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199:oral Should the Netherlands allow voluntary additional health insurance for expensive cancer treatments? A justice perspective
  1. Jilles Smids,
  2. Eline Bunnik
  1. Erasmus Medical Center, department of Medical Ethics, History, and Philosophy of Medicine, Rotterdam, The Netherlands


Objective In the Netherlands, an increasing number of effective but extremely expensive cancer treatments are (temporarily) not reimbursed through mandatory basic health insurance. It seems that access to such treatments is currently limited: patients are often not allowed to pay out of pocket, and health insurers do not offer voluntary additional health insurance (VAHI) to cover such cases (Calcoen et al., 2017). However, patient might benefit from and prefer such insurance. Why is this not provided?

Methods In this paper, we provide a normative analysis, specifically from the perspective of social justice, of the question whether the Netherlands (and countries with similar healthcare systems) should change this policy and allow VAHI.

Results While the Dutch healthcare system has a strong egalitarian ethos, and allowing VAHI will lead to unequal access to potentially beneficial treatments, we argue that there are no in-principle justice-based objections against the provision of additional insurance. As long as mandatory basic health insurance covers all medically necessary treatments that societies owe their members on the basis of justice, denying citizens access to additional treatments based on considerations of equality would invoke the raising-up objection (Eyal, 2013), and may not be just.

We then consider how the introduction of VAHI to cover expensive cancer treatments in practice might lead to objectionable changes to the healthcare system. We suggest that it should be possible to maintain the current Dutch full population coverage, extensive service coverage, and relatively moderate cost sharing. Yet, whereas only an affluent clear minority of citizens has the ability to pay for top-up payments, a considerable majority may be able to afford VAHI. This might lead to a problematic two-tiered healthcare system, that reinforces existing class differences and undermines equal social standing of citizens with low income that cannot afford VAHI (Cf. Fourie, 2016).

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: .

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