CAN WE DESIGN A MARKET FOR COMPETITIVE HEALTH INSURANCE?
The Netherlands also proposed a major reform, again influenced by Enthoven (Hurst 1991) with
competing insurers under a universal, capped social insurance scheme which would ensure a
minimum benefits package. The initial reforms of the early 1990s provided risk adjusted capitation
payments to the insurance fund, and allowed for selective contracting between insurers and
providers. The inadequacy of the risk adjustment mechanism, collusive rather than competitive
behaviour among both insurers and providers, and the limited financial risk to which insurers were
exposed, all limited the extent to which the plan was realised. Subsequently, the reforms were
modified greatly, moving away from pooled funding and competing insurers. However, more recently,
some competition among insurers based on a more sophisticated risk adjustment approach and
limited to a basic benefits package has been implemented (Schut, van Doorslaer 1999).
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