If all goes according to plans laid out by Minister of Health Riina Sikkut (SDE), next year will see increases not only in specialist visit fees but also in hospital bed day fees. Additionally, €1 will be added to every prescription drug fee. The healthcare sector is expected to receive the most additional funding – around €10 million – from prescription fees, while the quadrupled visit fees should bring in more than €8 million

"For over ten years, visit fees, prescription fees and bed day fees have not been reviewed, and now this modernization is taking place. But despite the timing, which coincides with discussions about the lack of healthcare funding, one thing must be made clear: Estonian individuals' out-of-pocket expenses are already high, and there is a significant difference between what healthcare needs long-term and what can be collected through increased fees. We are not raising visit fees to cover the €200 million shortfall in the Health Insurance Fund; that simply isn't possible," explained Sikkut.

Agris Peedu, the head of North Estonia Medical Centre (PERH), supports the visit fee increase, citing general price rises over time. However, while the additional funds will remain with the hospital, it will not improve the hospital's budget or access to treatment. This year alone, the number of treatment cases was reduced by 2 percent, and similar cuts are expected next year.

"On the one hand, there is additional funding, but since in the first half of this year we performed extra work – meaning we exceeded our treatment funding contract – and given that our funding contract was reduced compared to last year, we are really just covering that deficit," Peedu clarified.

While the health minister hopes that the €20 visit fee at emergency departments will encourage more people to visit family doctors, Peedu is skeptical. In the first six months of this year, 3,000 more people visited PERH's emergency room than in the previous period, most of whom did not need emergency care. Peedu believes that a successful outcome would be if the visit fee increase managed to slow the rise in ER visits.

In smaller shops, it's sometimes possible to make purchases on credit, but what happens if someone needs to see a doctor before payday and doesn't have €20? According to Peedu, if a person doesn't have a bank card or cash on hand, an invoice will be issued. Some unpaid invoices eventually end up with debt collection agencies.

"I suspect that with the increase in visit fees, our interactions with debt collectors may become more frequent. But of course, our customer service representatives will first contact patients and remind them," Peedu said.

"The median claim this year has been €5, mostly visit fees. But the average claim size is around €50, €40 or €30," said Merle Laurimäe, CEO of Julianus Inkasso, a debt collection agency.

When collecting a €5 visit fee, an additional €30 may be added to the original amount. Recently, debt to medical institutions has grown, particularly in Ida-Viru and Lääne counties, and Laurimäe expects more of these debts to end up with collectors in the future.

"The impact won't just come from the increase in visit and bed day fees, but also from the fact that people are already struggling more with their finances," Laurimäe explained.

Estonia has so far maintained a solidarity-based healthcare system, where healthcare costs for children and the elderly are covered by social tax paid by workers. However, the number of wage earners is decreasing.

"Many people now have other sources of income that don't generate social tax, not to mention that the population is aging. I think the future of various insurance systems in Estonia is becoming quite real," said Raul Adlas, head of Tallinn Emergency Medical Services.

According to Marja-Liisa Alop, CEO of the private clinic chain Meliva, insurance isn't always needed between a person and a private clinic. She believes that waiting times could be shortened if employers were allowed to pay directly for certain private medical services without incurring fringe benefit tax.

"We see that many employers are willing to invest in the health of their employees and take on healthcare costs. To make this possible, we would need to eliminate some legislative restrictions," Alop explained.

Both the health minister, the head of the major hospital, and the private clinic director agree that Estonia should continue to have a solidarity-based healthcare system. However, it can no longer be sustained solely by social tax, which is why Sikkut proposed to the government this year that the state start paying social tax for children.

"The fact that the government didn't decide to allocate additional healthcare funds for children starting next year doesn't mean the proposal was wrong. The issue was simply that the priority was purchasing ammunition, and I supported that decision. Next time, I will again propose making payments for children," said Sikkut.

Since the Health Insurance Fund is short nearly €190 million in next year's budget and additional state funding is not forthcoming, one option is to tap into the reserves that have been set aside for "rainy days." A week ago, Finance Minister Jürgen Ligi (RE) opposed this plan, and sharp debates on the issue continued in the government this week.

"Yes, the Health Insurance Fund can use its reserves. We're talking about around €160 million, but the exact figures with decimals will be finalized at next week's government meeting. As the saying goes, nothing is final until everything is final. We are almost there, but the final decisions will be made next week in the cabinet," Sikkut said.

At that time, the range and eligibility criteria for visit, bed day and prescription fee discounts will also be decided.

Changes to visit and bed day fees

The rates for visit fees and bed day fees have changed over time, regulated by the Health Insurance Act. In 1995, the visit fee was 5 kroons (approximately €0.32), rising to 50 kroons (around €3.19) by 2003, while the bed day fee was 25 kroons (around €1.59).

The current limits – €5 for home visit and outpatient specialist care fees and €2.50 for bed day fees – have remained unchanged for 12 years, since 2013. The law clearly states that the maximum limits for visit and bed day fees should be adjusted every spring according to changes in the consumer price index, but no minister responsible for the sector has yet implemented this provision.

Given that the fees have largely remained the same, they can be compared to other costs of living. For example, the average price of a movie ticket has increased from 16 kroons (approximately €1) in 1995 to around €7.50 today.

There are several exceptions when it comes to collecting visit and bed day fees, which will be clarified next week. What is known is that starting in January, the maximum bed day fee will be €5 and in April, the maximum visit fee will be €20.

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