Is the Swiss Healthcare System a Model for the United States?
Physicians for a National Health ProgramBoston, Novermber 2013
Claudia Chaufan, MD, PhD, University of California San Francisco
The Massachusetts health reform more or less follows the Swiss model; costs are running higher than expected, but the reform has greatly reduced the number of uninsured. And the most common form of health insurance in America, employment-based coverage, actually has some “Swiss” aspects: to avoid making benefits taxable, employershave to follow rules that effectively rule out discrimination based on medical history and subsidize care for lower-wage workers. So where does Obamacare fit into all this? Basically, it’s a plan to Swissify America, using regulation and subsidies to ensure universal coverage
‘Similarities’Switzerland
Major reform=ACA, 2010
Retains commercial insurance policies Individual mandate“Affordable” plans with “essential” coverageNo discrimination on pre-existing conditions
United States
Major reform=LAMal, 1996Retained commercial health insurance policies Individual mandate“Affordable” plans with “essential” coverageNo discrimination on pre-existing conditions
The Illusion of SimilaritySwitzerland
Major reform=ACA, 2010
Retains commercial insurance policies Individual mandate“Affordable” plans with “essential” coverageNo discrimination on pre-existing conditions
United States
Major reform=LAMal, 1996Retained commercial health insurance policies Individual mandate“Affordable” plans with “essential” coverageNo discrimination on pre-existing conditions
MANDATORY PURCHASE OF HEALTH INSURANCE
Guaranteed QualityComprehensive Coverage
Cost ContainmentSolidarity/Equality
SWISS RESIDENTS
(99.9% OF POPULATION)99.9% of population
Out of pocketpayments (1CHF=$1.08)
-Premiums vary per Canton-Deductible CHF 300/year (Mx. 2,500) -Max. co-insurance: CHR 700 /year-Hospital daily rate CHF15-No age discrimination. 26 and above= same price (Age categories: 0-18; 19-25)
MANDATORY BASIC INSURANCE PLAN
Regulated @ the national level
Covers all TX’S and DX’S prescribed by a licensed provider for both IN & OUT PT care, certain medications and medical goods, a # of hours of home & LT care, and (some) complementary TX
Supplemental Insurance
-dental, vision, private rooms (88% pop.)
$ PR
OFIT
$
Source: OECD
Review of H
ealth Systems, Sw
itzerland, 2011
Insurance Companies(80 to choose from)
NO PROFIT!!
Risk Equalization
insurance co.’s pay into the same pool
Subsidies-1/3 of pop.-50% discount of premiums for children/young adults-maternity care exempt-income-based for lower incomes
So…what’s the problem???
Managed care plans (i.e. restricted provider networks) becoming more common (‘popular’) & insurance companies providing ‘incentives’ (e.g. lower premiums vs. higher deductibles) to sign on
Higher deductibles lead to increasing out of pocket expenses (foregone care for low-income groups); Restricted networks lead to access problems
High costs – only lower than U.S. & Norway (11.4% of GDP), including higher administrative costs due to multiple payers
Major premium price variations between cantons & regressive pricing (same for all income levels)
IN COMMON: RELIANCE ON PRIVATE FINANCING!!
Is the ACA really “Swissified” Health Care?!....
mandatory requirement to obtain health insuranceAffordable Care Act
Source: Kaiser Family Foundation, 2013
30 Million Leftover
Undocumented Immigrant
Opting out
Exchanges/Marketplace
Individual MandateEmployer MandateAffordable Coverage
Increased QualityReduced Costs
10 broad categories
Does not apply to all plans
? ESSENTIAL HEALTH
BENEFITSIncreasingly ‘consumer-driven’ (i.e. more out of pocket) Very poor
>65 yrsVeteran
American Indian
PUBLIC PLANS
GOVERNMENT
Employer Coverage, (FTE & business >50 people)
Subsidies < 400% FPL
Self Employed/Small Firm Employees
Low income
Middle income
High income
PUBLIC
OPTION
The reality United States
Builds on commercial insurers, tied to employment, income or ageInsurers CAN MAKE PROFIT from medically necessary coverage (skimpy & no national standard)RESTRICTED PROVIDER NETWORKS (‘PREFERRED PROVIDERS’) IS THE NORMVERY FEW COMPARATIVE SHOPPRICE CONTROLS ANATHEMA! Service A can sell at whatever price!Financially fragmented – ‘profitable’ patients in private plans, ‘unprofitable’ in public plans (increasingly privatized)Price discrimination by age. EXCLUDES UNDOCUMENTED IMMIGRANTS, VERY POOR (‘HARDSHIP EXCEMPTIONS!)
Switzerland
Builds on long history of social insurance – coverage no longer tied to employment, income or ageInsurers CANNOT MAKE PROFIT from medically necessary coverage (very generous & national standard)All insurers must offer plans THAT INCLUDE ALL PROVIDERS EVERYBODY CAN COMPARATIVE SHOP (even if most do not!)PRICE CONTROLS! (same service, same price)Large pool overseen by government -- risk equalization, healthy/sick same poolNo price discrimination by age, immigration status, etc.
Conclusions
• The ACA is NOT a ‘version’ of LaMAL – doesn’t “turn US into Switzerland” (Paul Krugman)
• LaMAL has problems – may even not be working for the Swiss
• The fallacious debate and spin obscure real problems and undermine search for real solution
• If the goal is universal, equitable health care, we need a real National Health Plan
What to do?
• Educate ourselves, family, friends
• Join the single payer Medicare for All movement
• Connect the dots (with other public policy issues – war-making)
• Demonstrate!
Thank you!
My appreciation to my colleagues atPhysicians for a National Health Program, for their years of struggle to achieve health care equity for the American people