Marcel Slockers

91 Effects of health insurance policy changes on access to care for homeless people Uninsured epidemic According to the Dutch Central Bureau for Statistics (CBS), the number of people who are at least six months in arrears in paying health insurance, has increased by 22 per cent from 2010 to 2014 to almost 300.000 1 . Government measures to solve this problem have not had any effect. 1,2 Worse still, these measures were counterproductive for homeless people without a mailing address or registration in a municipal register. In 2014, medical insurance companies and the Dutch Department of Health, and Human Services (VWS) decided to remove all these homeless people from the list: no address, no health care insurance. Homeless people have the lowest life expectancy. 3,4 Moreover, this vulnerable group struggles with the consequences of substance abuse, psychiatric disorders and/or mental retardation which impedes keeping appointments and doing the required administrative paperwork. 5-8 And these people in particular should have easy access to basic medical care. Different municipalities organise this basic medical care for homeless patients in different ways. Co-ordination on a national level and guidelines to that end do not exist. For lack of univocal registration, we have no comparable data. 6 However, a questionnaire of the NSG on the number of uninsured homeless patients visiting the street doctors’ practices has rendered some results (January 2016). In 2013, a quarter of the new homeless people who visited the street doctors in Rotterdam, had no insurance and this number increased to 50% in 2015. In Utrecht as well, 23% of the new homeless patients were uninsured as opposed to 7% in the previous year. In Nijmegen, 18% of the patients in the homeless practice, Buitenzorg, were uninsured in 2014 and in 2015 this number was 31%. In smaller towns, the numbers of uninsured are increasing as well, although exact figures are limited or unknown. Recent studies among homeless people at the Salvation Army in Dordrecht and Venlo have shown that half of the respondents had no valid insurance. 7 Limited access to health care “I swear to practice medicine, to the best of my ability, in service of my fellow human beings”. This is the beginning of the oath that every physician takes. Unfortunately, the actual practice is often different. NSG’s experiences show that medical specialists and GP’s, apart from acute critical situations, don’t accept uninsured homeless patients so easily. The following case shows how street doctors struggle with the consequences of the uninsured patient. 1. Number of homeless people among defaulters is unknown as they can’t be counted when not registered