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health care system had become so massive that the government decided to remove budgetary restraints. In the plan “Zorg verzekerd”—“Care insured (or ensured)”—the government promised that all necessary treatments would be eligible for reimbursement (Actieplan Zorg Verzekerd, 2000). As a result, health care costs exploded, until new but less tight restrictions were reimposed around 2004.

As is often the case with trends in aggregate population health, it is difficult to produce direct evidence on cause-effect relationships. The evidence presented here for a role of health care utilization in the reversal of old-age mortality trends in the Netherlands is only circumstantial. It is partly by exclusion that we have arrived at health care factors as the most plausible candidate, and it is mainly on the basis of consistency of most of the descriptive findings with this interpretation that we feel confident in proposing this as a hypothesis—but it is currently not much more than that.

Sometimes international comparisons can help to test such hypotheses, but in this case these will not bring us very far. There are only three countries with similar histories of stagnation of old-age mortality decline, Denmark, the Netherlands, and the United States. While stagnation started around the same time in these three countries, suggesting similar explanations, the reversal from stagnation to progress differs strongly in timing. Denmark’s renewed decline already started in 1995, and in the United States it has not yet started at all. On one hand, for Denmark, improvements in lifestyle as well as in medical and surgical treatment have been suggested as explanations (Chapter 14, in this volume), which is partly similar to what we have proposed. On the other hand, the United States has a much higher level of health care expenditure than Denmark and the Netherlands, which reduces the likelihood that a reversal of life expectancy trends there can be expected to occur when health care expenditure would rise even further.

In conclusion, although important questions remain, the most plausible hypothesis for explaining the sudden reversal of old-age mortality trends in the Netherlands is more health care for the elderly, facilitated by a sudden relaxation of budgetary restraints.


Lany Slobbe of the National Institute for Public Health and the Environment provided the data in Figure 13-5. Agnes de Bruin helped with collecting data for Table 13-1. Agnes van der Heide provided useful comments on the trend in end-of-life practices in the Netherlands.

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