A Dutch friend wrote this up for a list I’m on, and kindly gave me permission to post it. It turns out that the Netherlands is to the left of Bernie and Warren when it comes to national health insurance.

Here are my friend’s comments.

The Netherlands has privatised all government health funds in 2006. They were regional organized and covered 65% of the population.

The remaining 35% had private health insurance. Partially coöps/non-profits and others for-profit.

Those 35% were higher incomes and/or self-employed and students without a (part-time) job.

The Netherlands doesn’t have Medicare. Elderly people have to purchase health insurance. We do have a mandate, and there are transfers to low income people, paid by a partial income related tax on the wages of working people.

In short, the Netherlands introduced the “Heritage Foundation Health Care System”. It was done by a center-right government who saw an opportunity to privatise the public health funds.

There are some interesting differences how The Netherlands implemented the “Heritage Foundation System” in comparison to RomneyCare and ObamaCare:

1. Employer provided health insurance was grandfathered into an individual polis (you could keep it, but the employer went out of the system)
2. There is a mandatory list called ‘basic insurance list’. Every insurer has to offer that list. It is the cheapest available.
3. Contraceptive pills have been kicked off the ‘mandatory list’ by centre-right governments and put back on the list by centre-left. Currently they are off the mandatory list.
4. Abortion is outside the mandatory list, except for medical necessity in hospitals
5. There is a specialist ‘Pro Life Health Insurance’. No abortion, no euthanasia, no transgender operations, no in-vitro-fertilisation, no sterilisation and no morning after pill coverage etc. ample on palliative care and courses for natural family planning / counseling. When I drive on the highway through the Bible Belt, I see billboards for them. 
6. Pro-Life Insurance is also the health insurer promoted by the PCOB and KBO. The Protestant Christian and the Catholic associations for the elderly, both are mainline protestant and catholic social organisations. They cover a lot of elderly people with the insurance they negotiated for their members.
7. The Netherlands has a ‘conscience clause’. Those who don’t want health insurance for religious reasons or any other personal belief, can call it in. The government then opens a health account and fills it with your health-tax payments. The account can only be used for paying health care/cure. If it is empty, your on your own. If there is still an amount when you die, it becomes part of your estate and goes to your heirs.
8. If you want insurance, you relinquish your health account to the insurer of choice, but you cannot go back from insurance to the tax-authority filled health account.

As far as I understand it, Switzerland also made reforms toward a “Heritage Foundation health care system” in the 2000s. 

And as a final note: keep in mind that the ‘hot button issues’ like contraception and inclusion/exclusion of abortion on the mandatory coverage list are political footballs here too.

There were 17 abortion clinics in the Netherlands. 7 went bankrupt in the early ’10s due to too low demand for their services. 4 were relaunched, so there are now 13 abortion clinics on a population of 17 million. California has ca. 150 clinics for ca. 40 million. I think only South-Carolina has a lower ratio in terms of Abortion Clinics per 1,000,000 women. Kansas and Missouri are more on par with the Netherlands.

In general, abortion policies are far stricter in Europe. The Netherlands isn’t much of an outlier in restrictive abortion policies, where restrictions kick-in after 13 weeks of gestation and a 5 working day “rethink period” with adoption counseling is mandatory. The big outlier in Europe is Great-Britain, which has abortion policies a lot like the USA. Northern-Ireland however is very strict, just like Ireland.

Off course this is far from China’s ‘one-child-policy’, where it was encouraged to have single-child families and abortion is easy accessible.

There are some intriguing points to make, about what went different.

1. The USA didn’t grandfather private health insurance policies from employers to individuals and continued employer provided health insurance.
2. As a result demand for the “ObamaCare exchanges” was much smaller
3. Due to the existence of Medicare, untouched by ObamaCare, there wasn’t massive ‘insurance pool organisation’
4. US Labor Unions still negotiate health benefits with employers instead of operating as the middleman towards health insurers c.q. owning a stake in a health insurance fund
5. The absence of “Conscience Opt-Out” and “Pro Life Insurance”, combined with employer based health care, caused a Supreme Court case (Hobby Lobby) which forced a ridiculous decision that a corporate legal entity now can have a ‘religious conscience’
6. This of course did extend to Catholic Nuns too, who were forced to pay for mandates that went against their beliefs.

It all smacked as incomplete design and as a result a set of flaws due to provisions not taken, probably because of political expediency.

Currently the Netherlands has 11 health insurance providers after a lot of M&A had happened. The interesting result is that the big winners have been 

a. A rather high-end private insurer, offering expensive “we cover everything” policies 

b. A former health fund which had worked in a blue-collar region (Delfland-Schieland-Westland), being the repeated price-breaker and as a result is now the darling of consumer organisations etc.

What is really different between the Dutch implementation and the USA, is the bargaining positions in the system. The collectives that sprang up (some spontaneously, around websites) and went shopping. It makes a difference when in a market of 17 million and 11 providers, someone shows up at your doorstep with ‘I have 200.000 signatories looking for a good insurance policy …’).

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Esther Dyson is giving a talk at Defrag. It’s called “On exploration … of yourself.”

“Everyone wants to know themselves, but some people are afraid of their genome.” She tells such people that the question is not what you’re going to die of, but what you’re going to live with. She wants to show us some cool interfaces that make data about yourself more interesting.

23andme.com (Esther discloses that she’s on the board) shows you your disease risks [based on your genome?]. It presents some friendly screens and lets you drill down. You can compare your genome to your relatives’. Esther says she found a lump in her breast this summer. It was benign, but before she found out, she reassessed her odds, which led her to think that the risk of going into space had dropped in comparison to the cancer risk. We need numeracy, she says.

Keas.com also produces a friendly health profile, she says.

But what counts is motivation, she says. It’d be helpful if we could increase the status of health markers, e.g., that you run 20 miles a week, etc. How do you design systems, services and tools where your healthy behavior connotes status?

She points to one not very effective attempt: TripIt.com shows her status in various frequent flyer programs, but ought to show her good behaviors (exercise, flossing, etc.).

She suggest someone here create the game Bodyville.com.

There are three health markets now: The health care market (doctors, hospitals, insurance, etc.). Chocolate muffins, and indolence. And the third market is for health, which hasn’t been much of a market.

Q: How about privacy?
A: With universal healthcare, the data have less of an impact. The data can still affect employability, etc. Privacy remains an issue, although your financial data is much more interesting to thieves. We’ve managed to deal with financial data pretty well. If you’re worried about your health data’s privacy, then don’t use this stuff. It’s somewhat overblown as an issue. I’ve put my entire genome up on the Web — 20Mb, and it doesn’t have a lot of meaning about it yet. Your behavior is much more revealing than your genome right now.

Q: How about data sharing tools?
A: Here are two I’ve invested in: Contagion Health. Health Rally. Suppose your friends invest in your not smoking? That creates a positive community and you don’t want to disappopint them. Med Rewards. PatientsLikeMe and CuredTogether.

Q: There can be unintended consequences, such as BMW’s mileage game leading people to run red lights. How do you avoid that?
A: Yes, I can see one of those tools aggravating anorexia. This things need to be designed carefully.

Q: Are you going into space?
A: Yes, I’d love to. I’d even go to Mars one way. That’s what they did to America in 1942. The older you get, the less you have to lose.

Q: How about how humans take to 3D visualizations?
A: Some like it, some don’t. I do. I love 4D with things changing over time. But not everyone likes them. Remember not to confused the visualization with the meaning. Some are cool but don’t convey any info. Read Tufte.

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Ashish Jha at the Harvard School of Public Health is giving a Berkman lunch talk on “U.S. Healthcare: Can Information Drive Better Care?” [Note: I am typing quickly, getting things wrong, missing stuff…]

He says the first few minutes should leave us depressed about the state of health care in this country. A major problem underlying all this, he says, is a lack of transparency.

We spend $2.1 trillion dollars on health care in the U.S. in 2006. That’s about a sixth of the economy, about $7,000 per person (minimum wage is $11K/yr). It’ll be a fifth in the next decade. We spent a much bigger percentage of our GDP than other countries.

What do we get for this, Ashish asks. He cites a Rand study that came up with 439 “indicators of healthcare quality.” These are core, non-controversial treatments and practices. Rand found they get done about 54% of the time, suggesting “the care we get is pretty inadequate.” Even for privileged groups — e.g., white, wealthy, educated men — it doesn’t go much above 58%. “There’s a disconnect between what doctors think they do and what they actually do.” One of the listeners says that recent studies show that this is because there are typically 7 health care people involved with any one medicare patient, and they don’t get this done because they don’t know what others in the group are doing. “It’s completely about the system,” says Ashish.

He continues depressing us: About 10% of people admitted to hospitals suffer an injury there. One in four doctor visits lead to medication injury. (Ashish says he’s not confident in that study.) 44k-98k deaths come from medical errors.

His conclusion: The quality of care is unacceptable.

Why? 1. Because we pay for the quantity, not quality, of health care. 2. Care has gotten complex, but the health care systems haven’t kept up. 3. Little transparency. E.g., usually we don’t usually know how much our medical care actually costs (as opposed to what our co-pay is). We know how much health care for our pets costs, but not for our children. 4. No adequate feedback loop: Medical malpractice has been a failure and regulation sets the bar too low.

Ashish talks about one part of the response: The Ny State Cardiac Surgery reporting program. In the early 1990s, NY found huge disparities in cardiac surgery mortality across 31 hospitals: 1 in 200 dying vs. 1 in 14. So the state started publishing mortality info about every hospital and surgeon. As of about 2000, it’s all on the Internet. Over the course of 12 years, the rates dropped dramatically. Why? The market share of the hospitals didn’t change; the bad hospitals didn’t lose business. But the hospitals now had data that reinforced good practices. There’s anecdotal data that physicians began to learn from one another. Most dramatically, the rate of surgeons leaving their practices among the bottom fourth was way higher. Ashish’s project tracked them: Some quit, some moved. Even after adjusting for age, etc., people in the bottom quarter were 3x likely to quit.

People don’t check the ratings. Ashish thinks this is a place where the Internet could help.

90% of hospitals are still paper-based. Even those that are electronic can’t share info. The law says patients always have a right to get their records, but the doctor or the hospital owns the record. Patients can view it but it’s not in exportable, shareable form. (There’s a discussion about the state of electronic health records and why it’s a more complex problem than it seems.)

Ashish says that the HQA initiative has hospitals reporting on 23 quality indicators, and performance has improved steadily. HCAHPS makes patient experience data available.

Gene Koo: Health care decisions aren’t made by purely rational agents. All sorts of quirks come into it. So, how does the transparency of info help us?
A: Maybe consumer involvement in health care won’t work out. I’m looking for empirical data.

Q: What’s the role of the consumer in this? Are there data now that consumers are taking on more of the responsibility for their health care?,br>
A: People on the right say that consumers aren’t behaving like consumers because they don’t have any skin in the game. You don’t know how much things cost. So, we need transparency (they say), linked to having skin in the game (i.e., you pay for visits out of your pocket). But, few have high deductible health plans. My personal feeling (says Ashish) is that this isn’t going to be big. People are generally in them not because they want to be involved but because the plans are cheap.

Rob Faris: There’s a huge role for intermediaries. Intermediation is not working well right now. We need intermediaries who looks at outcomes and figures out what works and what doesn’t. And I’d like to see how quality considerations can be inserted into this.
A: We’re at the beginning of a very interesting journey. If someone like you can’t navigate the health care system…

Q: What do you think of the candidates’ positions?
A: They all talk about the uninsured, which is just one part of a complicated set of issues. We have 47M uninsured because health care is expensive. Most of the health experts I talk with think Clinton’s health plan is a little more realistic. But all of this falls apart if we can’t get a grip on healthcare costs. They’re rising at twice the rate of inflation, and neither Obama nor Clinton have gotten serious about healthcare costs.

Q: (me) How do you contain costs?
A: Electronic records would help. Payers should pay more for outcomes not for particular tests, etc. And there;s a whole “comparative effectiveness” movement. E.g., what do you do for someone with low back pain? You get different treatments based on locality. Payers should start taking more of an active role. But payers have not wanted to take up that responsibility.

A (person in the audience): Part of the answer is that the amt of money spent in the last 6 months of life is shockingly high. We should spend more earlier on preventative measures.

Ashish: You don’t always know when the 6 months are. And there’s a huge issue around managing expectations at the end of life. Plus, when someone else is paying…From a policy point of view, it’s very hard to fix this stuff. Even though health reform comes up every five years, it doesn’t get done because the status quo is everyone’s second choice. [Tags: berkman healthcare health ashish_jha ]

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