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Swiss health care reform took ten years of contentious debate and a referendum
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Dr.Thomas Zeltner, Swiss Frederal Health Minister
discusses reforms made to the Swiss health delivery
system during a November 6 briefing in the Rayburn
Office Building on Capitol Hill in Washington.
(Photo Credit) Alan Portner)
Swiss Federal Health Minister, Dr. Thomas Zeltner, visited Capitol Hill last Friday, just one day prior to the House vote on health care reform, on a mission to share thoughts about the successes enjoyed by Switzerland during their experiment with health reform. A small crowd listened attentively as Dr. Zeltner explained the relatively recent changes in his country while being very careful not to suggest that the Swiss system was necessarily the answer for America.
America’s need to reform not unique:
A need to reform health care delivery systems is not unique to America. Instead, it is an ongoing process that has been debated in various countries for long periods of time. America is the only advanced economy where the discussion has yet to yield a conclusion.
According to Dr. Zeltner, the Danes argued about reform for more than 25 years. America’s debate goes back at least 65 years to when Harry Truman first proposed national health insurance in 1945 or even further when the first President Roosevelt discussed the need for reform.
History:
The present Swiss health system went into effect in 1996 ending ten years of debate when the Swiss legislature passed enabling legislation in 1994 followed by a national referendum. At about the same time, the Chinese on Taiwan were formulating their national health system and President Clinton unsuccessfully struggled with his efforts at health reform.
The Swiss and Taiwanese systems landed at absolutely opposite poles in a continuum of health systems. Both work well. President Clinton’s plan failed and America’s health system costs continue to spiral out of control.
Switzerland and America share ethnic mix:
Switzerland, like the U.S.A., is a country of great ethnic diversity. Four separate languages are spoken by eight million native Swiss in a physical space not much bigger than Maryland. The country is governed by a federal constitution modeled on the Constitution of the United States and broken up into 26 states called cantons.
The impetus for reform was very similar to America’s situation today. Women and all people with pre-existing conditions of any kind were being priced out of the system. The solutions that the Swiss eventually adopted had its origins in the German Bismarck system, but with some individual Swiss variations.
The Swiss system:
All persons who live or work in Switzerland are required by law to have basic health insurance. Business does not contribute to premiums. Insurance companies are required to offer the insurance to everyone regardless of age or pre-existing conditions at the same rates. They are not allowed profits on their basic policies. Prices are set in each of the 26 states or cantons as are rates that providers can charge for specific procedures. Each person in a family must have his or her own coverage. Children are allowed a discount.
Citizenship is not a requirement to participate in the system. All insurance companies use a mandated set of forms and payment system.
Switzerland is a rich country. They spend more for their health care than anywhere else except the United States. About 10.7 percent of GDP is spent for health care compared to the 17 percent currently spent in the United States or about 40 percent less.
No Medicare or Medicaid:
There is no Medicare and no Medicaid in Switzerland. Everyone subscribes to the same system. Should someone not be able to afford coverage, they receive subsidies in the form of direct payments from the government. The Swiss are expected to use that money to help buy health insurance.
Dr. Zeltner said the Swiss “would find Medicaid in particular to be an assault on human dignity.” In their system the medical provider has no way of knowing who has paid for the insurance and everyone is treated similarly.
Swiss Doctor salaries are comparable:
One might suppose this kind of canton control of costs would be borne on the backs of the medical professionals. Not so in Switzerland. Swiss doctors earn comparable salaries to those in America. Malpractice awards are almost unknown because contingent fee arrangements for lawyers are also almost unknown.
Differences:
One difference between Switzerland and the United States health systems is that hospitals in Switzerland tend to have wards for basic patients of four to eight beds. New hospitals in the U.S. many times feature all private rooms. Should patients want special services like private rooms, dental coverages, or vision coverages, these services are available at reasonable cost through a “for profit” gap insurance policy.
Health outcomes:
How is the health service in Switzerland? The Swiss have 3.6 physicians per thousand people compared to only 2.3 in America. The Swiss have 10.7 nurses per thousand of population compared to only 7.9 per thousand in the U.S. In Switzerland, there are 11 more hospital beds available per thousand of population; 65 percent more MRI machines, and nearly 40 percent more CT Scanners.
The Swiss live about 4 years longer than Americans on average. Rates of death from heart disease are more than 40 percent lower among the Swiss. Even cancer mortality rates are slightly lower in Switzerland. There are minimal wait times.
Costs to government:
The American Congress is obsessed with the cost of a new system to the budget and the deficit. The Swiss system has had the effect of making the government contribution to health care expenditures decline significantly since 1980. Tax financing has slid from 31.7 percent of the total in 1980 to less than 24.9 percent in 1997 when the system went into effect.
Why the big differences:
Why is Swiss health care so much less expensive than in America? It is the national will. Everyone is covered and at a community agreed same premium rate. Administration costs are kept to a minimum.
I was fortunate enough to ask Dr. Zeltner about Swiss administrative costs and whether there was a parallel structure in the doctor’s offices like in the U.S. The good doctor looked at me like I had three heads. Our system was briefly explained to him. He could not conceive of a system that required this kind of staffing.
Simplicity may explain success:
The real key to the success of the Swiss in reforming their health delivery apparatus appears to be its simplicity. There are 93 authorized insurance companies in Switzerland. Some are large, but some are very small. Dr. Zeltner admitted that eight of the Swiss insurers wrote about 80 percent of the business.
But Dr. Zeltner then shared the story of how one particular company thrives in a little village of 150 souls. Because the company in question knows its customers so well, in years when it is likely to need an expensive procedure, it applies for a slightly larger government subsidy. This company is very small. It satisfies all government mandates and requirements. It has a single employee.
I must have looked at Dr. Zeltner like he had three heads. Can any of us Americans conceive of a system where the insurance company could have only one employee?
The Swiss system is entirely private. Insurers, Doctors, hospitals, nursing homes, and even alternative medicine, while regulated, are all private.
System continues to be tweaked:
Dr. Zeltner talked about continued fine tuning of the Swiss health system. For example, nursing home coverages and disability coverages needed to added. Like us, they have what they feel is a continuing shortage of primary care doctors and other health professionals.
Still, America might have something to learn from our Swiss friends if we have the humility to ask.
Al Portner is a former daily newspaper editor and publisher in seven states and author of the forthcoming “Mark Twain and the Tale of Grant’s Memoir.” He can be reached at alanportner@gmail.com.
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