In mid-May, opposition MPs in Slovakia submitted a bill on healthcare fees to parliament. A few days later came a signal from the ministry that it was preparing changes to so-called “supplementary office hours” – likely connected to the same issue.
Fees come up at every other healthcare conference, and it is no secret that the ministry has been quietly working on the topic for a long time. Several expert publications have already addressed it, most notably from Henrieta Tulejová’s team at the Advance Institute (the latest in December 2025) and from Peter Pažitný’s team (June 2025). In April 2026, the Ombudsman also weighed in. Yet, a political solution has still failed to materialize.
The topic is, by now, well mapped out technically. So in this piece I want to add an economic explanation for why the change is proving so difficult to deliver.
Carve Out, Regulate, Ban
Most solutions proposed so far take a similar approach: “carve out, regulate, ban.” It works by sorting healthcare fees into a triage. The first carved-out group covers fees with no restrictions at all – things like cosmetic procedures or certain administrative tasks (issuing certificates, for instance). Here there is near-universal agreement, and nothing much left to fight over politically.
The second category can be called regulated patient co-payments applied across the board. This is where the agreement breaks down. Some do not want this category to exist at all (no legal patient co-payment whatsoever) and jump straight to the third category. Others push for a flat, motivational fee (say, EUR 3 per visit to a doctor’s office). More sophisticated proposals add annual caps and protective thresholds to this layer, to soften the social impact – similar to the caps already used for drug co-payments.
The third category covers provider activities where patient co-payment is explicitly banned.
The next step is enforcement against providers: “Fees are banned, on pain of fines and other sanctions, except in a very narrowly defined set of exceptions.” This step follows the logic of existing law, and in the short term it can genuinely help suppress fees in doctors’ offices. The previous Czech government took a similar path, tightening the conditions and penalties for unauthorized healthcare fees, effective this past January.
It is a logical approach, and it has only one real flaw: over the long run, “carve out, regulate, ban” does not address the actual reason fees exist in the first place. That reason is not the “poverty” of doctors’ offices. Yes, some medical specialties genuinely struggle economically in certain regions. But if you went looking for a correlation between how aggressively a practice charges fees and its financial situation, you would not find one.
The real reason fees exist is the clash of supply and demand. Doctors’ offices are not a uniform commodity. Some are in higher demand than others – because they have a more sought-after doctor, a more sought-after specialization, a better reputation, better equipment, a nicer waiting room, or better availability. Or they simply target their services at a particular segment of patients and conditions.
Higher demand creates room for additional payments. Let us just go ahead and call it what it is: a “gray market.” The situation with fees is nothing more than the textbook outcome of central planning. The budget – or rather, the ministry’s regulation setting reimbursement rates – sets the amount insurers are required to pay doctors’ offices. If that amount is 100, but the market price for the service is 120, that creates a gray market worth 20.
If we simply ban fees outright, what actually changes on the supply side of healthcare? Will there be more office hours, more practicing doctors, more patients treated, better service? No – at best, things stay exactly the same. In the worse case, some older doctors will simply pack it in, some will move to fully private practice, some to hospitals, some abroad. At the same time, the sector loses some of the capital that fees currently bring into it.
A Deeper Fix
The trouble is that the current state of affairs is out of step with the intent of existing law, and it has to be said plainly: this situation is not sustainable for society in the long run. A shift to a fully liberalized market for healthcare services is not on the table. What we need is to have our cake and eat it too.
How would a reformer approach the mismatch between supply and demand? One option is to build a two-tier network of outpatient practices. The first tier consists of practices fully covered by public funds, with no fees – or at most a flat, modest motivational co-payment of a few euros, paired with protective caps. The second tier consists of practices with partial reimbursement and more freely set prices. This does not require two physically separate networks – the difference can lie purely in the contracts. The very same practice could belong to both tiers at once.
A concrete version of this already exists in the Netherlands, where practices under contract with a health insurer are reimbursed in full (aside from a regulatory fee), while practices outside the contracted network are reimbursed by the insurer for only part – typically around 70% – of its standard fee schedule, with the patient covering the rest.
A second model is Singapore, where the first tier consists of public (hospital-run) clinics and contracted practices that receive direct state support and charge regulated, below-market prices. The second tier consists of practices charging market prices. Patients can choose between a public practice at a regulated (sometimes zero) price and a private one.
A third example is Austria, where the first tier resembles our own (a network of practices fully reimbursed by insurers), and the second tier consists of out-of-network practices charging patients market prices. Patients can claim back part of the cost from their health insurer, though in practice most rely instead on supplementary health insurance, which roughly a third of Austrians hold.
The regulator’s key task is to set the rules so that both tiers actually make sense – so that neither ends up being, in practice, an empty shell. Put differently: an essential part of any such reform is a better definition of what a patient is entitled to, and better enforcement of that entitlement. In the Netherlands, this role is played by the treeknormen – a sector-wide agreement on maximum waiting times for non-acute care.
The need to define the system’s parameters more clearly from the patient’s point of view is a universal one in Slovakia – it is not limited to the issue of fees. That makes it a natural starting point for reform.