Small steps, big change. Forging a public-private health insurance system in the Netherlands.

CONTEXT: History helps us to better understand the particulars of the form and functions of institutions. In this paper we present the case study of the evolution of health care financing in the Netherlands over the past 150 years, through the lens of incremental institutional change. METHODS: Our historical and political analysis is based on a review of secondary literature as well as relevant policy documents, parliamentary debates and archival material. We use the conceptual framework of incremental institutional change (i.e. layering, conversion, drift and displacement) for our analysis. FINDINGS: The constitutional program of the mid-nineteenth century laid down the foundations of a 'private initiative first, government last'-approach to health care financing in the Netherlands. Over the course of 150 years this led to the evolution of a complex layered system of financial arrangements consisting of direct public funding, national, social and private health insurance with complex interdependencies. This was not a conscious strategy, but a result of the fact that the central government in the Netherlands preferred to tackle specific problems in health care financing with very specific measures, so as not to intrude on the trade of civil society and commercial business in health care. CONCLUSIONS: Regulatory authority and statist power in and over health care financing is not something that was created through dramatic reform in the Netherlands, but came about through many decades of small, incremental, yet accumulating changes. This provides a case study for further analysis of incremental versus rapid change in health care systems internationally.

[The gobstopper of the medical job market: education of physicians and specialists from a historical perspective]. / De toverbal van de medische arbeidsmarkt.

Unemployment among young physicians has been a difficult problem for years. In this contribution, we are looking at the difficult medical job market from a historical perspective. The article shows that education of medical doctors and medical specialists has been politicised for a very long time, that ever-changing parties and interests are playing a role and that both the nature and objective of the issue - admission policy, whether to educate more or fewer physicians - have been shifting over time. We argue that there are no clear solutions available but that we, while learning from the past, must continually look for solutions that fit the current situation.

[Free choice of doctor: patient's right or doctor's power?]. / Vrije artsenkeuze: recht of macht?

This article outlines the historical development of the principle of patients' free choice of doctor in the Netherlands. Far from being the result of debates on patients' rights, this principle was used instead as an instrument by the medical profession to gain a foothold in the power relations between doctors and sickness funds back in the early 20th-century. This development created a medical power bloc that lasted for most of that century and forced sickness funds and private insurers to start organizing in this fashion too. Therefore, when the new market ideology of introducing competition in health care was introduced in 1987, the fields of health provision and insurance were already defined by a high degree of cartelization. These relations lingered even after the introduction of regulated competition in 2006. Knowledge of this history therefore leads to a better understanding of current debates and problems in the organization of Dutch health care.