Feb 27, 2010 - 10:56

Should thin people pay less health insurance?

There has been talk of an obesity epidemic developing in Switzerland (AP Photo/Franka Bruns)

A proposal that sees those with a healthy lifestyle – basically the thin and the fit – benefiting from lower health insurance premiums has triggered controversy.

Speakers at a debate on ways to reduce Switzerland’s spiralling health expenditure argued that punishing the overweight was unfair and there were other ways of tackling the heath cost and obesity issues.

The idea had the support of the centre-right Radical Party’s Felix Gutzwiller, who is a doctor. It called for a voluntary system in which patients agree to a healthy lifestyle, measured by Body Mass Index (BMI) or a fitness test. In return they would receive lower health insurance premiums than others.

Gutzwiller argued that the model would encourage personal responsibility and prevention, saving costs for everyone.

Although rejected by the rest of the Radical Party, the idea has caused political and media waves. It formed the main topic of a Swiss Consumers’ Forum public debate this week in Zurich.

This was held after a Forum survey found that rising health system and insurance costs were top of the list of consumer concerns, for the third year in a row.

Speaking at the discussion was Gutzwiller’s party colleague Doris Fiala, who recently lost 17kg, who said that the party had not shown enough courage over the idea.

Switzerland’s weight problem – almost 40 per cent of the population are now classified as overweight and almost nine per cent obese – had risen to “epidemic proportions”, she said. Diabetes and heart problems were a result and the nation’s children were getting fatter.

Proposal flaws

But fellow panel member Heinrich von Grünigen, head of the Swiss Obesity Foundation, said there were flaws in the “BMI bonus” proposal.

“It would be interesting to have some sort of positive-negative incentives, even on a financial basis, but BMI is not suited as a measuring means,” he told swissinfo.ch.

BMI is calculated from a person's weight and height to estimate a healthy body weight. A BMI of 18.5 to 25 may indicate optimal weight. Over 30 is considered obese.

“We have people with a low BMI who are much more apt to get illnesses than those with a slightly higher-than-normal BMI but are still active. These people with a slightly high BMI fare better than those with a low BMI who are lying around taking drugs or whatever,” von Grünigen said.

In any case, studies have shown that financial incentives, normally so effective, do not appear to be so for weight loss, he said, so it was not clear what could be done.

“One solution would be to make healthy food cheaper and unhealthy food more expensive,” he added.

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Punishment of poor

Franziska Troesch-Schnyder, president of the Swiss Consumers’ Forum, said the BMI idea was one-sided, targeting poor, hardworking people, many of whom had a migration background.

“You can’t punish them by asking them to pay more than those who can afford a fitness trainer, have time to exercise and the money to buy healthy food. We don’t think it’s a fair solution and it doesn’t save a lot of money.”

And while Felix Schneuwly from Santésuisse, the Swiss Health Insurance Association, was not against incentives to cope with weight problems, he could not see the idea working either.

“It’s too complicated to check that people are doing the right things to manage their weight. It would be too expensive, especially in administration,” he told swissinfo.ch.

Getting a grip

All participants agreed that Switzerland needed to get a grip on its health expenditure, which according to the latest official figures cost SFr55.3 billion ($51 billion) in 2007, making it one of the most expensive health systems behind the United States and France. The Swiss Economic Institute (KOF) predicts a rise to more than SFr60 billion for 2009.

Von Grünigen said targeting the overweight, who cost ten per cent of the health budget, was not going to lower spending significantly. It would be better, he said, to save money elsewhere, such as by stopping patients “doctor-hopping” until they get a diagnosis they like.

Schneuwly pointed to a lack of competitiveness in the health system, especially among health professionals, saying there should be incentives for them to do a better job for less money.

A fair solution, argued Troesch-Schnyder, would be a package of measures that would hurt everyone a little rather than target one group.

“Otherwise we won’t even be able to keep the costs at the same level,” she told swissinfo.ch. “You can only dream about reducing them. We have to do something.”

Isobel Leybold-Johnson in Zurich, swissinfo.ch

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peter, United States

What is mean or uncaring about wanting to create an incentive for making good personal decisions about lifestyle? Smoking is a personal choice, drug addiction is a choice and and like it or not, most overweight people choose to be overweight. The underlying issue here is choice. Clearly there are cases where people have medical conditions or other issues over which they have no control and in those cases, they should be given the benefit of the doubt. I suspect, however, that when compared to the general population of smokers, drug addicts and overweight people who choose their lifestyle, the number of people who do not choose their condition is small. To be honest, this debate sounds much like what is going on in the US today. Both the far right and the far left huff and puff over extreme positions on issues that need resolution thus creating gridlock. In the end it is the moderate, common sense middle that suffers. How sad.

stacy, Switzerland

Yes, if the fatties can afford all that extra food then they can afford extra premiums.

Dr Mo, Switzerland

So then smokers shouldn't quit because they will likely gain a lot of weight. Obese people should start smoking to try and shed some pounds. In case insurance rises for smokers ... cocaine is a good way to lose weight, but since that is illegal in Switzerland heroine, which can be got free from the government, would be another viable weight loss program (have you ever seen an obese heroine junkie?!). Or we could make all these pre-existing conditions, charge more, and end up with the American health insurance which has forced millions of people onto disability benefits so that they can afford their own health insurance. Oh, wait, in Switzerland their insurance would be subsidized by the government if they couldn't afford their premiums...so now we are back where we started, spread out the risk among insurers or pay higher taxes.

Dr Mo, Switzerland

Peter: It's pretty simple why your idea is unfair: You could get into a bad car accident, be seriously injured and disabled costing the healthcare system millions of dollars over the rest of your life. Or you could have a a genetic predisposition and come down with Parkinsons, Scherloderma, or any number of auto-immune diseases...or go hiking and get a bad case of Lyme disease or...the list goes on...all of this could cost a lot more than being a little chubby. Or your anti-depressent could cause weight gain...But you would probably prefer to be mean and live in denial thinking you have total control over your health and fate.

peter, United States

Why should an individual who exercises 3 to 5 days a week, doesn't smoke, doesn't drink and doesn't do drugs pay the same health insurance premium as an overweight, alcoholic, pack a day smoker. Isn't that like asking someone with a perfect driving record to pay the same car insurance rate as a person with a history of multiple traffic accidents and speeding tickets? People should be given an incentive to live better.

george, Austria

What's next ? DNA-check to increase payments for those with bad genes ? Race check to correlate risk factor with race ? Maximum reimbursement during a person's lifespan ?

akili ya mzee, Switzerland

Certainly more effort and resources should be put into prevention of unhealthy behaviour. Educating school children on healthy lifestyle and making sure that each pupil gets 1 hour of sports every day would be a good start. Reducing VAT on fruit, vegetables and cereals ane increasing it really sharply on all alcoholic beverages and on food that contains a high proportion of sugar, salt and/or unhealthy fats would also be a great move.

Dr Mo, Switzerland

This has to be one of the most ignorant and hateful suggestions I have heard in a long time. I agree with Digit that ordinary and poor families in Switzerland can't afford a normal Swiss restaurant (which are ridiculously and unnecessary expensive, one can eat over the boarder for 1/3 the price!) and that is how they end up in places like McDonalds. But more importantly most obesity is the result of metabolism problems and illness. Two people can eat the same foods and one stay thin and the other grow obese. Many women gain weight during menopause that pushes them into the obese category and work hard (sometimes for the rest of their life) to shed it. How will such a system identify people who have high weight not as a result of behavior but due to underlying medical issues? If it doesn't, then it is a sick policy that punishes victims. The sad thing here is that the Swiss have never had a period during which they have become sympathetic to disabled people, to the chronically ill, to severe allergy suffers (trust me I know about this one). Indeed, they have held contempt for these people like in the olden days in other countries. (By the way, the recent move to make the trams and train stations wheelchair accessible was forced on Switzerland by the EU and not part of a homegrown awareness campaign. Most buildings still lack wheelchair access.) To hold contempt for "fat people" is another form of this deep lack of empathy. So now we want to reward anorexics and punish people whose incomes, stressful lifestyles, and metabolism issues should be punished twice by a discriminatory insurance policy and an uncompassionate electorate? No way.

peter, United States

Yes, overweight people should pay more, as should smokers, as well as heavy alcohol and drug users. I do wonder about fairness and accuracy of enforcement, however. And for all the whining about not having access to health facilities, a good pair of shoes, an umbrella and a little discipline should be more than adequate for most people to get 30 to 60 minutes of execise per day.

Stevie, Switzerland

Gutzwiller has started a great discussion. How can we teach people to be responsible again? There has been much news about the problem of obesity increasing in Switzerland. Everyone knows that the health risk is much higher and the potential of creating more cost very clear. Health insurance already take the risk into consideration like for example age. How that could be implemented is obviously not as easy as proposed but I think it's a great start to find how we can keep people responsible for their own actions and decissions they make. I am not sure if the BMI alone would be a good measurment. Also I hope we don't just stop with obesity but also start targeting groups like smokers, that don't just cause health problems for themselves but more so also people around them. I hope this discussion will continue and some of the politicians will be bold enough to again put some responsibility back on the people and not just trying to please everybody.

Jim, United States

It's a brilliant idea Gutzwiller has. Fair and brilliant. We should have politicians here in the States that smart.

Digit, Switzerland

... and how about increasing insurance for smokers, alcoholics and other substance abusers .... why just stop at over BMI 24.9 ??

Digit, Switzerland

Health expenditure … a paradox of our times. This problem is based on several factors namely the law, the premium, lifestyle and disease type. I shall try deal with each briefly. Firstly the Law and Premium. If the motor behind this was NOT big greedy pharmaceutical firms, health costs would be very affordable – but this is another debate all together. Our system is ruled by a single law …. The LAMal. This guarantees a minimum level of medical aid that is of a very good standard – if not one of the best in the world. The inherent issue is, of course, the monthly premium. This is not applied UNIFORMALLY across the country, with some regions paying up to less than half of other regions. And yet, those paying half, have right to get treated (and they more than often do) in those regions with the most expensive rates. The premium HAS TO BE EQUAL throughout the country for the same insurance cover ( and no need, mind you, for a “Single State Insurance firm” – just apply a standard rate to all Health Insurance Firms in the current infrastructure for the LAMal ) . This for one part, levels the playing field. Secondly the Lifestyle. Now we want to “punish” the overweight and the obese for their lifestyle …. This is fine if the health insurance covers the costs of practicing sport like Gym Membership and courses, Sport Club membership and in many cases, the equipment required to practice some sports … ie. Cross country skiing and cycling, and other costs like Swimming pool seasonal ticket costs and so on. But none do and the insurance firms vehemently refuse to even negotiate on this matter – so NO, I do not agree with this proposal. A number of years ago, the US introduced the BMI standard and overnight, many people were considered overweight or obese … so much so that these figures seem to suggest that nearly 70% of the population there are in these categories … even an extremely high proportion of top sports men and women across the board due to their physical training programmes …. So the BMI standard is not that reliable unless it is simply used as a guideline and not the rule. The BMI does not calculate individual Bone and Muscle mass, nor does it take into consideration gender specific anomalies, medical conditions and ageing effects. Thirdly, no one seems to take into consideration that nearly 60% of health insurance expenditure is for “Psycological and Psychiatrical” conditions … matters of the HEAD !! If the so called “enlightened” really looked at these factors, maybe better practice can result as well as a greater awareness to those around us too as we aimlessly go on with our isolated lives. We have become completely numb to the plight of a great many of our neighbours because big business just worries about profit, cutting costs and minimum wages. But here we can also add in those who are substance dependant …. And naturally, many of these are on the opposite scale of the BMI ?? Will they qualify for a discount ?? … or do we “punish” them too? I would also add another Forth aspect that is completely ignored. Perhaps most importantly, this idea certainly does not consider the financial health of the population. The “statisticians” say the median monthly income per household in Switzerland is CHF 5’500.00 or thereabouts. And here I very strongly disagree. If we were to remove all those households that earn over CHF 300’000.00 annually, ( which I would estimate to be 15% of the population ), and then calculate this median monthly income, you will probably find this figure to be more representative of the average population and here I would venture a figure of no more than CHF 3’500.00 monthly. And statistically, the bulk of the overweight and obese are found in this category. Given current Swiss living expense, they just cannot afford targeted fitness programmes let alone higher premiums. You cannot LOAD responsibility on the consumer and simultaneously discharge the insurance firms responsibility and at the same time remove any consumer say in this matter. And one can certainly not sit back and say … well one can simply go walk, run, jump around etc free of charge. The mass population are just too busy trying to make ends meet … let alone trying to fit in time to manage families and social and personal interests - and now the “enlightened” want to add obligated sport to “save money” … for whom ?? the Insurance firms !!!!! A reasonable dose of common sense will be welcome here. The irony here is that the ones who advance these preposterous ideas are those whose household income is over CHF 250’000.00 per annum. Hardly a fair playing ground wouldn’t you think ? It seems to be easy to see clearly and live properly when you have the income to match.

Felix, Austria

Speaking as an Austrian who often works in Swiss hospitals I have to say I have never seen so many people waiting to have gastric band surgery. The level of Swiss obese is actually quite shocking and one hospital in particlar in canton Thurgau has a waiting list of 8 months for the 'Magenband' procedure.

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Health system

Switzerland has compulsory health insurance coverage, giving access to a broad range of medical services.

Switzerland spent SFr55.3 billion ($51.1 billion) – 10.8% of GDP – on health in 2007, making it one of the most expensive health systems, behind the US and France.

The increase in health costs for 2007 was at 4.9%, which was above the 3.1% average rate of the previous years.

Almost 43% of the total costs are covered by social security, 40% by individual patients and 17% by the state.

Health cost woes

In 2008 voters rejected a proposal aimed at simplifying the hospital funding system putting private insurance companies in charge of hospital care.

Five previous attempts to cut costs included an overhaul of the insurance system, the financing of hospitals and hospital care, as well as cutting costs of medicines.

In 2009 parliament threw out most of a package of cost-cutting measures put forward by the outgoing interior minister, Pascal Couchepin, which included a controversial fee for patients who consult a doctor and introducing phone consultations by health insurance companies. The last debate on the issue will be in March.

A cross-party parliamentary group also suggested a package, including making it more expensive for patients to go straight to specialists in order to encourage them to go to a GP first. They estimated this would save SFr1.5 billion. It had the support of the Swiss Consumers’ Forum. This proposal also did not get very far.

Premiums for mandatory health insurance are to increase by an average of 8.7% in 2010, the biggest rise in seven years.