Two countries. One idea.
The Netherlands and Switzerland cover every resident. Both kept their private insurers. Both kept their competition. Both simply decided that healthcare was not routine commerce, and regulated it accordingly.
Inspiration, not imitation. We aren't trying to copy another country's system. We're learning from a principle that works.
Two Countries, One Idea
Not socialism. Not a free-for-all. A guardrail in the right place.
Many Americans assume that any country with universal coverage must have given up something essential about capitalism. The Netherlands and Switzerland prove otherwise. They kept their markets, their private insurers, and their competition. Switzerland remains one of the most robust free-market economies on earth.
What they didn't keep was the assumption that a market left alone would protect something as fundamental as access to care. So they found the one place where profit and human necessity were most likely to collide, and they built a guardrail exactly there.
Both systems belong to a family that dates back to Germany in the 1880s: competing, tightly regulated insurers rather than one government payer. Germany, France, and Japan use versions of it today. It isn't one blueprint. It's a shared instinct, applied differently by each country.
Regulate the point where profit and necessity collide. Leave the rest of the market alone.
— Two Countries, One Idea
Two Countries, One Idea · Case Study 01
The Netherlands: changing what profit requires
The problem they faced
Before 2006, Dutch healthcare ran on two tracks. Public insurance covered most workers, but rising costs pushed more people into private insurance each year, where insurers could turn away anyone they judged too expensive. The country was quietly sorting its people into “insurable” and “not.” If that sounds familiar, it should. It's close to the path America's individual insurance market followed before the Affordable Care Act.
What they did
In 2006, the Dutch acted before collapse forced their hand. They didn't eliminate private insurance or create a single government payer. They regulated the market instead.
How it works
Four features show how the Dutch model changes the incentives while retaining private insurers and competition.
Everyone is covered
Every resident buys basic health insurance from a private insurer of their choice.
Insurers must accept everyone
Insurers must accept everyone for the basic package at the same premium, regardless of how sick they are.
Competition shifts to efficiency
Insurers still compete, but they can only profit by running efficiently: negotiating well with hospitals, managing chronic disease, and keeping administrative costs down. Avoiding sick people is no longer a way to make money.
Hospital pricing speaks one language
The Netherlands required every hospital to describe diagnoses and treatments with the same national codes. Hospitals still negotiate their own prices, but insurers can finally compare them side by side.
The government did not ask insurance companies to stop pursuing profit. It changed what pursuing profit required.
— Two Countries, One Idea
Two Countries, One Idea · Case Study 02
Switzerland: a line profit cannot cross
The problem they faced
Before 1994, Swiss health insurance was voluntary, and insurers could screen applicants by health. By 1993, about one in twenty residents had no coverage at all, while Switzerland was already one of the highest spenders on healthcare in the world.
What they did
Swiss voters approved reform in a 1994 national vote, narrowly, with 52% in favor. Since 1996, every resident has been required to carry health insurance.
How it works
Five features show how Switzerland sets a firm boundary around basic coverage while retaining a competitive private insurance market.
Everyone carries a basic plan
Every resident must obtain basic health insurance from a choice of competing private insurers.
No profit on the basic plan
By law, insurers must offer mandatory basic insurance on a nonprofit basis. They can still operate as for-profit companies and earn returns on supplemental coverage, such as private hospital rooms or dental care.
The floor is fixed
The government, not the insurer, decides what the basic plan must cover, so insurers cannot compete by quietly offering less.
Risk is shared fairly
If an insurer attracts older or sicker customers, money moves between insurers to balance differences in risk. An insurer's success depends on how well it runs, not simply on who walks through its door.
Citizens keep a voice
Swiss voters have weighed in directly on how far the guardrails should go.
The Swiss did not ask insurers to be virtuous. They built a guardrail so virtue would not be required.
— Two Countries, One Idea
At a glance
Same goal, different tools, and where America stands
The Netherlands and Switzerland show how universal coverage can coexist with private insurers and competition. The question is not simply who pays, but what rules govern the system.
| The question | The Netherlands | Switzerland | United States today |
|---|---|---|---|
| Is everyone covered? | Yes, required since 2006 | Yes, required since 1996 | No: 26.7 million uninsured in 2025 |
| Who provides insurance? | Competing private insurers | Competing private insurers | Employers, private insurers, Medicare, Medicaid, and more |
| Can insurers turn people away? | No. They must accept everyone at the same price | No. Every resident gets the basic plan | Not on ACA plans, though gaps and denials remain |
| How do insurers profit? | Only through efficiency, not by avoiding sick people | Not on the basic plan; only on supplemental coverage | Many ways, including through denials and network design |
| Who defines basic coverage? | Public rules | The government's benefits catalogue | Varies by plan, employer, and state |
| Price transparency | Required: one national language for hospital pricing | Premiums published and set by region | Limited and uneven |
| Shared guiding principle | Healthcare as infrastructure | Healthcare as infrastructure | Healthcare as ordinary commerce |
Is everyone covered?
Yes, required since 2006
Yes, required since 1996
No: 26.7 million uninsured in 2025
Who provides insurance?
Competing private insurers
Competing private insurers
Employers, private insurers, Medicare, Medicaid, and more
Can insurers turn people away?
No. They must accept everyone at the same price
No. Every resident gets the basic plan
Not on ACA plans, though gaps and denials remain
How do insurers profit?
Only through efficiency, not by avoiding sick people
Not on the basic plan; only on supplemental coverage
Many ways, including through denials and network design
Who defines basic coverage?
Public rules
The government's benefits catalogue
Varies by plan, employer, and state
Price transparency
Required: one national language for hospital pricing
Premiums published and set by region
Limited and uneven
Shared guiding principle
Healthcare as infrastructure
Healthcare as infrastructure
Healthcare as ordinary commerce
U.S. uninsured figure: U.S. Census Bureau, 2025. Country details: Two Countries, One Idea.
Other nations, same instinct
The same instinct, applied differently
The Netherlands and Switzerland are not exceptions. Other countries have built different systems around a shared idea: healthcare needs rules that protect its public purpose.
Germany
The birthplace of regulated, competing insurance. Most Germans choose among many nonprofit “sickness funds,” financed jointly by workers and employers under strict public rules. Higher earners may opt for private insurance instead.
Japan
Everyone is covered through a network of employer-based and community-based insurers. The national government sets a uniform fee schedule, so a procedure has the same official price regardless of who pays. Japan has one of the longest life expectancies in the world.
Australia
A public insurance program covers everyone, while private insurance operates alongside it, supported by public incentives. Australia ranked first overall among ten wealthy nations in the Commonwealth Fund’s 2024 comparison.
Source: Commonwealth Fund, Mirror, Mirror 2024 .
Honest about the challenges
No system is perfect, and that's part of the lesson
The Netherlands and Switzerland have established universal coverage. Cost growth is a different problem. Like nearly every advanced country with an aging population, both are still working to keep healthcare affordable. Access matters. So does the ongoing work of making the system sustainable.
01 / COST
Premiums keep rising
Dutch basic insurance premiums rose faster than inflation between 2020 and 2025. In Switzerland, average premiums increased 8.7% in 2024, 6% in 2025, and 4.4% in 2026. Universal coverage does not eliminate the challenge of controlling costs.
02 / ACCOUNTABILITY
Guardrails need defending
In 2024, Swiss voters rejected a proposal to limit health insurance premiums to 10% of household income. Even a carefully designed system depends on a public willing to debate, maintain, and improve its rules. The fact that the question went to a public vote is itself worth noticing.
03 / INCENTIVES
Risk finds new doors
An insurer that cannot charge sick people more may still design plans or networks that appeal disproportionately to healthier people. Rules need ongoing oversight to ensure competition rewards efficiency rather than risk selection.
Questions worth answering honestly
“Isn't Switzerland too expensive to learn from?”
Switzerland is a wealthy capitalist economy, and it chose to guarantee basic health insurance through a regulated market. Its costs are real, and rising premiums are a serious challenge. Yet it covers its residents through mandatory basic insurance. The useful comparison is not whether Switzerland is inexpensive, but how its rules distribute access, risk, and responsibility compared with the United States.
“Aren't these countries too small to compare to America?”
Scale does not make the underlying principle less relevant. Insurance depends on pooling risk, and a population of more than 330 million people offers substantial capacity to spread it. The United States has its own complexity and institutional constraints, so the goal is not to copy another country's system wholesale. It is to learn from the rules that make coverage work.
No institution, however well designed, gets to stop being watched. Not Dutch insurers. Not Swiss voters. Not whatever the United States eventually builds.
Two Countries, One Idea