Chapter 2

CEIS Health Report 2006
2.5 - Implementation of regulated
competition on a national scale; the case
of the Netherlands
Rutten F. 1
2.5.1 The final stage of the Dekker reform
The proposal to implement regulated competition of the Dekker committee in 1987 has
been guiding successive governments during the last 15 years. The proposal was
inspired by Enthoven’s ‘consumer health plan’ which made a plea for improving the
efficiency in health care through regulated competition on the markets for health insurance
and health care. According to the Dekker plan equity in the finance of health care
was to be guaranteed through payment of income-related premiums into a central fund
besides paying nominal premiums directly to the insurer. Further characteristics were:
• compulsory basic insurance;
• deposition of income related premiums into a central fund;
• allocation of risk adjusted capitation payments to insurers;
• comprehensive uniform benefit package described in functional terms;
• limited provider plans allowed;
• open enrolment.
Successive steps were made since then. Regarding the insurance market a sophisticated
formula for risk adjusted capitation payments to Sick Funds was developed (to
prevent cream skimming), a flat rate premium has been introduced in 1989, there is
yearly open enrolment since 1992 and risk sharing among Sickness Funds regarding
their expenditure has decreased substantially. Furthermore, Sickness Funds were
allowed to selectively contract with providers and set prices and fees, but have only
done so in a limited way. Since 1998 there is a new anti-trust law as well as an antitrust
agency, which gradually became more active in the health care sector. But until
2006 there still was no uniform health insurance system with a uniform basic health
care package. We still had the old two-tiered public/private system with its lack of
incentives for efficiency and its unfavourable equity characteristics.
In January 2006 a new Health Insurance Act came into force. The Health Insurance Act
can be seen as the final phase of the Dekker plan and sets out the conditions for the
introduction of regulated competition in health care, which should make the system
more responsive to the preferences of consumers and less burdensome to manage.
Public and private (voluntary) health insurance are integrated into a single scheme that
provides coverage to the whole population. Responsiveness is to be achieved by both
1 Professor of Health Economics and Chairman of the Department of Health Policy and Management, Erasmus Medical Centre
and Erasmus University Rotterdam.
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