Health insurance needs to be more democratic

If the initiative “For a single public health insurer” is adopted in the upcoming nationwide vote on September 28, Switzerland’s health insurance system will become less costly and more transparent, says Franco Cavalli, a doctor, university professor and former Social Democratic parliamentarian.

The Swiss health system is of high quality, and in general consumers are satisfied. However, there is one aspect of it which dissatisfies the vast majority of Swiss: the premiums we pay for health coverage, which are too high and are continually rising.

These creeping increases are largely due to defects inherent in the legislation on health insurance, which forms the basis for funding the health insurance companies. The first problem is that for stationary care [in hospitals and clinics] half the costs are paid by the government, whereas ambulatory care [independent medical practice and ambulatory care in hospitals] has to be covered solely by the health insurance companies.

This gives rise to an often unjustified shifting of services from the stationary sector to the ambulatory, which explains why health insurance premiums keep increasing more than health costs in general.

Franco Cavalli

Franco Cavalli is scientific director of the Oncology Institute of Italian Switzerland, visiting professor at the Faculty of Medicine of the University of Bern and chairman of the scientific committee of the European School of Oncology.

The other factor is that in Switzerland – almost unique among Western European countries – health insurance premiums are the same for all, rich or poor. And because the rich pay a lot less here than in other countries, this automatically leads to increases in premiums, which especially burden families with low and middle incomes.

Too many cooks

These problems are further accentuated by the existence of so many health insurance companies – up until recently there were about 100 of them [currently there are 61] – which makes the whole system anything but transparent, and also needlessly expensive.

Every so often a cantonal government or some other public body has called for an explanation for a particular increase in premiums or the structure of particular costs covered by the health insurance companies, but in the end they have had to give up, because the sheer complexity of the system makes it impossible to get a reasonable answer.

I can recall, for example, the absurd situation we had in parliament about this. It had become apparent that excessively high premiums had been paid in a number of cantons, and there was an attempt to find a solution as to how to reimburse the hundreds of thousands of people affected.

If parliament had had a single health insurance company to deal with, the solution would have been simple and straightforward. Instead, due to the complexity of the system, it took months to figure out what to do. In the end, parliament came up with a “mini-solution” which satisfied nobody.

No real competition

Too many health insurance companies also means too many executives earning high salaries. This explains why the administrative overhead is upwards of CHF3 billion ($3.3 billion) a year. The main excuse offered for the existence of so many health insurance companies is that they ensure competition, which is supposed to keep down costs.

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However, in a system where the cost of any particular service is fixed by the government, the only competition health insurance companies can engage in is increasing their own revenue, refusing to pay for certain services provided to their customers, or weeding out the bad risks (by fair means or foul), and on the other hand making every effort (including very expensive advertising campaigns) to sign up young people with a low risk of ill health.

Comparison with other kinds of social insurance

Most of these problems would disappear with a single public health insurer, which is what the initiative proposes. To understand this, it is enough to look at SUVA [the national workers’ accident insurance body], which is nothing but a single health insurer for accidents. Not only does SUVA manage to have transparent, understandable accounting, but its services are getting better year by year, while the premiums paid by the clients are going down – the opposite of what is happening in the health insurance sector.

What is more, being a single, efficiently functioning organisation, SUVA can hire well-trained examining physicians who can engage in ongoing dialogue with the doctor treating the patient so as to find the best solution together. The opposite is the case with the health insurance companies, where we doctors are used to filling out endless forms without being able to interact with an expert.

Often our requests are not adequately responded to, because, especially with the smaller health insurance companies, the independent examining physicians who decide on the patient’s treatment are often not very knowledgeable.

A single public health insurer would have a structure also very similar to that of the national old-age pension fund [contributions are set at a percentage of salary and paid in equal parts by the employee and the employer], which is highly regarded by all: there would be a logistical organisation at cantonal level with a three-pronged leadership at national level – like SUVA, managed by representatives of doctors, patients and the federal administration.

A more democratic system

This is not a matter of nationalisation but of democratisation of the system, which would thus become less costly and more transparent.

Being rational and logical about it, it is hard to think of an objective reason not to accept what is clearly an improvement in the way we fund our health care system – unless of course you happen to be an executive of one of the many health insurance companies currently in business.

Franco Cavalli

Franco Cavalli is scientific director of the Oncology Institute of Italian Switzerland, visiting professor at the Faculty of Medicine of the University of Bern and chairman of the scientific committee of the European School of Oncology, besides being a medical researcher of international reputation. He has also been politically active for many years.

Born in Ticino in 1942, he was a member of his canton’s parliament for the centre-left Social Democratic Party from 1987 to 1995, and of the Swiss parliament from 1995 to 2007. During his time in Bern he also chaired the Social Democratic group in parliament.

He has now retired from parliament but continues his political involvement, regularly taking part in political debates, such as the campaign on the initiative “For a single public health insurer”, to be voted on by the public on September 28.

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(Translated from Italian by Terence MacNamee)