Well, the maximum mandatory deductible is about 30 euros a month. It's not nothing, but it's also hard to find many situations where it's completely unaffordable, I'd guess this would amount to a small number of people. Those people all get 'zorgtoeslag', which covered virtually the entire premium of 100 a month, leaving only that deductible which can be paid monthly. And if that can't be paid, municipalities have all kinds of programs (e.g. bijzondere bijstand). It can be tricky to navigate the system, but the amount of people who cannot access care due to the deductible after exhausting all options really is quite low.
Having no deductible at all creates moral hazard problems for the other 17 million people in the Netherlands, which increases the total costs going towards ineffective care, and thus total premiums, making healthcare potentially less affordable. It's a tricky pros/cons assessment that must be done, but I have to say the current deductible set-up isn't too crazy to me.
What I would like to see are more deductible exceptions, particularly for issues with a low-moral hazard chance. For example my dad is on chronic medication for two decades, and will likely be for the rest of his life. Deductibles make no real sense here as there's no moral hazard issue.
> I think the deductible should be income dependent, and higher incomes should have the option to pay more premiums for less deductible. That amounts to a tax where people can pick their risk-appetite.
Well it's to start with a tax on income. I think that's completely fine, but we already have that massively. About 80% of healthcare costs in the Netherlands are paid by the state. In the Netherlands the richest 25% about 77 %of the income taxes. [0] The lowest 25% pay 1.3%. In other words, effectively the vast majority of healthcare costs are already income-based.
The second part is people setting their risk-appetite, but that has big adverse selection issues. There's massive correlation between health and income. If you'd split the population in two groups, low-income vs high-income, and let the market offer a competitive rate, the true premiums for the rich would be much lower than for the poor. This makes healthcare unaffordable for those who really need it. You can create a similar situation of having different insurance rates for rich/poor by having the same standard premium, but adjustable deductibles. Letting people set deductibles always increases insurance premiums for those who need insurance, which is why the Netherlands caps it at something like 800 euros. If you'd uncap it you'd find a lot of rich, healthy folks essentially self-insure, which means their premiums go down and the premiums for the unhealthy and poor tend to go up.
[0] https://opendata.cbs.nl/statline/#/CBS/nl/dataset/70991ned/t...
