The Netherlands: the struggle between universalism and cost containment

The Dutch home-care system is embedded in a universalistic and comparatively generous long-term care (LTC) scheme that was introduced in the late 1960s. The tension between guaranteeing access to good-quality care and controlling costs has been a key issue since the inception of the LTC scheme. The article addresses the question of how these two distinct objectives have been dealt with in the political debate and by policy-making in the past 20 years. It does so by looking at existing studies, official statistics and policy documents. First, the analysis shows that home care - the development of which results from the de-institutionalisation policies pursued since the 1980s - has shifted from being considered a cost-containment measure to representing a battlefield on cost containment. Second, the article argues that the issue of cost containment is a leitmotif in the development of home care that has been accompanied and legitimised over time by distinct normative views. On the one hand, traditional forms of cost containment - namely direct budgetary controls - have been predicated on the need to ensure the financial sustainability of the system and its universalistic features. On the other hand, the discourse and practice of cost containment has, since the early 1990s, also been accompanied by normative views that structurally challenge universalism through the introduction of new ideas about the responsibility for LTC risks, resource allocation and regulation of the system.