A year ago, the Health Insurance Fund board was looking for a new chair. One board member, Estonian Employers Confederation CEO Hando Sutter, said in several conversations that he wanted to find a leader who would be willing to bring the Health Insurance Fund's budget into balance within a couple of years without adding extra money to social tax revenue.

This vision and task set by Sutter is the basis for the principles approved on August 28 for planning the next four years of the Health Insurance Fund's budget.

In interviews, Health Insurance Fund board chair and Minister of Social Affairs Karmen Joller says the most important thing in funding decisions is that patients receive necessary care on time. She adds in all her appearances that reaching a balanced budget will happen while keeping access to care at least at its current level, possibly even increasing the volume of care.

Unfortunately, experts in health care management and economics, as well as leaders of public and private health care institutions, do not see a way to maintain even the current level of access to care.

Maintaining access to care while using less of the budget for services and medicines has been possible only during periods when Estonia had high employment and rapid wage growth, and social tax revenue grew more than twenty percent per year.

The current revenue forecast approved by the Health Insurance Fund board expects social tax revenue to grow five percent per year or less. The plan to move toward a balanced budget relies on cutting health care service costs.

Efficiency must always be sought and encouraged, and this has been done throughout the Health Insurance Fund's existence. Otherwise, our level of medical care and outcomes would not be what they are with funding below the European Union average.

Unfortunately, access to care has not met residents' health needs or expectations for years, and this lowers the health outcomes that health care can influence. Setting cost savings as the primary goal instead of improving how needs are met is shortsighted and also works against broader economic growth. Poor health and worry about loved ones' access to care do not help create jobs or raise productivity.

Is the cost savings sought by the minister and the Health Insurance Fund board achievable and sustainable?

The first step toward reducing costs is planned already in 2026. The forecast for health care services is €15 million less than what was planned when the 2026 budget was approved at the start of the year. The public may be able to read from the Health Insurance Fund's report where these savings will come from.

The main savings in 2027 are expected to come from not adjusting the wage component in health care service prices paid to providers. Coalition politicians explain that this is meant to slow down the overly rapid growth of minimum wages agreed for health care workers in 2023 and 2025 and to curb wage increases, which they say will help move health care toward sustainability.

Only someone who either does not understand how the health care labor market works or deliberately ignores it could say such a thing. Neither is encouraging when the person making decisions affects access to medical care that all of us need.

Estonia has fewer health care workers than needed. This is no surprise. Estonian health care currently functions thanks to doctors and nurses working past retirement age. The number of new doctors is smaller than the number retiring. Historically, Estonia has had fewer nurses relative to doctors than needed. Nurse training has been supported through cooperation between health care colleges and hospitals with on‑site training, but a sustainable level has still not been reached.

When there are fewer workers than needed, employees have more opportunities to choose their employer and negotiate their working conditions. This is also true in health care. The ministry and the Health Insurance Fund board do not centrally determine wages. The collective agreement sets minimum hourly rates that workers should not receive less than.

The Health Insurance Fund uses these minimum rates — not actual average wages — as the basis for calculating the wage component in service prices. Freezing the wage component in service prices does not freeze wages across the sector but creates several other effects.

In reality, health care workers' wages are higher than the collective agreement minimum and follow labor market dynamics. Under the agreement, the minimum hourly wage in 2026 is €20.96 for general doctors and €22.81 for specialized doctors. A hospital director hiring a general doctor for the ER today calculates a wage 1.5 times higher, plus extra pay for night and weekend shifts. This is just one example.

The wage component in the Health Insurance Fund's service prices has not covered actual wages for years. The gaps are larger in some specialties and smaller in others. Freezing the minimum hourly rate directly affects only resident doctors, who could earn more working as general doctors in family medicine centers, ERs and county hospitals instead of doing residency.

Health care institutions and nursing homes also cannot hire nurses and caregivers at the collective agreement minimum. Public job postings for nurses list hourly wages starting at €13, while the agreement minimum is €12.79. Some postings start at €14. The minimum hourly wage for caregivers is €8.10, but job postings offer €9–11. And there is still a shortage.

If an institution needs workers, it must consider the labor market, and the argument that the Health Insurance Fund board decided to postpone wage component adjustments by nine months carries no weight for job seekers choosing where to work.

So far, the gap between the wage component in service prices and actual salaries has been covered by efficiency efforts and internal reallocations within health care institutions. Health Insurance Fund staff know this well, and they also know that freezing the wage component for nine months only widens the gap between appearance and reality. This pushes doctors and nurses to provide paid services part‑time, where visit prices are not subject to the same limits.

Health care institutions that work mainly under Health Insurance Fund contracts have already begun reviewing which necessary activities could still be postponed and which services should be reduced — especially those that the Health Insurance Fund does not fund sufficiently or at all, such as home‑on‑call duties in several specialties.

Marja‑Liisa Alop, who heads Meliva, one of the largest private health care providers offering mainly paid services, and who also shapes the Employers Confederation's health care working group positions, told Meditsiiniuudised that she sees no such constraints. She said their institution "is continuously expanding its clinical team and recruits new doctors every year." Confido CEO Edvard Garder said they "are always ready to talk with good doctors and other health care specialists who are interested in cooperation."

If the minister's goal is more paid services, then it would be honest to say so. Based on the stated plans, it is not possible to maintain the current volume of care offered by the Health Insurance Fund.

The minister hopes for greater efficiency in the health care system next year by making e‑consultations mandatory in some specialties and by improving integration between health care and social services. Both require certain preconditions to be met to achieve good results. At the moment, both initiatives face problems with those preconditions.

E‑consultation has proven to be a very effective way for a family doctor to seek advice from a specialist without requiring the patient to attend a separate appointment. When needed, the patient can also get a faster physical consultation with a specialist. Unfortunately, we increasingly face the problem that people cannot take the first necessary step — getting access to a family doctor. When changing residence, it is often impossible to find a new family doctor, and there are problems contacting existing family doctor centers through digital channels or by phone.

For people who cannot reach primary care, e‑consultation offers no help. They have no choice but to go directly to the ER or call an ambulance. The less accessible primary care is, the more people end up in this situation.

The Health Insurance Fund's main effort should be directed toward making primary care accessible, but documents in this area speak mainly of remote services and digital solutions, which unfortunately do not meet the needs of people with poorer health.

The Ministry of Social Affairs presents health and social care integration projects as efficiency‑boosting initiatives that help keep costs under control. Explanatory memorandums for draft laws, however, speak more about additional obligations and budget pressure for the Health Insurance Fund.

Better coordination between health and social services is essential, but combining one underfunded sector with another that lacks the resources to meet needs does not create synergy or greater satisfaction. Instead, it leads to disappointment among both those who need help and those who provide it.

The reform transferring rehabilitation services from the Social Insurance Board to the Health Insurance Fund is said to aim at improving assistance, but the explanatory memorandum speaks of reduced assistance — sometimes more subtly, sometimes directly.

The so‑called winner in transferring rehabilitation services in this form to the Health Insurance Fund is the Ministry of Social Affairs, which will no longer have to request additional state budget funds each year for an underfunded sector. From now on, it will be the Health Insurance Fund's problem to manage. As one politician said several years ago during discussions about adding new responsibilities to the Health Insurance Fund, in a pragmatic and cynical tone: underfunded services are more likely to get money through the Health Insurance Fund. There is already so much missing there that eventually people will understand that more money must be provided.

We have not reached that point yet. The social minister is implementing a shortsighted vision that prioritizes cost savings for the Health Insurance Fund even though costs in the health care system are actually rising. At a minimum, it should be acknowledged that such a budget is sleight of hand — it fits within limits at the expense of access to care and increased workloads. Neither is socially sustainable and both increase frustration and the sense of unfairness.

The next minister will inherit the task of making up for lost time in discussions on sustainable funding solutions and bringing them to decisions that help keep medical care accessible to everyone who needs it and protect health care workers from burnout.

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