major design flaw in that system.


Read this Dutch report: http://www.rivm.nl/vtv/root/o33.html If we look at what the actual premiums are as well as the additional out-of-pocket, the amounts are staggering compared to U.S. costs. No wonder the Dutch like their system. If the U.S. had the same costs for the present system no one would be complaining. Here’s examples: http://www.justlanded.com/english/Netherlands/Tools/Netherlands-Guide/Health/Healthcare Basic monthy premium: “The fees for the basic health insurance package are annually determined by the health insurance companies and are normally approximately €95 per month.” 95 Guilders = about $55us Add to that: “Increase in additional chronic-illness-related expenses. In 2005, 87% of people with chronic… Read more »

Deron S.

If our per capita costs were half of what they are now, would our discussions be different? Would many see the need to redesign the financing? In my mind, we shouldn’t be devoting resources (time and money) to redesigning how healthcare is paid for. Those are resources that could be better deployed finding ways to make healthcare more affordable. Healthcare reform seems more daunting when we worry about the financing at the same time that we worry about our high costs issues. If we redesign the financing first, do we run the risk of limiting ourselves when it comes time… Read more »