Six lessons from Swiss healthcare vote

The clear rejection of two healthcare initiatives hasn’t put an end to the discussion but reignited it. Keystone / Marcel Bieri

The Swiss are moaning about the heavy costs of a healthcare system that is luxurious by international standards. But they rejected two initiatives that offered solutions. Why? And what happens next? Our analysis.

1. Left-wing momentum backfired

Left-wing political parties seemed to have momentum on their side ahead of the June 9 vote. The Social Democratic Party started campaigning for the “Premium Relief Initiative” after voters backed an initiative to boost pensions in a nationwide vote in March. The pension vote was seen as a sign that people are fed up with rising prices and want more social redistribution.

But the political victory in expanding pensions turned out to backfire for the bill on health insurance premiums. Financing higher pensions has been a political fiasco. The reality that someone has to pay for social initiatives reached the public consciousness just as the healthcare premium initiative came to a vote. And this in an environment of tight public finances.

This was fodder for opponents of the initiative on healthcare premiums. Their argument that the premium relief initiative could cost up to twice as much as boosting pensions, which was an extreme scenario, may have tipped voters to reject the initiative.

When it came to covering the costs of limiting premiums, it was clear from the outset who would foot the bill: the taxpayers. In contrast to the expansion of pensions, where completely unrealistic ideas for financing were put forward (financial transaction tax, etc.), no one could be fooled into believing that they would remain unaffected by the additional costs of paying for healthcare premiums.

2. The Swiss Abroad stood by low-income households

It’s noteworthy that the Swiss Abroad filled a gap in the voting population. They came out in support of low-income households, who would have benefited most from healthcare premium relief. Many low-income households belong to the 27% of people who live in Switzerland and pay taxes but don’t have a say on voting day because they aren’t Swiss.

This demographic faces the most hardship. However, their concerns – childcare costs, parental leave – are consistently rejected at the ballot box in Switzerland.

Swiss nationals living abroad are not affected by health insurance premiums because they are not allowed to take out insurance in Switzerland. However, as Swiss citizens, they were allowed to have their say here too – as with every proposal. Irrespective of any tax consequences, they were more positive about the premium reduction initiative than Swiss citizens.

3. Why change what works?

The Swiss people have once again confirmed their attachment to a healthcare system that is an exception in Europe: It is financed largely by households and the premiums are similarly high for everyone. This may seem less socially minded, at least from the outside.

But the Swiss don’t seem to mind. In the last 30 years they have rejected five left-wing initiatives calling for a single health insurance fund or income-related premiums.

The Swiss healthcare system weighs heavier on the shoulders of the middle class. But it has one unbeatable advantage: it works. Whether rich or poor, urban or rural dwellers, Swiss or non-Swiss, they all receive high-quality healthcare services, and relatively quickly – in a country with one of the densest concentrations of hospitals in the world.

In the referendum campaign, for example, the English model was discussed, which is financed entirely by taxes but doesn’t work as well. Nobody wants this, because a two-tiered healthcare system and poor provision of medical services are scenarios that are reliable deterrents in Switzerland.

In the country of personal responsibility, the liberal healthcare model still seems to be destined for a long life.

However, there was an outcry in French-speaking Switzerland and Italian-speaking Ticino: in these minority regions, the insured pay the highest health insurance premiums. This signal should not be underestimated. If politicians don’t find answers to spiralling health costs, the issue will become a threat to national solidarity.

4. Who would benefit was never really clear

The Social Democrats’ initiative sounded simple, but it was complicated. And Swiss voters avoid nothing as reliably as complex initiatives. It sounded simple because 10% of income is a figure that every voter can probably name for their personal case without thinking. 

But then it gets complicated. Whether single or a family, a single parent or a pensioner: all these factors play a part in determining whether someone would have benefited or not, depending on the canton.

There were other aspects that weren’t clear: which insurance model would receive a premium cap? If you want to redistribute money and demand solidarity, you have to explain why. Parliament should have worked out the details of the insurance model, as well as what should be considered “disposable income”.

Another mistake was that the initiators did not rule out an insurance model with direct access to medical specialists. This expensive option was a poor fit for a social policy issue. The impression remains that Switzerland can afford the luxury of direct access to specialists in basic insurance.

5. The Centre Party’s cost brake was detached from people’s reality

A complexity problem was also inherent in the “Cost Brake Initiative” launched by the Centre Party. First, it would only have gone into effect under certain conditions. Second, it called for measures that weren’t specified from precisely those institutions and associations that have not yet been able to come up with any solutions to the cost explosion in the healthcare system.

And third, it operated entirely in the realm of politics, far away from citizens’ wallets and far away from patients’ experiences. It was more reminiscent of an initiative in parliament instead of one meant for the people.

Accordingly, the campaign never really took off. Not even the party’s own members appeared willing to come out in support of Centre Party president Gerhard Pfister’s idea. It was telling that when we planned a discussion on the initiative as part of our Let’s Talk discussion, we received over a dozen refusals from Centre Party politicians.

6. The problems aren’t resolved and are only getting worse

Switzerland spends more on healthcare than most countries. Some 11-12% of GDP goes to healthcare. If the economy continues to grow, the government will have the means to pay for healthcare.

Citizens’ wallets, on the other hand, are less elastic. They pay around 60% of healthcare costs. The pressure on low-income households remains high, even with the indirect counterproposal, which will require cantons that are reluctant to grant premium reductions to do so.

No one doubts that Switzerland needs to get its healthcare costs under control. And there is no shortage of ideas. Redistribution from rich to poor remains an option, especially for the political left. On the right and in the centre of the political spectrum, hospital density has become a target. One idea being proposed is for the federal government to look after hospital planning rather than leaving it to the cantons.

The clear rejection on Sunday hasn’t put an end to the discussion but reignited it. The fundamental problem remains: none of the proposed reforms have managed to secure a political majority. Many players are lobbying in the CHF90 billion ($100 billion) Swiss healthcare market. Together, they have the people and parliament in their hands.

Edited by Mark Livingston. Adapted from German by DeepL/jdp.