Medical bills are a part of the U.S. health system the same as doctors are. We know we're going to see a medical bill when we go to see a doctor. And while we may find ourselves perplexed by the dollar amounts printed on these bills, we don't question their arrival. This isn't true in other parts of the world.
In this episode of The Dose, Shanoor Seervai talks with Marthe Haverkamp, a medical doctor, and former health policy adviser to the Dutch government. Marthe is from the Netherlands, where by law, everyone must have health insurance, so everyone gets access to the same care.
Shortly after she came to the U.S. with her family, Marthe was astonished to find herself facing medical bills running into thousands of dollars. Listen as she shares her story of bewilderment.
SHANOOR SEERVAI: Imagine that your child is born with clubfoot, a health condition in which one or both feet is rotated inward and downward. Often, clubfoot can be treated by a simple process to change the position of the foot. In some cases, however, it requires major surgery.
Marthe’s son was born with clubfeet, and he was treated in his home country, the Netherlands. Both feet improved, but he needed an operation on his left foot when he was four.
When the family moved to the United States a couple of years later, his right foot had a relapse. He needed surgery, this time in the U.S. Marthe’s going to tell us the story.
MARTHE HAVERKAMP: So Constantin was diagnosed at birth, and he was treated in the Netherlands. His treatment involved fixing his feet for months, and then only at night for years, on a metal bar with special shoes attached at each end. At some point, the doctor decided that one foot needed surgical intervention. We didn’t have to pay anything extra for any of this. Not even for the physical therapy afterwards. Our insurance covered everything.
SHANOOR SEERVAI: Hi everyone! Welcome to this week’s episode of The Dose, where we’re talking about health care in other developed countries where everyone has coverage, and how their systems are different from what we have here in the United States.
Today we’re going to talk about the Netherlands, where by law, everyone must have insurance. And everyone has the same health care. People pay a small monthly premium, and then no more than 385 euros (that’s around 475 dollars) per year in out-of-pocket costs for health services. Above that, their insurance covers everything. And primary care is always free — no one has to pay for that.
Marthe Haverkamp, who you just heard from, was astonished when she found herself facing medical bills running into thousands of dollars when she came to the U.S. with her family.
Marthe is a medical doctor, and was a health policy advisor to the Dutch government. She came to the U.S. to study how to make better care available to patients at a lower cost. But even her experience as a researcher was not enough for her to understand the exact costs of health care her family received here.
Marthe, thanks for joining us.
MARTHE HAVERKAMP: It’s good to be here.
SHANOOR SEERVAI: We’ve heard a little of what it was like getting your son’s foot operated on. Could you tell us what happened after you came to the U.S.?
MARTHE HAVERKAMP: When we came to the U.S., his right foot started to turn back inwards again. So we took him to a treatment center that — much to our surprise — was next door to our apartment in New York.
SHANOOR SEERVAI: So in the technique that is often used to treat clubfoot, there’s no major surgery: the baby wears casts to correct the alignment of the foot. Then there’s a small intervention to lengthen the Achilles tendon, and then the child has to wear a brace for years to keep the foot in the right position. But sometimes additional surgery is necessary.
MARTHE HAVERKAMP: Yeah, so the orthopedic surgeon found that we needed to operate on my son’s right foot. The surgeon and the medical treatment we received was absolutely fantastic, but it was very hard for us to get an idea in advance of how much the operation would cost. And funny enough, the people dealing with finance in the hospital were kind of surprised that I wanted to know. As if I was the first to ask. So I made a lot of phone calls, and then I learned that if a certain procedure has not yet taken place, there is no code yet assigned to it by the physician. The staff has no idea how to track down how much something will cost until it is done and there is a code. In the end, we had to pay around 3,000 dollars up front for the surgery and after the operation we got 1,000 back, no idea why. But the bills kept coming.
SHANOOR SEERVAI: Bills for what?
MARTHE HAVERKAMP: There were separate bills for the hospital, separate bills for the orthopedist, separate bills for the anesthesiologist . . . if the cleaning lady had sent an extra bill I would not have been surprised.
We also had 800 dollars in extra out-of-pocket costs. That was for a physical therapy evaluation, which happened before the operation, to see if we could perhaps prevent it.
SHANOOR SEERVAI: What? 800 dollars for one session of physical therapy?
MARTHE HAVERKAMP: Yeah, and in the end, the operation couldn’t be avoided. Just after the operation, when my son received crutches, they advised us again to see a physical therapist who could teach him how to walk with those. And then of course my alarm bells went off, and I said, “Learning how to walk with crutches? How much will that cost? Well, he’ll have to do it by himself.”
SHANOOR SEERVAI: Did he have physical therapy after the first surgery in the Netherlands?
MARTHE HAVERKAMP: Yeah, some twenty sessions.
SHANOOR SEERVAI: And everything was covered?
MARTHE HAVERKAMP: Yep. And I have to admit that in the States, after I refused to go to the physical therapist for the crutches, they were very sweet, and came to us while we were in the waiting room and did the session without billing us for it. The operation itself was a very good experience — I had no doubt about the quality of the operation and the personal care was excellent, but it was unclear, even to me as a M.D. Ph.D., how much things were going to cost.
SHANOOR SEERVAI: And in the Netherlands, money isn’t a worry?
MARTHE HAVERKAMP: No. In the Netherlands, we pay health care premiums, on top of what the government and employers pays for care out of our taxes. I paid something like 150 dollars 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.
SHANOOR SEERVAI: Tell me more about the insurance system in the Netherlands. In the U.S., we have a mix of public and private health insurance and how much money you have can figure into which doctors you’re able to see. So if you’re on Medicaid or Medicare, you may not have the same options as people who buy private plans.
MARTHE HAVERKAMP: No, we don’t have that difference in tiered care for people with different financial means. We do, just like the U.S., have both the government and private insurance companies paying for health services. But everyone goes to the same hospitals, everyone goes to the same physicians. In fact, I used to think that maybe it would be good for someone to be able to pay a bit more to get something the patient wants but that is not completely necessary. Like, if I need a cast, but I want a pink cast, why shouldn’t I be able to pay a bit more and get that? But I have to admit that now, seeing how this works out in the U.S., I’m kind of swinging back to the other side.
SHANOOR SEERVAI: The side that says everyone should have access to the same care?
MARTHE HAVERKAMP: Yes, and then preferably limited to the care that is really appropriate and necessary.
In the U.S. some people feel that, if they’re healthy, that is because they did well — they deserve it. And if they’re sick — or, if someone else is sick — it’s as if they did something bad and it’s their own fault. The premise in the Netherlands is that if you’re sick, that’s bad luck, and no matter what, you should be taken care of.
SHANOOR SEERVAI: Well, some people in the U.S. would agree, but our health system as a whole isn’t there yet. Could you tell me a little about how this attitude plays out when it comes to primary care in the Netherlands?
MARTHE HAVERKAMP: 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 U.S. and the Netherlands. If you need a doctor in the Netherlands, you first go to a primary care center, even at night. In the U.S., there are no primary care centers open at night and you have no choice than to go straight to the emergency room — the ER.
SHANOOR SEERVAI: What if it’s something major in the Netherlands and you do go straight to the ER?
MARTHE HAVERKAMP: ERs in the Netherlands are not allowed to refuse patients, but the patient will have to pay part of his deductible. So he is much more likely to go to his primary care center first. And if your problem is too serious for them to handle — like a full-blown heart attack — then they would send you to the ER.
SHANOOR SEERVAI: I wanted to ask about another problem we have in the U.S. We have a lot of challenges with getting doctors and hospitals to share medical records. So patients end up filling out a lot of forms. What would happen if you moved to a new town in the Netherlands and needed to change primary care physicians?
MARTHE HAVERKAMP: Then you ask your old doctor to send information to your new primary care physician. And that’s it. The whole forms circus in the U.S., where for each doctor’s visit you need to come a half an hour in advance to fill out forms, where you have to repeat your date of birth six times and put your signature on so many “patient-agreement forms” that I cannot imagine anyone — at least not me — reads whatever you agree on. That’s not how we do it in the Netherlands.
And you hardly see a bill with the amount of money that is paid on your behalf. The insurance directly pays the hospital or the doctor, so patients aren’t even aware of how costly their care is.
SHANOOR SEERVAI: Wow. So no going through the whole process of getting reimbursed by the insurance company, like some people have to do in the U.S.
Tell me more about the insurance companies in the Netherlands. I was surprised to learn that these are all private companies.
MARTHE HAVERKAMP: Yes. In contrast to what many people think, the Netherlands is not a single-payer system. The government and employers (via taxes) contribute to a common pot and individuals pay their premiums to private insurance companies. The Dutch government determines what is covered in a health plan — what is “necessary care.” And insurance companies offer additional packages with care that is not deemed “essential” like extra physical therapy, or the orthodontist, or alternative medicine.
SHANOOR SEERVAI: And what about preventive services, like vaccines for kids?
MARTHE HAVERKAMP: Vaccinations for children are not given by general practitioners. We have separate institutions, we call those “Consultatiebureaus,” that are managed mostly by nurses where every child is supposed to come until he or she is 4 years old. These nurses visit babies at home to screen for medical problems, do all the vaccinations; they give you advice on how to breastfeed and take care of your child. Physicians linked to these centers will do four or five general checkups of the children within these four years, but other than that, we never go to a primary care physician, let alone a pediatrician or gynecologist. In the Netherlands, you go to a physician when you have a problem.
SHANOOR SEERVAI: Is this a good thing? One of the things we worry about in the U.S. is that people only seek health care when they are sick, which means that small issues that may have been easy to treat could have gotten worse.
MARTHE HAVERKAMP: Well, the idea is that, because there is no barrier to seeking health care from your primary care physician and practically none from any medical specialist in the Netherlands, people do not wait to go to a doctor when they do have a small complaint. Here in the U.S., I think twice before I take my kids to a doctor. Is their problem really serious? Can I wait for the next year so the costs can count for next year’s deductible? Should I take them to a primary care doc first or directly make an appointment with a specialist so that I don’t have to pay twice?
SHANOOR SEERVAI: All questions you shouldn’t really have to ask about your child’s health!
MARTHE HAVERKAMP: Yeah, it’s because I never know what it all is going to cost me, and that’s a scary thought . . . I never ever would have those thoughts in the Netherlands. There I would just ask the opinion of my primary care doc — and often it will not be necessary to go to the much more expensive medical specialist.
SHANOOR SEERVAI: Well, is there anything you like about our health care system?
MARTHE HAVERKAMP: What is really good here in the U.S. is the technical quality of the care. As a patient, I know I will get state of the art therapies. Also, things go very quick. You don’t have to wait for an appointment and test results are almost directly available to the patient.
SHANOOR SEERVAI: Is the care equally good in both countries? Say, if you had to choose between what you used to receive at home in the Netherlands and what you receive in the U.S., which one would you choose?
MARTHE HAVERKAMP: I would choose the Netherlands for almost everything that’s routine or requires long-term care. But if I discovered tomorrow that I had a very rare brain tumor, or something technically very difficult, I would be happy to be here.
SHANOOR SEERVAI: So why is that?
MARTHE HAVERKAMP: Because you know that in the U.S., there will not be any limits to using everything out there to treat the disease. And you are close to the cutting edge of the research. I mean, the care in the Netherlands would be great, too. I wouldn’t be worried at all about the quality of care being with a rare brain tumor in the Netherlands. I would know that I would be taken care of well. But in the U.S., you feel you get anything you could possibly need.
SHANOOR SEERVAI: Is there a downside to this cutting-edge care?
MARTHE HAVERKAMP: Well, it comes at a cost, and not everyone can have that cutting-edge care here. The U.S. has trouble with access to health care — even under the Affordable Care Act, not everyone is covered.
But once you’re in, there seem to be no limits. Take, for example, mammograms. In the U.S., these are done much more often than in the Netherlands, every year instead of every two years, and on women in a much broader age range. In the Netherlands we only screen women between the ages of 50 and 75. If you do a mammogram every year on everyone, you may indeed save a few more lives. But in the Netherlands, we accept that risk, because we understand you cannot do every test on everyone all the time . . . that is simply not financially or logistically sustainable.
SHANOOR SEERVAI: Do you think all people in the Netherlands think that’s okay?
MARTHE HAVERKAMP: I think that as a society, we have some consensus to limit the amount of care to what we, as a society, accept is necessary. And then we make sure individual patients do not have to worry about the costs of their care when something goes wrong.
SHANOOR SEERVAI: You’ve been in the U.S. since 2015. Will the cost of health care be a factor when you think of whether to stay here or move back home?
MARTHE HAVERKAMP: Well, where we live will depend on where our careers bring us. But for sure, one of the things we think about is — the edgy feeling you have living with the U.S. health care system. Everything is fine until you drop off that edge because of a disease or an accident. That is definitely one of the reasons not to want to live here, and certainly not grow old here. I just think of the costs for long-term care for something like Alzheimer’s. And when my children climb up a ladder, I think, “Oh, be careful, because I can’t afford you breaking your leg.”
SHANOOR SEERVAI: What would you do if your child broke his leg in the Netherlands?
MARTHE HAVERKAMP: Well, like I said earlier, our primary care is 24/7. So first I would take him to a primary care physician, and they would help me figure out next steps. But I wouldn’t be worried about the cost.
SHANOOR SEERVAI: Have you needed to go to the ER for something minor here?
MARTHE HAVERKAMP: Yes, we had a problem with my daughter. She got a small cut in her leg playing tennis later in the evening. We had to go to an ER because everything else was closed. It was just a cut in the leg, not a big thing. But it had to be treated. In the Netherlands, a primary care physician would have taken care of it. But there’s no way, even in New York, I can get to a primary care physician at night, and we ended up paying a lot of money for the ER.
SHANOOR SEERVAI: Well, there are places for urgent care in New York, but I can imagine that it was stressful to figure out what to do when you’re used to going to your primary care center.
MARTHE HAVERKAMP: Yes, but most of those urgent care centers close at 9:00, surprisingly. So we were at the ER and my biggest worry was whether “we” would be in network. It was the first question I asked the nurse. It appeared that the hospital was in network, but then the physician wasn’t — and of course I only found out when we got the bills afterwards . . . sometimes I really think — how am I supposed to understand this system?
SHANOOR SEERVAI: That was Marthe Haverkamp from the Netherlands, talking about the challenges she faces taking care of her children in the U.S. Even though Marthe is a doctor herself, and is doing research about our health care system, it is a lot to wrap her head around. Thanks for listening to The Dose.