(Interview Jan 2019, oil and acrylic on canvas, 60 ins. x 40 ins.)
Artist Note (2020)
I write this portrait story in the time of coronavirus, April 2020.
I’ve spent months learning about the Netherland’s healthcare system. I wanted to see how the US system stacks up against other wealthy nations. (Spoiler alert: we are the outlier and not in a good way.)
If I tack on the 15 months I spent focused on the Dutch to the 11 years before that doing a deep dive into our own US system, I’ve spent as much time on healthcare as it took for Tolstoy to write “War and Peace” – twice. In other words, long enough to connect the dots to get a detailed and comprehensive big picture. But also long enough to know that the big picture has thousands of bits of information any one of which I could fall into and spend a lifetime learning about. Wonks do. My hats off to them.
I have a lot to say, and I’m using these Artist Notes before this portrait story to share my thoughts.
It’s long. Come back to my Artist’s Notes later if you want to get straight to Marthe’s portrait story about the Dutch healthcare system and how the US measures up. Scroll down to “Infectious Disease Physician with European license, PhD, Research Fellow (fundamental and health services science), Healthcare Policy Advisor, Consultant, Age 45, Insured.”
March 2020 A pandemic has stopped the world. The economy has bottomed out. The nation is self-quarantining. Medical personnel, essential workers like grocery clerks, and people buying food and medicine are the only ones out. The roads are deserted. Retail stores are closed. Government buildings are closed. Restaurants are closed. Schools are closed. My local park is closed. I must stand 6 feet apart from anyone I meet if I go out for groceries or medicine. Some are hiding in closets having nervous breakdowns. Some are keeping it together in self-isolation. Many are stand-in schoolteachers for their kids at home. Some are afraid they won’t have money for food or rent. Some are locked in apartments with abusive partners. We are afraid of getting sick. We are afraid of everyone we meet. Anybody could be a killer. If they aren’t sick, they could pass the virus to somebody who will die from it—maybe somebody we love. The well-off can afford to jest. They have enough money. We are afraid of the healthcare costs if we get sick. We wash our hands until they are raw. We wait.
April 2020 Face masks are de rigueur. (Expect for President Trump who said, “I don’t see it for myself. And Vice President Pence who visited the Mayo Clinic without a mask, ignoring Mayo’s guidelines. Lack of leadership is a problem.) We’ve settled into the idea that we’re living through a pandemic and that means we must stay at home so we don’t spread sickness to others or get sick ourselves. Many have received modest government stimulus checks to tide them over for a short while. We have calmed down a bit except for those who are very sick or are watching their loved ones die alone in hospitals or nursing homes because contact is forbidden. The death count today has topped 60,000 in the US --more deaths than during the 20 yearlong Vietnam War --- and counting.
One doctor in the news committed suicide. Medical personnel and essential workers are the 21st Century heroes. I hope we all remember the low-wage earners providing essential services like food delivery and stocking grocery shelves when we take up the minimum wage, and health insurance debate after the pandemic.
The one thing this COVID-19 pandemic is showing us is that we should never be afraid of getting appropriate treatment in the United States when we are ill. But we are. If we don’t seek testing or treatment because we are afraid of getting medical bills, we could harm ourselves and infect others. The pandemic makes very clear that real, affordable access to healthcare benefits society as a whole, not just the individual.
Is real, affordable access to health insurance and healthcare a human right?
Uwe Reinhart was a health economist at Princeton University. His colleagues considered him the “national conscience” in health policy. Uwe asked the question this way. “Should the child of a poor American family have the same chance of receiving adequate prevention and treatment as the child of a rich family?"
If the answer is no, make me understand?
Reinhardt said. “When you go to international conferences, there's always two themes. They admire our medical clinical care, because we're advanced. They admire some of the stuff we try to do with quality control, and they abhor our insurance system. They call it ‘asocial’, ‘inhumane’, ‘inegalitarian’. They really think it's a horror show.”
The US system is an African bush elephant sitting on our chest. If the disease doesn’t kill us, worrying about how we’re going to pay just might.
This portrait story is the first of several that will look at healthcare systems in other wealthy countries and how they compare to the US. A special thanks goes to the Commonwealth Fund. This portrait was inspired by an interview on the Commonwealth Fund’s podcast, The Dose.
In this portrait story, I compare our US healthcare system to that of the Netherlands. Marthe’s story offers a real-life comparison of the Dutch and US systems by an individual who has used both.
Marthe’s son was treated in the Netherlands for club foot up until age 4. Later in the US, her son required further corrective surgery. The differences between the two systems are stark from the user’s point-of-view as Marthe’s story reveals.
Marthe has mixed feelings about the US healthcare system. Did she prefer the Dutch system over the US?
With very complicated procedures or very rare conditions, Marthe would probably choose the US. “I mean, the care in the Netherlands would be great. I wouldn’t be worried at all about the quality of care with a rare form of cancer in the Netherlands. I would know that I would be taken care of well. But in the US, you feel you can get anything you could possibly get – even if the things that typically need to be sorted out before new forms of care become available in the Netherlands (extensive evidence, access for all, acceptable payment systems) are not fully sorted out yet.” But for everything that is chronic or more long term, she would feel much more comfortable in the Netherlands – if only for the financial risks associated with undergoing care in the US.
In some cases, American medicine can deliver the magic pill to treat a rare disease. The NY Times reported that a 49-year-old patient can return to work and resume a normal life after being prescribed a drug to treat a debilitating rare bone disease. But the $6 million/year price tag looms over future access to the drug. From the New York Times, “It is part of an unsettling trend in which ultra-expensive drugs are becoming more common, spurring a national debate over whether any drug should cost millions of dollars, and whether Americans will be priced out of lifesaving treatments as drug companies maximize their profits.”
“The latest technology comes at a cost in the US.” Marthe said. “Not everyone can have that cutting-edge care. The US has trouble with access to healthcare – even under the Affordable Care Act not everyone is covered.” The Commonwealth Fund reported that the US ranks last among all other wealthy nations in access to healthcare.
What good is the best healthcare in the world if it is unavailable, or getting that care comes with so many pieces that confuse, scare and leave us in a financial bind or even bankrupt?
Another way of putting Marthe’s observation is that the US rations healthcare. Does it?
The methods we use to ration may differ from other prosperous countries, but we ration, and ration in cruel and shady ways. The Commonwealth Fund article entitled Does the US Ration Healthcare? points out how the US system rations healthcare with high cost-sharing, plans with narrow networks or skimpy coverage, or no way to access health insurance at all.
The article states, “There are 30.4 million uninsured people in the U.S. Not having affordable, comprehensive insurance coverage often means that sick Americans do not even get in the door to see a doctor. For those who do have coverage, new rules that allow states to circumvent the Affordable Care Act’s mandated essential health benefits may mean skimpy coverage for some.”
Skimpy plans that don’t cover our costs, and high deductible plans, those policies that require policyholders to pay large sums before bills are paid, are costing us a lot. A Gallup and West Health poll found that Americans borrowed about $88 billion over the last year to pay for health care,
Does the US ration care? Most definitely.
Marthe sits on an informed perch as a doctor and former Dutch health policy advisor. Her ambivalence about US healthcare – which system would she choose? – speaks volumes about why the best healthcare in the world, as Americans like to tout, isn’t a slam-dunk first choice for her.
Marthe sees our system with fresh eyes as only a newcomer can when she navigates the US healthcare and health insurance systems. This portrait story looks at the Dutch and American healthcare systems through Marthe’s experience. Can we learn from other systems and draw inspiration to help us to improve our own?
Infectious Disease Physician, PhD, Research Fellow, Healthcare Policy Advisor, Consultant, Age 45, Insured
Marthe Haverkamp is a medical doctor and a PhD. Her resume mentions several US fellowships. Marthe also served as a health policy advisor to the Dutch government. Her medical training did not prepare her for the US healthcare system’s complexity and lack of transparency when her son needed medical care.
Marthe, her American economist husband, and their three children moved from the Netherlands to the US in 2015. In the Netherlands, Marthe’s son was born with clubfoot, a medical condition where one or both feet are twisted out of position.
Marthe’s health insurance in the Netherlands covered all required treatments for her son’s condition. He received medical devices to straighten his feet, surgery, and post-operative physical therapy all covered by insurance. In the Netherlands Marthe had no concerns or fears about her son’s medical bills being paid.
In the second year after the family moved to the US, Marthe’s son required another surgery on his right foot. Marthe and her family had a high-deductible health insurance plan through her husband’s US employer. Marthe describes her US insurance coverage this way. “A $3,500 in network deductible and a $12,000 out-of-network deductible. After paying that full amount (nothing from insurance), the insurance company would pay 85% of the bills and we would still pay 15%. That would stay like that up until we had met the full out-of-pocket maximum of $6,000. After that, everything (all amounts) will be paid by insurance with all numbers falling back to zero in the next year.”
A $6,000 in-network deductible ($12,000 out-of-network) can be a daunting amount even for a couple with big careers. Raising three children in New York City is expensive. Marthe admits to guessing and putting off her son’s treatment. Did her son need treatment at all? was the perplexing question. If she guessed wrong, and he did not need care, seeking treatment was still going to cost a lot.
Marthe joined throngs of others relying on high-deductible health insurance plans when they enter the US healthcare system. As a parent she weighs the cost of all her decisions against the big picture of raising a family.
As a policy expert she understands that high-deductible plans are designed to encourage personal responsibility. But she knows that, “In real life, with the hi-deducts, we forgo care – necessary and unnecessary care, equally.”
“I’m a doctor. I looked at my son’s foot for a good 6 months. I called friends in the Netherlands. I feel a bit guilty.” Like so many Americans with high deductible plans, Marthe put off care.
The research confirms the trend to forgo all care. If we are not sure, we often default to waiting. In 2018, health economist Austin Frakt wrote in the NY Times. “A body of research — including randomized studies — shows that people do in fact cut back on care when they have to spend more for it. The problem is that they don’t cut only wasteful care. They also forgo the necessary kind. This, too, is well documented, including with randomized studies. “
Skipping care extends to emergency room visits. To even be in the position where one has to agonize over whether to seek emergency care is a failure of the US healthcare system. We are expected to be doctors and self-diagnose. If a woman guesses wrong and her severe abdominal pains are menstrual cramps, she would have to pay for the ER visit if insurance companies had their way. The American College of Emergency Physicians President Vidor E. Friedman, MD, FACEP wrote in a Newsweek opinion piece, “In a disturbing healthcare trend, insurers appear to be trying to scare patients away from seeking emergency care by denying coverage retroactively if the insurer—after the fact—deems an ER visit was ‘avoidable.’ This type of dangerous insurer policy —which can leave patients on the hook for thousands of dollars in medical bills—defeats the basic purpose of health insurance and violates federal healthcare standards. This must be stopped by lawmakers at the state and federal levels.”
Marthe praises the quality of care and personal attention her son received in the US, but says the experience was fraught with uncertainty and anxiety. She could not find out how much her son’s operation would cost. After some calling around, Marthe discovered that the staff needed a code to look up a price. But she couldn’t get the code until after the procedure. Marthe could not shop price – an aim of high-deductible plans -- even though she tried to.
After the operation, the bills kept coming. Marthe feared getting a surprise balance bill. Another reason to be anxious. What if a doctor, working in the in-network hospital was not on her insurance company’s approved doctor list, treated her son, and she didn’t know it? She would get a bill from the out-of-network doctor. Out-of-network costs are always higher and sometimes not covered at all depending on the insurance plan.
Marthe and her husband would be responsible for an out-of-network doctor working in the in-network hospital where their son was being treated.
Marthe rightly asked, “Where does my responsibility end trying to figure out who is in-network? The supplier of the intravenous drip? Every nurse? We were expected to pay upfront, and then get money returned if we overpaid? All very murky. I didn’t know what I would end up paying in advance.”
Marthe received separate bills from the hospital, orthopedist and anesthesiologist. She and her husband paid $800 out-of-pocket for a physical therapy evaluation before the operation, hoping they could avoid the surgery. When doctors recommended another session with the physical therapist to teach her son how to walk after surgery, Marthe balked. She knew she would get a bill for an indeterminate amount. “He would learn on his own,” she said.
In the Netherlands Marthe was not inundated with bills from the hospital or different providers after her son’s treatment. Nor did she have huge out-of-pocket costs, or surprise bills. Marthe said being sick in the Netherlands is only about being sick. “In the Dutch system, people don’t worry about bills arriving after getting treatment. Never ever would I think about money. The focus in the Dutch system is on getting well.”
In a The Dose podcast interview, Marthe said, “In the Netherlands we pay healthcare premiums, on top of what the government and employers pay for care out of our taxes. I paid something like $150 per month for myself and my three kids, and we had coverage for everything including the dentist. My son’s care for a similar operation was completely free. No bills. That means we could fully focus on the disease and the treatment. And it would have been that way for every Dutch citizen – the care people receive is not related to how much money you have.”
The Dutch national view about healthcare is spelled out on the Government of Netherlands website. “The health insurance system in the Netherlands is based on the principle of social solidarity. Together, we all pay the overall cost of health care. Everyone contributes, for example, to the cost of maternity care and geriatric care.”
The Dutch government regulates and subsidizes insurance. Private insurance companies sell the insurance plans. Insurance is mandatory. No one can be discriminated against for having a preexisting condition or because of age.
The current Dutch healthcare system is relatively new. A center-right government spearheaded healthcare reform in 2006. “The 2006 Health Insurance Act merged the traditional public and private insurance markets into one universal social health insurance program underpinned by private insurance and mandatory coverage” The Commonwealth Fund said.
The Netherlands Ministry of Health, Wealth and Sport wrote “In 2006 the new Health Insurance Act entered into force, under which all residents of the Netherlands are entitled to a comprehensive basic health insurance package.”
This revamped Dutch healthcare system is often described as managed competition. Vox’s Dylan Scott explains. “Managed competition uses a combination of private markets and government regulations to try to reduce health care costs and improve the quality of care. The Netherlands strives to have the different parts of its system — the general practitioners, private insurers, home nurses, the emergency department — work together seamlessly.”
The basic health package that all private insurers deliver must include hospital admission, general practitioner medical consults, medical aids, medication, treatments by specialists, emergency treatments abroad, maternity care, obstetric care, ambulance, dental care until the age of 18 years.
Children under the age of 18 must have health insurance but do not pay premiums for the standard package according to the Government of the Netherlands website.
The Dutch can also purchase supplemental insurance to cover additional services like adult dental care, alternative medicine, orthodontics for children, glasses and more. Insurers can look at health history, however, before selling someone a supplemental policy
Primary care is the gatekeeper to the Dutch healthcare system. Primary care visits are free and available 7 days a week even at night. Primary care physician cooperatives formed to handle after-hours calls. Patients have the option of going to an emergency room but will incur out-of-pockets costs.
On the Commonwealth Funds’ The Dose podcast, Marthe says, “When you move to a town in the Netherlands, you have to go to the local government and say, ‘We’re here in this town, and we live at this address.’ That’s probably the first thing you do. And the second thing you do is, you find your primary care doctor. Then once you’re registered at a primary care center, you are cared for 24/7. That’s a big difference between the US and the Netherlands. If you need a doctor in the Netherlands, you first go to a primary care center, even at night. In the US, there are no primary care centers open at night and you have no choice than to go straight to the emergency room.”
Standard basic insurance in the Netherlands costs about $1600/year ($1450 euros) or $134/month with an annual deductible capped at about $425 (385 euros) per adult
To these American ears, the Dutch out-of-pockets costs sound liberating– like having a 2-ton rhinoceros lifted off one’s back. The Affordable Care Act (ACA), the 2010 US healthcare reform legislation, capped out-of-pocket costs too. In 2020 those out-of-pocket costs are $8,150 for an individual and $16,300 for a family, so high that a cap is meaningless to the average American. (Still, even those steep out-pocket caps are considered better than what was in place in the US before healthcare reform.)
As part of the overall economy the Netherlands spends much less than the US. About $5300 per person per year comes out of the Dutch economy for healthcare. The US healthcare chunk of the economy eats up a lot more, about $10,200 per person. More is not better in this case. In 2016 The Harvard Gazette reported that “the U.S. spent nearly twice as much on health care as other high-income countries yet had poorer population health outcomes. The main drivers of higher health care spending in the U.S. are generally high prices — for salaries of physicians and nurses, pharmaceuticals, medical devices, and administration.”
In 2020, an employed person in the Netherlands earning $50,000/year can expect to pay about 38% of her wages in payroll taxes. Deductions include a wage tax plus contributions to national programs. Employee payroll deductions in the Netherlands, along with employer contributions, form a vast safety net that includes healthcare, elderly care at home or in a nursing home, guaranteed income if one is ill or unable to work, unemployment benefits, retirement and death benefits. Employees are entitled to a minimum of 20 days paid leave each year. Holiday pay is calculated at 8% of wages.
By contrast, a worker earning $50K/year in the US can expect payroll deductions to be about 22% of wages. US deductions include federal, state and local income tax deductions, Social Security tax, Medicare tax. The US does not have a national insurance scheme that covers paid sick leave, holiday pay, health insurance, or long-term care regardless of net worth. (Medicaid will pay for nursing home care for the impoverished elderly which accounts for 65 % of nursing home residents.)
Health insurance premiums for a family of 4 in the US can cost over $20,000/year. Even sky-high premiums do not shield insured consumers from extremely high out-of-pocket costs that can get as high as $16K/year. While 160 million Americans get health insurance through jobs with employers footing a big chunk of the cost, more companies are expecting employees to contribute ever more toward their health insurance premium costs.
Greater premium contributions and monster out-of-pockets costs like high deductibles and coinsurance are putting health insurance coverage out of reach especially for those working for smaller companies.
Some US policymakers consider the Dutch healthcare system a workable model for the US because it provides mandatory universal coverage with regulations and competition among private insurers.