A defense budget of 3.5 to 5% of GDP comes to EUR 42 to 59 billion per year (current: EUR 22 billion). How to pay for this extra spending is a political choice. But there is no such thing as free money: the additional expenditure has to come from somewhere: higher taxes, rising national debt or savings on other government spending. In practice it will undoubtedly be a combination of those three.

Suppose we assume that we do not pass the defense bill on to future generations (no rise in national debt), but cover it entirely through savings in other sectors. And suppose that healthcare takes its fair share. That would mean the healthcare sector, which accounts for roughly a quarter of government spending, would need to save EUR 5 to 9 billion. That comes down to a 4 to 8% contraction.

For comparison: the total cost of GP care does not even reach EUR 5 billion, the cost of mental health care is just above EUR 5 billion. The whole of Dutch community nursing costs ‘only’ just over three billion euros. And five billion is roughly equal to the combined revenue of the two largest Dutch hospitals, the 25 smallest hospitals or 500 nursing homes.

In other words: a savings task of EUR 5 to 9 billion is huge. And that comes after years in which money in healthcare was the least of our worries. Most attention went to accessibility through, for example, the COVID pandemic and the shortage of staff in acute care.

That focus on accessibility will, in the short term, need to broaden into a focus on affordability. VWS has a number of levers it can pull. As far back as 2020, the CPB calculated the financial impact of various system reforms, and those calculations are still relevant.

Of the 147 measures the CPB looked at, only a handful are big enough to deliver savings of this magnitude. Those are measures that increase out-of-pocket payments or reduce the package of insured care. Increasing out-of-pocket payments can be done, for example, by raising the deductible, bringing GP care under the deductible, asking wealthier older people to contribute more towards elderly care, or introducing fixed contributions for hospital care. Reductions in the package can happen under the Health Insurance Act (e.g. no more long-term community nursing, removing maternity care from the basic package) as well as under the Long-Term Care Act (e.g. raising the entry threshold to very heavy care needs).

These are all far-reaching measures that run against the trend of recent years and against public sentiment. None of them is sufficient on its own: a combination of these unattractive options is needed. The financial impact of more attractive sounding measures such as fall prevention in older people, early detection of skin cancer and a ban on alcohol advertising, is low.

One way or another, the healthcare sector will pay part of the defense bill. Just like every other public sector, from education to social security to the public broadcaster. The challenge will likely be large and there is no simple solution. That is why a public and political debate about savings in healthcare needs to be held in the short term.