Wouter Bos: Solidarity by stealth

Spiralling costs are a threat to the solidarity principle that props up the healthcare system, says columnist Wouter Bos.  Is there a limit to solidarity? And are we helping or hindering solidarity by focusing on the discrepancies between those who pay most and those who benefit most?


I once saw a reputable economist make a fool of himself on the dance floor. From that moment I could never take anything he wrote seriously. It was a case of too much information. In other words: perhaps the world functions better if you don’t know and understand everything.

I was reminded of the dancing economist when I read the reactions to the Centraal Plan Bureau (macro-economic think-tank, DN) report on the cost of healthcare. There are quite a few things wrong with it but its central premise holds: the biggest threat to solidarity in healthcare is the spiralling costs.

It’s not hard to work out that if the costs of healthcare outgrow our average earning power, more households will have less disposable income, even to the point where the costs of healthcare outstrip their income altogether. This situation can only be remedied by bringing down healthcare costs or by redistributing the financial burden between high and low income groups to a greater extent than is happening now.


The fact that the CPB in its analysis doesn’t pay any attention to the first solution –bringing down the costs of care –  is careless to say the least, especially in view of the fact that it’s here the knife will be wielded in the years to come. When the CPB then homes in on redistribution and why this may become a big problem, the organisation could be accused of scaremongering.

The CPB’s analysis is intriguing nevertheless, because it conjures up a clear picture of what may lie ahead if redistribution were to become a necessity. The CPB looks at the differences between the well-educated and those with a low level of education. The economists show that the latter consume relatively more care during their life time than the former and also pay relatively less for it.

The economists are wondering how long the well-educated will be willing to fork out for the less well-educated, especially if the bills keep getting bigger. Solidarity becomes much harder to organise when people think they are paying for something that is benefiting someone else, instead of supporting a collective insurance that is benefiting them as well.

Knowing what’s good for you is a much healthier base for solidarity than altruism. 


This is where the dancing economist comes in. Do we help solidarity by making the discrepancies between those who pay most and those who benefit most transparent? Or are we creating a discussion about something we did not previously think of as controversial? Don’t the people of Eindhoven pay for their fellow men in Groningen? Or the young for the old? Do we turn this into a problem or stick to what we have?

I would love to say that transparency is the way forward and that it will enable us to have a grown-up and proper discussion on how to shape solidarity. But I doubt that it will.

Let’s take another look at the unrest caused by the income-dependent care premiums of a couple of months ago. Some people are saying it proved the CPB right: there is a limit to solidarity. I don’t agree.


The new proposals are redistributing wealth as much as the old ones, with some middle-income groups even ending up worse off. It’s just that this is happening by the invisible means of tax income brackets and tariffs instead of the very visible route of the healthcare premium.

If the revolt proved one thing it wasn’t that we have reached the limits of solidarity but that solidarity by stealth is much more acceptable than solidarity based on transparency. Is this something we should be thankful for or something that we, modern emancipated people, should question?

I haven’t made up my mind yet.


Wouter Bos is a partner at professional services firm KPMG where he is responsible for healthcare. He was political leader of the PvdA and finance minister and deputy prime minister under Jan Peter Balkenende from 2007 to 2010.

This article was published earlier in the Volkskrant


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