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The performance of the Dutch healthcare system has been attributed to the introduction of regulated competition as a guiding principle for medical care in the 2006 Health Insurance Act. The slow growth in costs over a decade can be considered a major accomplishment. However, in the day-to-day practice of this principle, several assumptions underlying the market theory have not been implemented or have proven to be problematic. The market for insurers and providers has become more concentrated. While the theory states that insurers need maximum room for maneuver, low institutional trust in insurers limits this. The hospital system has remained exclusively private non-profit, and there has been a sharp increase in the number of outpatient surgery centers. Freedom of choice has especially benefited young, highly educated, and healthy people, who can navigate the abundance of insurance information, but it also strikes a healthy balance between people who change their insurance plans and market stability. Access to good quality care is virtually universal. Two key lessons are that the “active payer” policy1 is not working as intended and—partly because of excessive administrative costs—that fragmentation is increasing. These are two major challenges.