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The paradoxical way healthcare is financed for undocumented individuals in the Netherlands is a burden on everyone.

A homeless man (30 years old) is experiencing severe abdominal pain. A volunteer visiting him notices that he looks unwell and takes him to the GP out-of-hours service (in Dutch: huisartsenpost). The patient himself is unsure if and how he can receive medical assistance. The receptionist of the GP out-of-hours service turns him away because he doesn’t have insurance: he is undocumented (see Box 1). The next day, it turns out that he has a perforated appendix.*

In May 2024, the Lancet published Universal Health Coverage for undocumented migrants in the WHO European Region: a long way to go, stating that “undocumented migrants face some of the biggest challenges to accessing Universal Health Coverage (UHC) and are often left behind by systems that exclude and stigmatise them”.[1] The Netherlands is no exception to this. Numerous studies, articles, and blogs have already been published on the subject: access to medical care for undocumented migrants in the Netherlands is downright inadequate. One important reason is that healthcare for undocumented individuals is not financed through regular channels. Switzerland shows this can be organised in a better way.

Box 1: Undocumented migrants An undocumented person is someone residing in a country An undocumented person is someone residing in a country without legal residency status. In a recently published book, the undocumented population residing in the Netherlands is roughly divided into three broad categories: ‘asylum seekers’ (asylum seekers who have had their asylum claim rejected, often still with strong aspirations for legal status), ‘investors’ (labour migrants without work visas, who aim to earn money through work to support their families), and ‘adventurers’ (respondents who primarily left their homeland to explore the world, but who, over the years, often face a shrinking social network, sometimes homelessness and other social problems).[2] There are also children born to undocumented parents, making them undocumented as well.

The exact composition of this group in the Netherlands is not well known but an estimated 23,000–58,000 undocumented individuals reside in the Netherlands.[3]

A paradoxical and confusing structure

Since 1998, undocumented migrants in the Netherlands have been excluded from social services (such as benefits and allowances) through the Koppelingswet (Linkage Act) as part of a discouragement policy. This also means that undocumented individuals cannot take out health insurance. In principle, undocumented people must pay for medical care themselves. However, every person, according to the constitution and international treaties, has the right to ‘medically necessary care’. So this includes undocumented patients without sufficient funds.

What is ‘medically necessary care’ anyway? In 2007, the Klazinga Commission in the Netherlands elaborated on the concept of ‘medically necessary care’ on behalf of professional organisations and created guidelines. These guidelines state that healthcare providers must offer undocumented individuals ‘appropriate and responsible care’. And appropriate and responsible care equates to nearly the same level of care as insured individuals and goes far beyond emergency care.[4] This is more extensive than in many other countries.[5] If an undocumented person cannot pay for this care, the CAK (Centraal Administratie Kantoor = Central Administrative Office) reimburses nearly all healthcare that falls under the basic insurance package of the Health Insurance Act or the Long-Term Care Act, provided the healthcare provider deems the care ‘medically necessary’.

All of this, however, leads to a paradoxical and complex structure: undocumented people are not allowed to take out health insurance and cannot pay taxes, but they are entitled to appropriate and responsible care, almost equal to the basic healthcare package. They are required to pay for this care themselves, but if they cannot, there is a financing arrangement entirely funded by the government. Then why not simply allow them to take out insurance?

Everybody loses

You might think that it makes sense that undocumented people cannot take out health insurance. After all, they are not Dutch citizens, and there is a financing arrangement in place. But this system actually makes no sense. In fact, everybody is a victim of this system. Allow me to introduce all the victims to you.

Victim 1: The undocumented person

Not being allowed to take out health insurance leads to poorer access to healthcare. This starts at the general practitioner (GP). In Amsterdam, 40%(!) of general practitioners sometimes refuse undocumented migrants, and 18% impose a maximum number for their practice.[6] Reasons GPs give for refusing undocumented people are a lack of time and the medical problem not being perceived as urgent.[7] Helping undocumented individuals takes up a lot of the GP’s time and brings little financial return (see Victim 2). Many undocumented people therefore have no GP and depend on volunteer organisations like Médecins du Monde or the Kruispost. But the problems do not end at the GP’s office. When undocumented people are referred further along the healthcare chain, more problems arise. The paradoxical structure also creates confusion in hospitals, as the case at the beginning of this article illustrates. Stories continue to surface of receptionists or doctors in the emergency department who deny care to undocumented individuals, despite their legal rights.[8] The system also puts up a barriers to outpatient hospital care. Undocumented people are regularly forced to make a down payment at the hospital,[8] receive bills and reminder letters at home, and even have debt collectors sent to their door. Undocumented individuals find this frightening and humiliating, and therefore avoid seeking care.[9] As a result, they only go to the doctor when the situation becomes critical, leading to more severe and harder-to-treat conditions.[9]

Victim 2: The healthcare provider

The financing arrangement via the CAK costs healthcare providers both time and money. For a single claim to the CAK, which must be submitted separately for each consultation or medical procedure, a healthcare provider can spend up to an hour filling out forms which are still entirely paper-based. In addition, claims are regularly denied by the CAK because of small mistakes or get lost, leading to more paperwork.[7] GPs find this bureaucracy too time-consuming for a return of a few dozen euros.[7] Of the GPs surveyed, 22% report not submitting claims to the CAK at all.[6] Additionally, health care providers (with the exception of health care related to pregnancy and birth) only receive 80% reimbursement for the care they provide to undocumented individuals. Hospital financial departments also face a heavy workload. They have to make an effort first to recover costs from patients, before they can submit a claim to CAK.[10] A peripheral hospital in a major Dutch city reports dedicating approximately one and a half days per week to handling CAK-declarations.

Victim 3: The taxpayer

The costs of the CAK arrangement increase every year.[7,10] In 2022, the costs amounted to 51 million euros, although this increase can be largely attributed to inflation and the overall rise in costs observed in the health care sector.[10] Additionally, the CAK-regulations have become better known in recent years.[10] The costs are fully borne by the taxpayer since the undocumented person is legally unable to contribute to healthcare premiums.

But, you may wonder, wouldn’t it be even more expensive if undocumented people had ‘unhindered’ access to healthcare? Probably not. Research, albeit limited, suggests the opposite: hindering access to care for undocumented individuals ultimately leads to higher costs, as delays in care result in costly hospital treatments instead of cheaper GP care.[11,12]

Universal health coverage

In addition to all parties being a victim of the system, this system also fails to meet the Sustainable Development Goals (SDGs) to which the Netherlands, as a United Nations member state, is committed. One of these goals is achieving “Universal Health Coverage”, which means that everyone worldwide should have access to quality healthcare services when and where needed, without facing financial hardship.[1,13] One article aptly stated: “The WHO has declared that ‘all roads lead to universal health coverage’ (UHC), yet undocumented migrants do not travel those roads”.[14,15]

In short, it is time for a better system – one that truly guarantees access to care, places less burden on healthcare providers, reduces costs, and protects human rights. My proposed solution: access to health insurance.

Switzerland

Let’s travel to Switzerland where things are organised differently. Health insurance is mandatory for anyone residing in Switzerland for more than three months, regardless of residency status. This means that also undocumented individuals in Switzerland are required, or rather, entitled, to obtain health insurance. Health insurers cannot refuse anyone and are not allowed to share information with the government. Furthermore, when an asylum seeker’s application is rejected (making them undocumented), they retain their health insurance in many cantons.[16] As a result, Switzerland ranks second on the Migrant Integration Policy Index (MIPEX) in the ‘health’ category – a much higher position than the Netherlands, which is in 17th place.[17]

This Swiss mandatory health insurance system has been in place since 1994.[18,19] Since 2000, the right to basic healthcare for everyone on Swiss territory has even been enshrined in the constitution, although this right already existed implicitly through several court rulings.[18] A motion submitted in 2010 to deny undocumented people the right to health insurance was rejected by the Federal Council, which stated that “healthcare for the entire population represents enormous social progress that should not be restricted” and that “healthcare is a fundamental right.”[20]

The number of undocumented people in Switzerland does not explain this more liberal approach. In absolute and relative terms, there are more undocumented migrants in Switzerland than the Netherlands. Estimates suggest about 90,000 undocumented individuals (compared to 23,000–58,000 in the Netherlands), while Switzerland’s population is less than half of the Netherlands.[3,21]

There are, however, some caveats to the Swiss system. There are significant differences between cantons in outcomes. Basel is the most successful, where 80-90% of undocumented individuals have insurance, but nationwide, this figure may be less than half of that. Basel’s success is due to the canton offering an easily accessible “health allowance” and an NGO dedicated to helping undocumented individuals obtain insurance.[19] The reason that a small number of undocumented migrants remain uninsured is likely due to fear of authorities and financial uncertainty.[18] A second caveat is that there is no backup plan for the remaining uninsured undocumented individuals, whose access to care is very poor. In other words, they have almost no access unless they pay for everything themselves or seek emergency care.[10] But for those undocumented migrants with health insurance, access to care in Switzerland is smooth, and there are no bureaucratic obstacles or instances of care denial, according to the NGO Anlaufstelle Basel.[19]

Applying this to the Netherlands

What can the Netherlands learn from this? Health insurance for undocumented individuals is possible, and would benefit all parties. Undocumented individuals would have less trouble registering with a GP, would no longer be unjustly turned away at emergency departments, and would not face debt collectors. Healthcare providers could deliver care without time-consuming forms and with full reimbursement. Having an insurance card would also clarify for the undocumented individual what they are entitled to, and the available evidence suggests that overall costs for society would decrease.

How can we apply this in the Netherlands? The “linkage principle” for medical care in the Koppelingswet (Linkage Act) needs to be reinterpreted. Medically necessary care should also be insurable for undocumented individuals. If an undocumented person cannot (fully) afford the premium, they could receive a healthcare allowance or subsidy. Additionally, asylum seekers should be able to retain their health insurance after their asylum application is rejected.

However, it is crucial that for those who remain uninsured, the current CAK arrangement remains in place. This backup plan is vital for those people in the most vulnerable situations who remain unable to take out health insurance (likely mainly asylum seekers and ‘adventurers’). Also, it is essential that data on undocumented individuals is never shared with authorities to facilitate deportations. This shockingly happened in the United Kingdom and has led to lasting mistrust of the NHS among undocumented individuals.[22]

Not solvable without government intervention

In 2023, a group of initiators from organisations such as Médecins Du Monde (Doctors of the World), the Protestant Diaconate of Amsterdam, and the Regenbooggroep (Rainbow group) initiated meetings with two health insurers that showed interest in making health insurance possible for undocumented individuals. Unfortunately, these discussions did not lead to any practical results. The main stumbling block proved to be the financial risk for insurers, as ‘risk equalisation’ cannot be applied to this group. Normally, through the risk equalisation system, insurers are compensated by the government for patients expected to consume a lot of care, based on factors like age, gender, and income as well as care usage and hospital care. For undocumented individuals, such calculations based on these equalisation characteristics are not possible, meaning that insurers’ income would only come from premiums. Therefore, including undocumented migrants in the health insurance system would pose a larger financial risk to health insurance companies making them more than reluctant to do so. This demonstrates that government intervention is essential to make health insurance for undocumented individuals possible, for example by establishing a fund to compensate insurers and embedding the system in a national structure.

Health care is not a pull factor

The Linkage Act was initially introduced as part of the “discouragement policy aimed at discouraging undocumented migrants from residing in the Netherlands”.[23] Regardless of ethical concerns, does restricting access to healthcare actually discourage people from staying? In other words, if undocumented individuals no longer had to jump through bureaucratic hoops to access healthcare, would that lead to a significant increase in migration? There is no evidence that suggests this. Contrary to the claims of right-wing politicians, access to healthcare is not a major pull factor for migration. Work (48%), political, sexual, or religious orientation (19%), and family ties (14%) are the most common reasons for migration.[24,25] Only 1.6% of undocumented migrants in the Netherlands cite healthcare as a reason for migration. This figure is similar to other EU countries, even those with different healthcare policies.[25]

In conclusion, health insurance must be made available to undocumented migrants. Switzerland proves that it is possible and can work. Every person has the right to health and health care. And this right cannot be exercised without health insurance. As doctors, we have taken an oath to promote health and care for the sick – all the sick, not just those with documents. The system must support this. Let’s pave the road to universal health coverage for all.

* This case is based on a true story

** For readability, undocumented migrants are referred to as ‘he’. However, it is estimated that 18-35% of undocumented migrants are female.[26]

An earlier version of this article was published in Medisch Contact on September 21, 2023

With special thanks to:

Frederiek Vlaming, Amsterdam Centre International Law, De Regenboog Groep Gianni Da Costa, Protestantse Diaconie Amsterdam Katharina Boerlin, Anlaufstelle Basel Sam van Vliet, Dokters van de Wereld, Lampion

References

  1. Stevenson K, Antia K, Burns R, Mosca D, Gencianos G, Rechel B, et al. Universal health coverage for undocumented migrants in the WHO European region: a long way to go. Vol. 41, The Lancet Regional Health – Europe. Elsevier Ltd; 2024.
  2. Staring R, Boesveldt N, Kox M. Vechten met het leven. Een kwalitatief onderzoek naar de leefomstandigheden van ongedocumenteerde oudere migranten in Nederland. 2022.
  3. Heijden PGM Van Der, Cruyff MJLF, Engbersen GBM, Gils GHC Van. Schattingen onrechtmatig in Nederland verblijvende vreemdelingen 2017-2018. 2020;(oktober). Available from: https://repository.wodc.nl/handle/20.500.12832/3010
  4. Commissie Medische zorg voor (dreigend) uitgeprocedeerde asielzoekers en illegale vreemdelingen. Arts en vreemdeling. 2007.
  5. Cuadra CB. Right of access to health care for undocumented migrants in EU: A comparative study of national policies. Eur J Public Health. 2012;22(2):267-71.
  6. Moons N. Service accessibility to general practitioners for undocumented migrants in Amsterdam, the Netherlands, Moons, N. (2021). Service accessibility to general practitioners for undocumented migrants in Amsterdam, the Netherlands. https://doktersvandewereld.org/ [Internet]. 2021. Available from: https://doktersvandewereld.org/onderzoek-huisartsentoegang/
  7. Verschoor S. Zorg voor onverzekerden staat bol van de vastlopers. Med Contact (Bussum).
  8. ongerloo M van. Nederland is een wreed land als je aan de verkeerde kant staat. Med Contact (Bussum) [Internet]. 2022 Sep 22; Available from: https://www.medischcontact.nl/opinie/blogs-columns/blog/nederland-is-een-wreed-land-als-je-aan-de-verkeerde-kant-staat.htm
  9. Hintjens HM, Siegmann KA, Staring RH. Seeking health below the radar: Undocumented People’s access to healthcare in two Dutch cities. Soc Sci Med. 2020;248(January):112822.
  10. Ministerie van Volksgezondheid W en S. VWS- Verzekerdenmonitor 2023 [Internet]. 2023 [cited 2024 Sep 13]. Available from: https://open.overheid.nl/documenten/89c315b6-bda9-4259-a1b0-df572e13e961/file
  11. Bozorgmehr K, Razum O. Effect of restricting access to health care on health expenditures among asylum- seekers and refugees: A quasi-experimental study in Germany, 1994-2013. PLoS One. 2015;10(7):1994-2013.
  12. Trummer U, Novak-Zezula S, Renner A, Wilczewska I. Cost savings through timely treatment for irregular migrants and European Union citizens without insurance. Eur J Public Health. 2018;28.
  13. World Health Organization. Universal Health Coverage (UHC) [Internet]. 2023 [cited 2024 Aug 2]. Available from: https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)
  14. Onarheim KH, Melberg A, Meier BM, Miljeteig I. Towards universal health coverage: including undocumented migrants. BMJ Glob Health. 2018 Oct;3(5):e001031.
  15. Ghebreyesus TA. All roads lead to universal health coverage. Vol. 5, The Lancet Global Health. Elsevier Ltd; 2017. p. e839-40.
  16. Büro Vatter AG Politikforschung &-berating. Krankenversicherung und Gesundheitsversorgung von Sans Papiers. 2011.
  17. Solano G, Huddleston T. Migrant Policy Integration Index 2020 [Internet]. 2020 [cited 2024 Sep 20]. Available from: https://mipex.eu/
  18. Marks-Sultan G, Kurt S, Leyvraz D, Sprumont D. The legal and ethical aspects of the right to health of migrants in Switzerland. Public Health Rev [Internet]. 2016;37(1):1-16. Available from: http://dx.doi.org/10.1186/s40985-016-0027-2
  19. Bilger Veronika, Hollomey Christina, Efionayi- Mäder Denise, Wyssmüller Chantal. Health care for undocumented migrants in Switzerland : policies, people, practices. 2011.
  20. Bilger Veronika, Hollomey Christina. Policies on Health Care for Undocumented Migrants in Switzerland. Country Report. Health Care in NOWHERELAND: Improving services for undocumented migrants in the EU. 2011;(April).
  21. Federal Office of Public Health (FOPH) Switzerland. Healthcare provision for undocumented migrants [Internet]. 2022 [cited 2023 Jan 31]. Available from: https://www.bag.admin.ch/bag/en/home/strategie-und-politik/nationale-gesundheitsstrategien/gesundheitliche-chancengleichheit/chancengleichheit-in-der-gesundheitsversorgung/gesundheitsversorgung-der-sans-papiers.html
  22. Papageorgiou V, Wharton-Smith A, Campos-Matos I, Ward H. Patient data-sharing for immigration enforcement: A qualitative study of healthcare providers in England. BMJ Open. 2020 Feb 12;10(2).
  23. van der Leun JP. The Dutch ‘Discouragement’ policy towards undocumented immigrants: Implementation and outcomes. Irregular Migration, Informal Labour and Community: A Challenge for Europe. 2007. 401-412 р.
  24. Ingleby D, Petrova-Benedict R. Recommendations on access to health services for migrants in an irregular situation: an expert consensus [Internet]. 2016. Available from: http://equi-health.eea.iom.int/index.php/9-uncategorised/336-expert-consensus
  25. Chauvin P, Simonnot N. Access to healthcare of excluded people in 14 cities of 7 European countries Final report on social and medical data collected in 2012. 2013;91(April):1-91. Available from: https://www.hal.inserm.fr/inserm-00419971/document.
  26. Heijden PGM Van Der, Cruyff MJLF, Engbersen GBM, Gils GHC Van. Schattingen onrechtmatig in Nederland verblijvende vreemdelingen 2017-2018. 2020; (oktober).