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Swiss advise US over healthcare reforms


The Swiss system is far from perfect but the United States use it as a model for healthcare reform, says Thomas Zeltner, director of the Federal Health Office.

Since the election of President Barack Obama, there has been a multiplication of contacts between Swiss health officials and their American counterparts.

The US president is fighting to push through healthcare reforms and extend coverage to the 46 million Americans who have none. On Wednesday he delivered a speech in Congress hitting back at opponents, whom he accuses of “scare tactics”.

Zeltner will retire at the end of the year after 19 years as head of the Swiss Federal Health Office. He will take up a one-year “Advanced Leadership Initiative” post at Harvard University from January 2010 to advise on global health issues. Can you describe the growing US interest in the Swiss health system?

Thomas Zeltner: There is media and political interest. In August a delegation from the US Congress met experts from the Health Office. I have been in touch with the Obama administration and I know the US deputy secretary of state for health; we have had an exchange of views. The American media have also shown an interest in talking to us.

It started five to six years ago with a couple of articles by Harvard professor Regina Herzlinger, who said the Swiss health system was the most interesting one for the US to look into.

Over the past two years there has been quite a bit of interaction between Harvard University and Swiss health experts. Several faculty members are very interested in the regulated market model, where the Swiss and Dutch systems are the best examples. What can America learn from Switzerland about healthcare reform?

T.Z.: In Switzerland we have succeeded in getting universal health coverage. We now have almost 99 per cent of the population with a health insurance plan – even illegal immigrants are covered once they seek medical help.

The US is dealing with several very similar problems to those Switzerland faced before the major health insurance law [LAMAL] reform in 1996. At that time we didn’t have a compulsory health insurance system, insurance companies could cherry pick, our benefit package was not complete and in some areas health insurance was linked to employment.

The US started looking at different systems and stopped at the Swiss system as it solves some of their problems by engaging privately-run health insurance companies. Isn’t it presumptuous of Switzerland to want to export a model that is criticised back home, especially for rising health costs and expensive health insurance premiums?

T.Z.: We don’t hide the fact that our system has difficulties too, and we have explained the results of the [critical] 2006 external audit by OECD/WHO. Our system is far from perfect.

Costs are a problem but if you look from an international perspective, Switzerland is not doing as badly as we tend to believe. Total healthcare costs have increased by 2.1 per cent a year over the past ten years, which is below the OECD average. In terms of cost control we are doing as well as other OECD countries, but at a higher level.

Eleven per cent of GDP [in annual health spending] is a lot but when you look at what you get and the levels of public satisfaction, we are not doing that badly. Why does the US system not work?

T.Z.: The prices of everything are high – medicines, doctors’ salaries and hospital stays.

There must also be substantial inefficiencies in the system partly due to the lack of healthcare coverage. Those without insurance don’t go to the doctors or go late, thus generating even greater costs.

Prevention is also a priority. One of the biggest challenges in the US is obesity; the number of cases of diabetes and cardiovascular illnesses are a very heavy burden on the system. Do you think the idea of solidarity, which is the basis for the LAMAL, makes sense in the US?

T.Z.: The issue of solidarity, and what the community should do when you fall ill, is perceived differently.

Whenever we talk about solidarity our US counterparts always look at us with astonishment. They don’t have the same deeply rooted sense of what it means. Nobody talks about it, that is apart from the very poor and elderly, who are looked after by the Medicare and Medicaid programmes.

In Switzerland access to healthcare is guaranteed by the law, which puts a lot of responsibility on cantonal and federal governments. In the US it’s much more up to the individual to remain healthy, and employers have an obligation when it comes to health insurance plans. The role of the state is therefore much smaller. Do you think Obama will manage to push through his reform?

T.Z.: US visitors, even Republicans, say this issue is too big to fail. Something will come out but what and how big is still a question mark. Dropping the proposed federal government-run insurance scheme might be one solution to help convince Republicans to join. Obama needs a bipartisan proposal.

It’s the number-one issue over there right now, as it’s had such media attention. You can’t open a newspaper or turn on the TV without hearing or reading about healthcare reform. It’s very high on the agenda which makes it such a challenge for the Obama administration. They need to get a result.

Simon Bradley,

US President Barack Obama has instructed Congress to come up with proposals to overhaul the system, where premiums have grown three times as fast as wages since 2000.

Medical costs are the top reason for personal bankruptcy. Benefits have decreased for many as costs have climbed.

At the current rate, costs will consume more than 20 per cent of the US gross domestic product by 2018.

According to the European Observatory on Health Care Systems, formalised health insurance began in Switzerland as early as 1899, but the system, based on Germany’s, was rejected at the polls.

A new proposal passed by referendum in 1911. To qualify for federal money, “health funds” had to provide a set list of benefits and allow consumers to change plans. Cantons could decide whether to make insurance compulsory.

Partial reforms came in 1958, followed in 1964 with measures that bolstered federal subsidies. Rates continued to increase and in 1987 legislators introduced reforms to control costs. The measure failed.

On March 18, 1994, the Swiss voted in favour of more reforms that contained costs. Another round of reforms will go into effect in 2012 that are designed to make hospitals more dynamic by restructuring subsidies and requiring providers to publish quality indicators.

Switzerland ranks third in health spending in industrialised countries, spending 10.8 per cent of gross domestic product. This is below the US (16 per cent) and France (11 per cent).

Switzerland also ranks higher than the OECD average on spending per person, which totalled $4,417 (SFr4,760) in 2007, below the US ($7,290) and Norway ($4,763). The OECD average is $2,964.

Switzerland also has a high density of people working in the health sector, with 3.9 doctors and 14.9 nurses per 1,000 residents.

The Swiss have a life expectancy of 81.7 years. US life expectancy is 78.1 years.

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SWI - a branch of Swiss Broadcasting Corporation SRG SSR