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decisions and change insurers on the basis of

tion also buys supplemental insurance cover-

price and quality.

ing services over and above the required stan-

dard benefits package.213

Price competition under the new system has

increased significantly and at least 20 percent of

Employers generally pay half of insurance

Dutch consumers have switched insurers.222

premiums, with individual workers picking up

the other half.214 Individual premiums are tax

When the system was initiated, the Dutch gov-

deductible.215 Subsidies, or care allowances, that

ernment predicted premiums would cost

€€1,106 on average. However, competition has

help low- and middle-income income workers

forced the average premium down to €€1,028,

purchase the basic insurance plan are extensive

097.6 percent below the prediction.223 Overall,

and reach well into the middle class. Currently, 5

million Dutch citizens qualify for some level of

the new system is estimated to have increased

subsidy on a sliding scale based on income.216

the purchasing power of Dutch households by

as much as 1.5 percent.224 However, not every-

Those subsidies are financed through a tax on

salaried workers. Because of the high levels of

one has been a winner. The community rating

subsidy, the Dutch government remains a large

requirement has resulted in steep increases in

source of health spending, one area of signifi-

premiums for younger workers who were more

cant difference with the Swiss system.217

heavily subsidized under the old system.225

As many as

Insurers negotiate quality, quantity, and

Under the old system, waiting lists were

750,000 Britons

price of services with providers. Notably,

widespread--for example, more than three

many insurers require providers to docu-

months for a hip replacement and two months

are currently

for a prostectomy or hysterectomy.226 One

ment the quality of the care they provide, fre-

awaiting

quently relying on evidence-based guidelines

study estimated that at least 100 heart patients

and performance metrics.218

died each year while on waiting lists.227 Early

admission to

evidence suggests that some improvement has

Some insurers provide care directly, using

NHS

come as a result of the 2006 reforms.228

their own staffs and their own facilities, such

hospitals.

as primary care centers and pharmacies.

Hospitals are beginning to compete by

Other insurers contract with a network of

expanding services such as neurosurgery and

radiation therapy.229 Although some experts

providers similar to U.S. preferred provider

organizations (PPOs). Patients can go out of

have expressed concern that smaller hospitals

network but will receive only partial reim-

offering these services may not have sufficient

bursement. Most insurers require a referral

utilization rates to ensure quality and efficacy,

from a primary care provider before a patient

the expanded availability of services will likely

can see a specialist.219 Pharmaceutical prices

increase access to care and reduce queues.230

are capped nationwide at the average price of

The new system may even be having a pos-

medicines in a therapeutic class. Individuals

itive impact on health care costs. Since the

may choose more expensive drugs but must

new system took effect, health care costs have

pay the difference out of pocket.220

been growing at an annual rate of just 3 per-

cent, compared to more than 4.5 percent in

The new system has been in place for only

the year before the reforms.231

two years, which is not enough time to per-

mit a thorough evaluation. However, prelim-

The jury is still out, and the Dutch system

inary indications suggest that it is an

still falls well short of a true free market, but

improvement over the pre-2006 system.221

the Netherlands appears to have taken a big

step in the right direction.

Dutch consumers appear to have em-

braced the reforms. Consumer organizations

are participating in negotiations with pro-

Great Britain

viders, insurers, and lawmakers. The system is

becoming more transparent, with far greater

information available regarding both price

Almost no one disputes that Britain's

and quality. Consumers seem willing to make

National Health Service faces severe prob-

23