Swiss healthcare: between the state and the free market

Is a health system with a single payer or with competing insurance companies more efficient? GAETAN BALLY

Two-speed healthcare systems are now a reality in Europe. Although there is a general trend towards systems combining state control and free market, rich countries such as Switzerland have the edge and the gap with poor countries continues to grow.

“No to a health system like in Italy!”, “We don’t want the French social security system”: opponents of a proposal to introduce a single public health insurance company compare in their campaigns the quality of the Swiss healthcare system and the defects of those of other countries. But is this valid?

“The comparison with Italy is out of place – it doesn’t make any sense,” Giuliano Bonoli, professor of political science at the University of Lausanne, told ahead of a nationwide vote on the issue on September 28.

“In western Europe there are basically two large families of systems for financing healthcare: one is based on social insurance, funded essentially by payroll taxes or other contributions, and care providers who are self-employed professionals; the other is based on state service, predominantly funded by taxes, and doctors who are on public wages.”

Italy belongs to the latter group, whereas in Switzerland even if the current 60 or so private insurance schemes were replaced by a public scheme “there wouldn’t be a nationalisation of the healthcare system” according to Bonoli.

“There would only be a bit more of the state, regarding the regulated competition, than there is now.”

He says generalised international comparisons are “extremely difficult since they are complex systems in which the details can be very important”.

In western Europe alone, within the two “large families” practically every country has a system with its own peculiarities.

Consumer index

Therefore comparisons between countries should be carried out “in a targeted manner on precise aspects”, Bonoli believes.

“For example, it’s interesting to compare the containment of costs or efficiency.”

Revealing in this regard are comparisons made by the World Health Organization (WHO) and the Organisation for Economic Co-operation and Development (OECD): the two international bodies do not draft a general classification of health systems, but formulate distinct classifications for the various indicators.

Every year Health Consumer Powerhouse, a Swedish group of experts whose aim is to promote evaluation and transparency in the health sector in order to reinforce patients’ influence and responsibilities, calculates the Euro Health Consumer Index. This compares 35 countries, combining the results of public statistics, patients’ surveys and independent research, looking at 48 indicators in six fields of the health sector.


‘Political choice’

In principle, “one notes that the systems with more state involvement are better for the containment of costs but tend to create waiting lists, while those with less state involvement have shorter waiting lists but have greater trouble in containing costs”, Bonoli said.

However, it’s not a question of absolute rules. “There are countries with a nationalised health system which don’t have waiting lists – it depends on the funds which are made available. It’s a political choice,” he explained.

For their part, the authors of the Euro Health Consumer Index 2013 assert that “the public healthcare systems which score the best results are basically those in countries which are small and rich, such as Denmark, Iceland and Norway. The clear majority of countries with good results when it comes to healthcare adopt insurance-based systems, such as the Netherlands, Switzerland, Belgium, Germany and France”.

They concluded that, based on the Euro Health Consumer Index, “insurance-based healthcare systems seem to generate better results than publicly financed systems”.

In any case, if the initiative and a single public health insurance company were to be accepted in the September vote, the system of financing in Switzerland would remain insurance based.

“Instead of paying premiums to a private system, we would pay them to a cantonal system,” Bonoli said.

The premiums would remain individual and not taken as a percentage of one’s salary or income, but would vary among the country’s 26 cantons.


Furthermore, “there wouldn’t be a revolution”, if the initiative were approved, Bonoli believes. The change in Switzerland would be part of the movement of reforms implemented by the majority of European countries over the past two decades which has been characterised by a convergence between the two main models.

“The trend is to head towards an intermediate model which blends elements of the market and elements of state control. Countries with highly state-controlled systems have inserted market mechanisms to try to use their limited resources more efficiently; countries with liberal systems have introduced more state control and interventionism,” Bonoli said.

Switzerland already took a big step in this direction, he added, when the law on health insurance entered into force in 1996.

But according to the authors of the Euro Health Consumer Index, what determines the quality of medical treatment even more than the type of financing is the country’s economic strength.

“In the 2013 list, rich countries are concentrated in the upper part – the phenomenon is also more noticeable than in previous years,” they pointed out.

The gap is getting bigger and healthcare systems in Europe are now running at two speeds depending on national wealth. It is therefore not surprising that Switzerland is ranked second, just behind the Netherlands.

Health insurance

The Law on Sickness Insurance, which came into force in 1996, obliges every Swiss resident to take out basic health care insurance covering a range of services.

Anyone who wants more than the basic cover can take out supplemental insurance. This includes, for example, complementary or alternative medical treatments, or greater comfort such as individual rooms during hospital stays.

The insurance is private and the insured person can choose his/her insurer freely. The health insurer is obliged to accept anyone regardless of age and state of health. Companies have the right to reject new applicants for supplemental insurance.

The premiums vary from canton to canton and differ from one insurance scheme to another.

One of the guiding principles is solidarity: a sick elderly person pays the same premium as someone who is young and healthy.

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Swiss health system

The Swiss health system is recognised around the world for its quality, topping virtually all indicators when it comes to health.

However, this quality comes at a price: in 2012, health costs represented 11.4% of Swiss gross domestic product, nearly 2% above the OECD average: $6,080 versus an average of $3,484.

Health policy is defined at the federal level but Switzerland’s 26 cantons enjoy a high degree of autonomy in health matters.

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