Last time on World TravelERs we visited with ACEP Now columnist Dr. Ryan Radecki in New Zealand, a country whose health care system runs similar to Britain’s National Health Service due in part to their inclusion in the United Kingdom’s Commonwealth of Nations. Also termed the Beveridge system, named after William Beveridge who designed the UK system, New Zealand’s system is also strikingly similar to the United States’ Veterans Affairs Medical Centers.

This month we visit the Netherlands, a nation of 17 million people famous for its tulips, windmills, and wooden clogs. The Dutch possess a different type of health care system, one which began in 1941, and followed the German (or Bismarck) model. In 2006, the Netherlands merged the traditional public and private insurance markets into one universal social health insurance program that is underpinned by nonprofit private insurance and mandatory coverage. The Dutch model is a compulsory system that leaves fewer than 0.2 percent of people uninsured—all residents are required to purchase statutory health insurance from private insurers and all insurers are required to accept all applicants.

If that sounds familiar to you, well, it should because that’s what the Affordable Care Act (ACA) did several years ago for the individual insurance market in the United States. Just like with the ACA, a standard benefit package in the Netherlands includes things like hospital care, physician care, home nursing, mental health care, and prescription drugs. However, there are some things that are left out. People tend to purchase supplementary insurance to cover items such as dental care, alternative medicine, physiotherapy, eyeglasses, or contraceptives.

To learn more about the Dutch health care system, I spoke with Dr. Terrence Mulligan, adjunct professor of Emergency Medicine at the University of Maryland School of Medicine, vice president for the International Federation for Emergency Medicine, and a board member for the American Academy of Emergency Medicine. Dr. Mulligan lived in the Netherlands from July 2006 through November 2010 and went back two to three months per year over a period of three years.

In the U.S., we tend to see people that lose their insurance or are in between insurances. Do people wind up in between insurance at all or is it just a seamless transition if they want to go from one insurer to another insurer without having any detriment to their health care plan?

Dr. Terry Mulligan: Everybody there has private health insurance and you are mandated by the government to have private insurance. If you cannot afford it, then you are enrolled in government subsidy programs that work with you to determine when, why, and how it is that you can’t afford it. One of the big barriers to buying private insurance in the U.S. is the unbelievably enormous cost. I think it’s somewhere between $15,000 and $20,000 for a family if you just buy it on the open market. In the Netherlands, my whole family was covered at a cost of about 1,000 euros a year out of pocket. My employer paid for another 1,000 or so, and the government picked up 2,000 or 3,000 of that. It is a private insurance market, but it’s mostly provided by government subsidy.

There are a couple other things that were mandated as part of this private insurance competition market—it is all not-for-profit. That doesn’t mean that people aren’t making a living, not-for-profit doesn’t mean that people don’t do it for the wrong reasons, but they have mandates on the way that those insurance companies behave in that there’s no cherry picking. There are little to no copays or out-of-pocket costs. There are very few exemptions and [their system] encourages a lot of intra-company streamlining and efficiency building, kind of proprietary gamesmanship in order to make themselves more competitive in that market. 

What is the greatest lesson you think you learned from the Dutch that could inform how we might structure our health care system in the U.S. moving forward?

TM: The things about [the Dutch] experience that showed how successful they were and things that we should borrow are that they’re very open to looking outside the field of medicine. For example when they borrowed pieces from IT and from the internet, [in the early 2000s] online teaching and learning was still kind of a new thing. They had a lot of sharing and collaborations. Also, look outside your borders, your country borders, your ethnic borders, your language borders, your socioeconomic borders. There are a lot of countries where everyone speaks English, but they might not open their arms to somebody coming in and teaching in English. [The Dutch] are very open to outsiders and outside concepts.

What‘s one thing you love about the Netherlands? What do you miss about living there?

TM: I’d really loved my experience of five years in the Netherlands. I was a newlywed and we had our two children there. Nearly half of the babies in the Netherlands are born at home. We decided to have our kids in the hospital, and I don’t think we paid anything except for my insurance premiums; we didn’t have to pay for anything [extra]. I did break my wrist when I was there. I was thrown off a horse and I didn’t have to pay anything for treatment. And so, my experiences as a patient were very good. 

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