The importance of mutuality… …solidarity takes work!

In the Dutch healthcare system, solidarity is premised on the notion that the system belongs to everyone and benefits everyone. At any given moment there are those who are bearing the cost of premiums so that others can receive the facilities they need. But those who are paying now know that there may come a time when these roles are reversed and they become the recipients. Consider it a form of delayed exchange; though the exchange is not a requisite, it offers an assurance in case of need.

The sustained rise in healthcare costs and hike in care premiums and personal excess in recent years, together with the current economic malaise, is eroding the Dutch public’s confidence in the solidarity principle as defined above, and testing faith in the promise that a contribution made today offers guarantees for the future. Compounding this is the growing number of people with chronic conditions such as diabetes – with to an estimated half a million new patients over the next 12 years – and a parallel increasing awareness about the behavioural components that factor into (and cause) illness.

Solidarity is essentially about transfers between citizens (i.e. insurance policyholders). Solidarity and its associated transfers can take many different forms, from small-scale, informal arrangements to statutory provisions for the population as a whole. Arrangements of the latter, comprehensive, type seek to guarantee access for all citizens to the primary necessities of life and have resulted in laws such as the Social Assistance Act (ABW), social insurance schemes and the collective healthcare laws (Exceptional Medical Expenses Act [AWBZ], Care Insurance Act [ZVW] and Social Support Act [WMO]). Everyone helps to pay for these schemes through statutory premiums and taxes: after all, a loss of income or need for care can happen to anyone.

Chances that a person will need to seek recourse to collective solidarity are unevenly distributed over the population. Here, one of the most effective indicators is education. Highly-skilled members of the population are more resilient. However, these differences conceal a complex constellation of contributing factors. For example, virtually everyone accepts the fact that, broadly speaking, people fall on two sides of the net, with those who pay more on one side and those who receive more on the other. But when there is a perception that individuals or groups can influence what they receive from the system, this acceptance declines. This is one factor.

Another is that recourse to solidarity grows in step with growth in the cost of care, the crimp it places on expendable income and the increasing difficulty people have in paying these costs. This chain lays bare one of the fundamental weaknesses of systems based on solidarity: that resources are vulnerable to misuse, abuse and fraudulent use – not just by citizens-cum-patients, but equally by care providers and insurers. But if we consider solidarity in a broader sense, looking beyond income solidarity to include socio-economic differences in health – for example factoring in the need to continue working beyond pensionable age – there is more of an incentive to invest in health for less-educated segments of the population. Of course, this would include informal solutions that fall outside the domain of institutionalised care.

Thus, the prevention of improper use and conscious actions to promote health by citizens-patients and the care sector contribute to people’s faith in the solidarity principle and foster solidarity itself. After all, solidarity is a collective achievement; our own solidarity depends on the solidarity of others. This means that solidarity can prosper or plummet in a society depending on the measure of trust people have in the solidarity of others. For solidarity to ‘work’, there needs to be a sense of mutual trust in mutual solidarity.

The best way to prevent improper use is to ensure that all stakeholders feel responsible for the care system, bearing out the knowledge that the system exists not only for them, but because of them. This scenario is far preferable to minute supervision and control, which basically only serves to undermine confidence in solidarity even more, eventually sending it into a downward spiral. Recognising the public good is in our own self interest here, for only then will we all be able to continue banking on solidarity in the future.

So who are the stakeholders, exactly? First and foremost, the people who pay the premiums, the custodians of health, the patients, the care consumers – in short: citizens. But the circle extends much wider. The care sector must also accept its responsibility, in particular those at the helm: the healthcare insurance companies and the municipal authorities. They organise and finance healthcare facilities and determine the participatory capacity of their policyholders and citizens. And the care providers, too – the main contractors and subcontractors who deliver care and assistance – have a responsibility to ensure the quality and expediency of care.

Essentially, it all comes down creating and building trust in mutual solidarity by making people more aware of and responsible for the public good.

In this context, mutuality imposes an obligation on everyone involved to limit recourse to formal transfers of solidarity to that which is necessary and to expend collective resources as efficiently as possible. Much of this mutuality can be organised informally. To achieve it, and thereby ensure that we can continue banking on solidarity in the future, the RVZ1 has defined a number of recommendations aimed at strengthening mutuality. These recommendations supplement those previously issued by the RVZ regarding the management of care packages and entitlements to care, behaviour and care, and regarding the importance of a comprehensive set of financial incentives. The recommendations will ensure that centrally defined care directives get translated into expedient care at the local level, in healthcare purchasing and treatment.

Several of the new recommendations are:

The RVZ issues an urgent appeal for all parties to accept their responsibility for viable collective care. An important criterion for this is greater transparency for patients and treatment providers regarding the costs of alternative treatment options. In addition, there needs to be more transparency about the income solidarity and remuneration of directors, medical specialists and healthcare insurers.

Mutuality can be stimulated by enlarging citizens’ responsibility for their own health. The RVZ proposes laying down measures in guidelines and legislation. It further recommends building incentives into group insurance policies, with discounts given on the basis of a healthy lifestyle.

Finally, the RVZ suggests integrating a system of personal payments to foster proper use of care facilities.