Embargoed Until:
April 8, 2008
12:00 a.m. Eastern Time



Christopher Fleming

Dutch And German Health Ministers Talk With Leading U.S. Analysts In Health Affairs Web Exclusive Interviews

Health Systems In The Netherlands And Germany, Which Achieve Universal Coverage Through Regulated Competition Among Nongovernmental Insurers, Have Been Cited As Models For U.S. Reform

Bethesda, MD -- As the United States debates health reform, the Dutch and German health systems have been increasingly put forward as potential models. These nations have achieved universal coverage through competition among nongovernmental insurers within a governing regulatory framework, along with government subsidies for those with low incomes.

In interviews conducted in November and published today on the Health Affairs Web site, the health ministers from the Netherlands and Germany discuss their systems with three of the most respected U.S. health policy analysts. Dutch minister of public health, well-being, and sport Ab Klink talks with Alain Enthoven, the Marriner S. Eccles Professor of Public and Private Management Emeritus at the Stanford University Graduate School of Business. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.3.w196 German minister of health Ulla Schmidt speaks with Tsung-Mei Cheng, the host and executive editor of the International Forum at Princeton’s International Center, and Uwe Reinhardt, the James Madison Professor of Political Economy at Princeton’s Woodrow Wilson School of Public and International Affairs. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.3.w204

Both Klink and Schmidt highlight efforts their countries are making to increase competition in their health systems. For example, Klink tells Enthoven: “Competition now is especially at the level of the insurance companies. Still, many of the prices for care are fixed by the Dutch government. What we are trying to do in the coming years is to free prices, on the one hand, and to make insurance polices transparent, so that these two issues form pillars of the competition that we want to achieve.”

Schmidt describes several changes to the German system over the past decade, including a 2007 reform designed to increase competition among the nation’s “sickness funds,” or insurers. Under the 2007 law, sickness funds will pass premiums from employers and individuals to a central national fund, which will then pay “each sickness fund a uniform capitation rate for the people who have chosen that particular fund. That capitation rate, however, is risk-adjusted for age, gender, and some eighty distinct chronic conditions of the insured … Each sickness fund will then have to make do with the total budget it gets through the risk-adjusted capitation payments from the central fund.”

Other interview highlights:

Ab Klink on the why the Netherlands has 98 percent compliance with its “individual mandate” requiring people to purchase health coverage: “The biggest part is cultural. When policies are enforced in Holland, people usually do what is mandatory, and they are aware of the fact that they have to insure themselves. But still, we have about 250,000 people out of 16.5 million who don’t.”

Ab Klink on the role of risk adjustment -- or risk “equalization” in the Dutch terminology -- plays in Holland’s health care system. “Risk equalization is a cornerstone of our health care system. The insurance companies are competing also for those who have chronic diseases because they know that although such patients cost more, insurers get an equalization payment from the Risk Equalization Fund.”

Ulla Schmidt on Germany’s consensus approach to technology assessment through its Joint Federal Committee. “No political committee can decide whether a new medical procedure should become part of our universal coverage or not. We feel that this should be left to the experts, who, in our case, are hospitals, physicians, dentists, and sickness funds. The Joint Federal Committee also has patient representatives as well, so that patients can be heard, too … It is our experience that the decisions rendered by the JFC are widely accepted, including by patients.”

Ulla Schmidt on how Germany can provide comprehensive, universal coverage while spending less per capita than the United States: “First, because we do not have any uninsured in Germany, we do not have to rely as heavily as you do in the U.S. on expensive emergency room care. Second, related to universal insurance coverage, is that Germans get timelier interventions, which often avoids more expensive postponed tertiary care. Finally, our insurance system is structured so that we can bargain and act collectively, within an overall constraint set of general economic conditions.”

After the embargo lifts, Enthoven’s interview of Klink will be available online at

After the embargo lifts, Cheng and Reinhardt’s interview of Schmidt will be available online at



Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org.


©2008 Project HOPE–The People-to-People Health Foundation, Inc.