As Affordable Care Act subsidies expired at the end of last year and millions of Americans now face a sharp spike in premiums, there’s talk of reforming Obamacare to make it more affordable for enrollees and for the federal government. Some U.S. politicians are advocating for reform towards a single payer system, such as the Medicare for All proposal championed by Vermont Sen. Bernie Sanders. But perhaps a more feasible approach would be to examine and draw lessons from the Dutch. Their health care system is somewhat similarly structured, though with a stricter set of government regulations. And experts suggest it resembles what architects of the ACA hoped to establish.
Passed in 2010, the ACA (also called Obamacare), introduced a regulated health insurance exchange marketplace on which people can purchase coverage from private insurers and receive financial help to reduce their premiums and out-of-pocket costs. Americans who opt for Obamacare marketplace plans to do so because they’re self-employed or their employer doesn’t offer health insurance, or they’re not eligible for the public programs Medicaid or Medicare. Roughly 24 million people were covered through in an ACA marketplace plan in 2025.
During the Covid-19 pandemic, the federal government expanded eligibility for subsidies for individuals earning more than $62,600 a year and increased subsidy amounts across the board. For some lower-income enrollees, this meant they could receive coverage with no monthly insurance premium. And for higher earners, premiums were capped at 8.5 percent of a person’s income. But without these enhanced subsidies, which expired on Dec. 31 and have not been extended by Congress, more than 20 million enrollees are now seeing their premium costs more than double this year.
Some U.S. politicians are advocating for reform towards a single payer system, such as Medicare for All.
People with employer-sponsored plans are feeling the pain, too. A rising number of private plans offered carry deductibles of thousands of dollars before insurance kicks in. Moreover, health insurance premiums have quadrupled since 1999.
Compared to its peers, the U.S. spends more per capita on health care and generally has worse health outcomes. Given all this, it might be helpful to seek lessons from abroad.
The Dutch operate a tightly regulated private insurance market to achieve universal coverage across the entire population. By contrast, the ACA expands and subsidizes coverage by private insurers for a relatively small fraction of the population within a fragmented health care system that coexists with employer-based plans, Medicare, and Medicaid. Despite this discrepancy, there are certain parallels.
Both the Dutch and ACA systems forbid insurers from denying coverage to a person based on preexisting health conditions. And both seek to maintain their respective systems’ financial stability by spreading risk among insurance carriers. This involves the government redistributing funds from plans with healthier enrollees to those with sicker ones. Additionally, the Dutch and ACA insurance policies offer a similar set of benefits.
What the Dutch call basic health insurance includes benefits such as hospital stays, physician services, emergency care, and prescription medications. Patient co-payments are relatively low and capped at $295 in total annually. The system is funded, in part through an income tax of 5.3 percent for those who are self-employed, and 6.6 percent for those with employers. Employers pay the contribution on behalf of employees. Individuals also pay insurance companies approximately €158 ($185) monthly in premiums. Strikingly, community-rated premiums are equal for all policy holders, regardless of not only health status but also age. Conversely, ACA insurers can charge older enrollees up to three times as much as younger ones.
The annual deductible for the Dutch system is €385 (about $445). This applies to anyone 18 or over, but general practitioner visits and maternity care are exempt. The government funds full coverage of children under 18 (who are also exempt from the deductible) and subsidizes low-income people so they can afford premiums and pay medical expenses. Statistics Netherlands states that roughly 30 percent of the adult population receives a health allowance. To be eligible, individuals are means-tested based on both income and personal asset levels. Individuals can receive an allowance of up to €123 ($145) a month, depending on income.
In the U.S., a rising number of private plans offered carry deductibles of thousands of dollars before insurance kicks in.
In contrast to the Dutch system, the ACA doesn’t have a comparable health care tax applicable to all, nor does it subsidize enrollees directly. Instead, among other funding mechanisms, the law imposes taxes on people earning over $200,000 as well as on pharmaceuticals. A typical ACA plan’s monthly premium average has more than doubled since 2014, from $273 to $625 in 2026. Dutch enrollees did pay roughly 30 percent more in 2025 in individual premiums than in 2020, which is comparable to the hike in average premiums for family coverage in U.S. employer-sponsored plans. But it’s not nearly as steep as what ACA enrollees are now experiencing.
There’s a lot of variation in terms of rates for ACA coverage, not just by type of plan chosen but also dependent on a person’s age, income, and the state they live in. The federal government subsidizes ACA insurers to lower premiums for eligible recipients, as well as patient cost-sharing. More than 90 percent of enrollees receive at least some form of subsidy on a sliding scale. Deductibles vary depending on the plan selected. The average deductible on a typical Silver plan has seen a 119 percent increase since 2014, from $2,425 to $5,304, which is roughly 12 times higher than the Dutch annual deductible.
While both the Dutch and ACA systems adopt forms of regulating health care markets, there are key differences that may help better temper cost growth in the Netherlands.
For one, the Dutch system includes an individual mandate, a requirement that each person obtains insurance. This ensures that both healthy and sick individuals participate. In turn, this can stem cost growth and prevent spikes in premiums. The ACA used to have this, but it was repealed in 2017.
Conspicuously, Dutch subsidies to reduce premiums go directly to consumers. As part of an ACA reform effort, the Trump administration wants “health care funds” to be sent directly to individuals as well, rather than being sent to insurance companies. The key difference, though, is that since there is a mandate to buy a statutorily basic level of insurance in the Netherlands, the consumer can’t spend this money on alternate, less comprehensive forms of insurance.
Secondly, insurers in the Netherlands may set global budgets, which give health care providers such as hospitals a pre-specified amount to finance all costs associated with the care of different subgroups of patients for a fixed time period. In the U.S., by contrast, this is fairly uncommon.
Besides budgets, the Dutch government plays a more active role in the process of price-setting of health care services and technologies. To illustrate, while the government doesn’t negotiate directly on behalf of health insurers for all drug prices, it does establish maximum prices and reimbursement limits. Insurers then negotiate separate price agreements with manufacturers.
Insurers in the Netherlands are paid by the government a risk-adjusted amount for each beneficiary they enroll, similar to what happens in the ACA. But the Dutch use an especially sophisticated framework to spread revenues among insurers. In addition to demographic and health status variables, risks are adjusted based on a wide range of socioeconomic factors. If an insurer has a disproportionate number of high-risk enrollees, it receives compensation from a pooled fund.
Dutch government plays a more active role in the process of price-setting of health care services and technologies.
Notably, virtually all health insurers in the Netherlands are not-for-profit cooperatives. By contrast, the U.S. market, including ACA exchanges, is dominated by for-profit health insurers. Furthermore, given that insurers operate in the Netherlands in one unified system, they can’t drop enrollees’ basic health care coverage unless they’re exiting the market altogether. In the U.S., large insurers like Aetna and Humana have left the exchanges. This can create marketplace instability, with fewer available options in certain regions.
Broadly speaking, Dutch regulated competition attempts to systematically balance the use of government regulations and market forces. Also, holding insurers in check appears to foster a relatively fair and secure arrangement. These principles could inform ACA reform efforts to better align the American public’s interest in greater and more stable access to coverage, a fairer distribution of the financial burden, and fiscal sustainability.