1. The long road to managed competition? Sickness funds and the changes in the Dutch health insurance system, 1941-2006 drs. R.A.A. Vonk Centre for the history of health insurance, VUmc, dept. Metamedica Waver, 22 June 2010

2. Structure - Centre for the history of health insurance - changes in the system of health insurance, 1941-2006 - the role of sickness funds Centre for the history of health insurance, dept. Medical Humanities

3. Centre for the history of health insurance, funded by: -Ministry of Health, Welfare and Sports -Zorgverzekeraars Nederland -Innovatiefonds Zorgverzekeraars Main objectives: -research to the history of health insurance, social security and the welfare state in the Netherlands and elsewhere -provide information and expand knowledge of (the history of) health insurance, social security and the welfare state -collect and preserve relevant historical archives (sickness funds, private health insurers, sector organizations, etc.) Centre for the history of health insurance, dept. Medical Humanities

4. - Archives: ca. 500 m. - Documentation: ca. 8000 titles -Health insurance -Health care -Law -Policy -Ethics Centre for the history of health insurance Centre for the history of health insurance, dept. Medical Humanities

5. A.S. Talma, Minister of Labour (1908-1913) 1913: Sickness Benefits Act passed 1929: Sickness Benefits Act effectuated Insurance scheme for wage-earners covering the risk of loss of income due to illness Carried by ‘Raden van Arbeid’ (labour councils) Sickness funds did not offer ‘sick-pay’ insurance Centre for the history of health insurance, dept. Medical Humanities

7. Sickness funds Decree, 1941 - German occupying authorities impose a tripartite system: compulsory social health insurance for wage earners and their dependants voluntary social health insurance for non-wage earners their dependants private health insurance - social health insurance schemes and private health insurance separated by an income threshold Centre for the history of health insurance, dept. Medical Humanities

8. The compulsory social health insurance scheme General Fund Sickness funds Care provider Insured & Employer Centre for the history of health insurance, dept. Medical Humanities - compulsory enrolment (ins) - obligatory acceptance (sf) - income related premiums (ins) - employer pays half of the premium - retrospective reimbursement (sf) - gov. det. package of service benefits

9. Voluntary social health insurance scheme Centre for the history of health insurance, dept. Medical Humanities Sickness fund Care provider Insured - open enrolment (ins) - obligatory acceptance (sf) - community rated premiums (sf) - no retrospective reimbursement - gov. det. package of service benefits

10. Changes and Additions, 1950-1970 - 1951: DGVP/IZA public insurance for civil servants - 1957: SHI scheme for the elderly (65+) - 1968: AWBZ (Exceptional Medical Expenses Act) -National insurance against: -long term care (including nursing home care), -psychiatric care -care for the mentally and physically disabled Centre for the history of health insurance, dept. Medical Humanities

11. SHI scheme for the elderly Central Elderly Fund Sickness fund Care provider Insured General fund compulsory scheme Government contributions Centre for the history of health insurance, dept. Medical Humanities - open enrolment - obligatory acceptance - age-limit: 65 or older - income threshold linked with state-pension plan - premiums covered ¼ and ½ of the estimated expenses - premium shortfall replenished by government and General Fund. - dependants insured free of charge

12. Centre for the history of health insurance, dept. Medical Humanities

13. Elderly and voluntary social health insurance, 1970-1980 - a worsening economic crisis forces the Den Uyl (1973- 1977) government to invest heavily in premium reduction schemes for the elderly - low risks leave voluntary health insurance scheme in great numbers (risk skimming, crowding in) - voluntary social health insurance scheme failed due to weak financial basis Centre for the history of health insurance, dept. Medical Humanities

14. J.P. van der Reijden, State Secretary of Health (1982-1986) - WTZ (Health Insurance Access Act) - MOOZ (Act on the Co-funding Over- representation Elderly Sickness fund Insured) - Strict separation Social Health Insurance and Private Health Insurance - meant as a ‘temporary measure’ Centre for the history of health insurance, dept. Medical Humanities

15. The WTZ and reform of the elderly social health insurance scheme, 1982-1986 - Both elderly- and voluntary social health insurance were dissolved - The membership base of the elderly social health insurance scheme was transferred to the compulsory social health insurance scheme - Regulating the private health insurance sector -Standard private health insurance policy -Obligation to accept everyone for this policy - Act on the Co-funding Over-representation Elderly Sickness Fund Insured (cross-subsidization) Centre for the history of health insurance, dept. Medical Humanities

16. Managed competition? - 1987: Dekker Committee - ‘Willingness to change’ -One national insurance scheme -Fixed basic insurance (85% Sickness funds/AWBZ) -Supplementary insurance -Competing risk bearing insurance carriers -Mixed system of income related and nominal premiums - 1990’s: Dekker-plan deemed ‘too revolutionary’ and consequently mothballed Centre for the history of health insurance, dept. Medical Humanities

17. State secretary of Health, H.J. Simons (1989-1994) Minister of Health, J.F. Hoogervorst (2003-2007)

18. Zorgverzekeringswet 2006 - basic insurance (90% SHI) + suppl. ins. - legal obligation to buy insurance/ accept appl. - fixed max. premium and compensation - ban on premium-differentiation - no income limit - competing risk bearing carriers - risk-equalization scheme (retrospective) Centre for the history of health insurance, dept. Medical Humanities

19. Changing role of sickness funds? - Sickness funds have shown an impressive ability to adapt to changing situations - Sickness funds were the driving force behind market-oriented changes in the health insurance system Centre for the history of health insurance, dept. Medical Humanities

20. Adaptability: 1941 Sickness funds faced a sudden loss autonomy -1941: maintain voluntary insurance scheme -1942: successful introduction of supplementary ins. -1947: sickness funds start penetrate private health insurance through bovenbouw-insurance -1947: sickness funds gain strong foothold in Sickness Fund Council Centre for the history of health insurance, dept. Medical Humanities

21. Bovenbouw-insurance Centre for the history of health insurance, dept. Medical Humanities Bovenbouw- insurance Sickness fund A Sickness fund B Sickness fund C Private Health Insurance Social Health Insurance Income threshold - acquisition - administration - board

22. Centre for the history of health insurance, dept. Medical Humanities

23. Type / Year1950195519591960196519701975198019851986 Commercial574335424036 332925 Mutual3529252625 273332 Bovenbouw82840323539 403843 Total100 Source: F.T. Schut, Competition in the Dutch health care sector (1995) 139. Market share of health insurance carriers in percentages, 1950-1986

24. Centre for the history of health insurance, dept. Medical Humanities

25. H.J. Anbeek (1918) -1945: Sickness fund ANOZ -1962: secretary KLOZ -1980: Chairman Vereniging van Nederlandse Ziekenfondsen -1980: Treasurer V.G.C.N. Centre for the history of health insurance, dept. Medical Humanities

26. Sickness funds and Bovenbouw-insurance - Strong alliance with private health insurers against ‘Nationalization’ (1955, 1968, 1977, 1986, 1992) - Market-oriented proposals (1950 – 1971 – 1984) - ‘socializing’ private health insurance - 1992: merging of sickness funds and bovenbouw resulting in large conglomerates (Achmea, CZ, Menzis, Univé, VGZ) Centre for the history of health insurance, dept. Medical Humanities

27. 2006: clean sheet? Centre for the history of health insurance, dept. Medical Humanities - basic insurance = sickness fund insurance - strong position supplementary insurance schemes - market orientation => bovenbouw - financial responsibility from 1990 onwards

28. Thank you, for your attention