1. Equality of access to healthcare services in the Netherlands: challenges and opportunities within a market system Nicoline Tamsma, EHMA Annual Conference Athens, 26 June 2008

2. N Tamsma Athens 2008 Overview Context -HealthQuest project -Dutch situation Salient findings -Access barriers -Zooming in on situation of migrants Does system help or hinder? Opportunities, pitfalls, challenges emerging? Conclusions

3. N Tamsma Athens 2008 HealthQuest EU Lisbon agenda: social protection & social inclusion Equal access to health care for people at risk of soc. inclusion Country studies: Eng, Ger, Fi, Pol, Sp, Gr, Rom, NL Barriers of relevance to groups at risk of social exclusion Specific groups at risk: -Migrants; asylum seekers; illegal immigrants -Older people with functional limitations -People with mental health disorders

4. N Tamsma Athens 2008 Aiming to understand: Access barriers to health care services faced by vulnerable groups exposed to social exclusion; Barriers stemming from supply and demand side; To what extent organisation of healthcare systems eases or reinforces barriers; National policy initiatives to realise access for all; Policy measures to ensure access to health care to the most disadvantaged Based on existing material

5. N Tamsma Athens 2008 The Netherlands Low overall poverty risk (11% NL vs. 16 % EU25) -Especially for > 65: ( 5 % NL vs. 19% EU25) Life expectancy above average Low unemployment Non-western immigrants: -10% population but 23% minimum income households Lower socio-economic status and poorer overall and mental health interrelated Poor health key driver of social exclusion Chronically ill/disabled higher risk of poverty

6. N Tamsma Athens 2008 Dutch health care performance in 2004: (Westert et al, 2006) Overall accessibility relatively good Comparatively little co-payments Regional differences small Access to care differs little across population groups However: -remain vigilant re. marginalised groups: volume & nature of health problems -Persistent under-utilisation care for some subgroups and services

7. N Tamsma Athens 2008 Service utilisation: income levels (Kunst et al, 2006)

8. N Tamsma Athens 2008 Market system with social safeguards Mandatory private insurance Insurers obliged to accept all applicants basic package under same conditions for same price Risk equalisation fund compensates insurers Nominal premium Cost compensation measures: -Advance compensation via tax allowance -Tax relief excessive costs Role of ‘collectives’ (incl. local authorities)

9. N Tamsma Athens 2008 Dutch barriers: coverage & scope Legal safeguards: all applicants accepted for basic package -Residence criterion excludes illegal immigrants 1.5 % population uninsured: group is changing -Socially excluded no longer automatically covered -People on social benefit / income support: < 1% -Immigrants 4 % -60 % children without coverage are from immigrant populations Scope: -Physiotherapy, dental care, ambulant mental health limited: 95% take out additional cover -Often cost sharing for medication

10. N Tamsma Athens 2008 How system and policy changes interact: illegal immigrants Immigration law Rights to social security linked to residence status Emergency and medically necessary care only Health Insurance Act ‘Emergency fund’ for hospitals disappeared Hospitals to ask ID Only cost incurred for insured patients covered Managers put doctors under pressure

11. N Tamsma Athens 2008 Dutch barriers: costs Overall health care costs have increased for many Compensation measures for nominal contribution: -Limited uptake; complicated procedures -Only for those who pay tax -Will they keep pace with premium increase? 5 % do not take out additional insurance: is cost a factor? Collective discounts (and more inclusive packages): -More options for employed?? -Participation collective: requires social inclusion!

12. N Tamsma Athens 2008 New opportunities: coverage Collective contracting by local authorities Collective contracts: 10% discount Plus broader package negotiable LA’s responsible for implementation social benefit Includes vulnerable client population Collective contract for their clients ensures their coverage New local level social health insurance?

13. N Tamsma Athens 2008 Barriers: Geographical barriers of relatively little importance -Some underserved regions, also with more poverty/unemployment? -Effects of local mergers? Organisational barriers -Waiting lists: norms agreed with stakeholders work well Supply-side responsiveness -Lower educated groups: less uptake dental services, mental health counselling, cervical cancer screening -Older people: less uptake mental health services

14. N Tamsma Athens 2008 Non-western migrants Relatively high poverty risk (esp. women) -Yet relatively little uptake tax compensation Poorer health status: mainly caused by socio-econ factors Mental health services -High uptake outpatient services -Low uptake inpatient services Older Turks and Moroccans: -Higher risk for depression (esp. Turkish women) -Less specialist/hospital care: unmet demand? -Rely more on informal care: impact formal access barriers? Help seeking behaviour influenced by: -Education level; length of residence, employment status

15. N Tamsma Athens 2008 Service utilisation: non-western/native (Kunst et al, 2006)

16. N Tamsma Athens 2008 Older migrants: interplay risk factors urgent challenge for growing client group? Lower health status More health care needs More unemployment Less income Lower pension Less language skills Less informed consumer skills Less ability to pay additional packages Less uptake financial compensation

17. N Tamsma Athens 2008 Potential system pitfalls Solidarity measures not all fit for target group? Health literacy bias: -Pro-active engagement with insurer -Understanding rights, opportunities and obligations -Making regular payments -New transparency instruments rely on computer literacy and Dutch language skills Responsiveness measures (incl. cultural sensitivity) no longer government responsibility

18. N Tamsma Athens 2008 Overall conclusions Poverty, social exclusion and ill health go hand in hand Groups with greatest / most complex needs underserved Client-centred health system and services should re- focus on serving needs of these prominent ‘clients’ Yet reforms often centre around empowered and informed ‘health care consumer’: increases access gaps! Health access impact assessment of system changes needed