What medicine helps against the premium explosion?

Rising healthcare costs are a cause of concern for many Swiss.

This was also evident in last week's "dialog" debate with the question " Is Swiss happiness a reality or an illusion? ". The "dialog" user Martin Zürcher wrote, for example, that there are numerous opportunities in Switzerland to optimize one's happiness and individual spending. He also cited as examples, among others, the choice between telemedicine or primary care model and the choice of deductible. User Claus-Jürgen Hartmann sees things differently. For him, happiness in Switzerland is an illusion, as he explains. At the end he writes: "I don't want to dwell on the health care system that prevails here. But I have never encountered so many sick and health-impaired people as here in Switzerland." This makes him sad, but not happy.

So are expensive healthcare costs affecting happiness in Switzerland? On the SRF page of the social media platform Linkedin, user Heidi Kübler, a qualified nurse, commented that she too is very concerned with the cost explosion in the healthcare system. In their opinion, the controllers and the administration are the real problem. They would give more and more specifications. At the same time, the desired quality of care is increasingly declining.

These days, health insurers announced that they expect a "premium hammer" of 8 to 9 percent for the coming year. Today's premiums would no longer cover expenses for medications, hospital treatments and doctor visits. This is a development that has been observable for years. As the Federal Statistical Office writes, in 2001 health care still cost CHF 523 per month per inhabitant. In 2011, the figure was already 673 francs, and in 2021 it was a whopping 827 francs per capita per month.

According to the major opinion poll conducted by the GFS Bern Institute on behalf of SRG, people are also among the most concerned about rising healthcare costs. 84 percent of the more than 50,000 respondents said that this issue was of great or quite great concern to them.  

Health insurance costs have become a major campaign issue. The parties have a wide variety of solutions on the table, ranging from abolishing the mandatory health insurance system to linking it to disposable income. Former Federal Councillor Ruth Dreifuss (SP), under whom the Federal Health Insurance Act came into force in 1996, also intervened in the debate. She told Le Matin Dimanche: "There is no pilot on the plane. Or rather, there are too many pilots, all steering in different directions. The result is that the aircraft does not fly very straight. It doesn't crash, but too many passengers get very shaken up."

This shows that the looming "premium hammer" is causing frowns on all fronts. However, the right medicine is still being worked on.

Healthcare costs: Is the system broken?  Join the discussion now on "dialog"!

What medicine against the rising costs?

Health insurance companies want to increase 8 to 9 percent

Health insurance companies demand an 8% to 9 % premium increase next year. Health Minister Alain Berset, however, wants to prevent such a massive increase at the last minute.

Claire Micallef

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"Yes, this really is a lot", says Verena Nold, director of the health insurance association Santésuisse in the SRF programme "Samstagsrundschau." But an increase of eight to nine percent is necessary to cover the costs, she said. The premiums would no longer cover the expenses for medications, hospital care, doctor's visits, etc. This year in particular, costs have risen massively and above average.

A thousand Swiss francs more for families

An increase of eight to nine percent would mean additional expenses of one thousand Swiss francs per year for a family of four in the Swiss middle class. According to Nold, there is no more leeway in the reserves of the health insurance funds: These would only be enough to cover all expenses for two and a half months. Without this increase, she said, there is no way: "If we don't fix this now, it will just catch up with us next year."

However, President Alain Berset's Federal Office of Public Health has not yet approved the premium increase. About four weeks before the final decision, there's a tug-of-war going on behind the scenes between the authorities and the insurance companies: "The Federal Office has asked us to calculate more tightly", says Santésuisse Director Verena Nold. But there is no more room for manoeuvre. She hopes that Health Minister Berset will not artificially push the health insurance premium down.

Pressure on the insured with free choice of doctor

In the fight against cost growth, health insurance companies are now targeting customers who can freely choose their doctor. In future, the family doctor model or a telemedicine model should become the standard for health insurance companies. These are models in which the insured always have to see their primary care physician first - or consult a hotline. According to Santésuisse's proposal, the free choice of doctor as a model would have to be explicitly purchased in the future. More than two million people are still insured with a free choice of doctor. "They could continue to choose freely in the future - but they simply need to know that it comes at a price", says Verena Nold.

Premiums could rise up to 9%

Health care: seducing the idea of a single health insurance fund

The hypothesis is approved by 79% of respondents in a survey conducted in recent days

A large proportion of the population would favor a single health insurance fund. This is according to a survey of nearly 9,200 people in German-speaking Switzerland and French-speaking Switzerland conducted by the online portal Watson between Aug. 29 and Sept. 1.

In fact, 79 percent of respondents favor the hypothesis; even among those who are close to the center-right alignments. A figure at the antipodes, compared to what emerged from the ballot box on the issue in the past: in fact, the idea of a single fund was rejected by 71.2 percent of voters in 2007 and 61.9 percent in 2014.

The majority of people surveyed then look favorably on both the idea of making premiums proportional to income (63 percent) and the introduction of a cap on premiums equal to 10 percent of a household's income (69 percent): the SP initiative that could be submitted to the people in the spring of 2024 goes in the latter direction.

Finally, the same survey shows that 77 percent of respondents call for maintaining mandatory health insurance.

Aug. 28, 2023: Health insurance, how to fight rising premiums

Single health insurance is popular

Healthcare costs: is the system broken?

"Politicians seem to have given up on the issue of health," laments Thomas Boyer

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Healthcare costs and the announced rise in health insurance premiums this autumn were at the heart of the debates during a session of the Federal Assembly at the end of May 2023. Interviewed on the 19h30 news programme, Groupe Mutuel director Thomas Boyer felt that Parliament was not doing enough to limit this rapid increase.

On May 31, the National Council debated health care spending, focusing in particular on Tarmed, the price scale for medical services in doctors' offices and hospitals.

But while healthcare costs have already risen by over 7% in the first few months of 2023 according to Santésuisse, the association of health insurers, politicians seem to be at a loss.

Even the President of the Confederation, Alain Berset, was baffled ath the end of May when he appeared on RTS 19h30. "Together with the Federal Council, we've done everything we can to conduct our own business. We need strong support from Parliament to push through plans for better cost control, and that's not easy."

In parliament, reforms are either wiped off the table, as in the case of reference prices for generic drugs, or pushed through in a watered-down version. Example on May 30, 2023 in the Council of States with the reduction of health insurance premium costs. The senators initially rejected the text before finally adopting it. Josef Dittli, Radical-Liberal Party/UR member of the Council of States, admitted that the fear of seeing the Social Democratic Party's initiative "Maximum 10% of income for premiums" go through to a popular vote had prevailed. "We have to accept this counter-project and not play Russian roulette. That could lead to a Yes vote on the initiative, and then it would be a catastrophe.

Groupe Mutuel health insurer Thomas Boyer believes that parliament is not doing enough to solve the problem. "Overall, I have the impression that politicians are resigning from health-related issues. Of the nine health-related topics on the agenda for the summer session in May, six relate to financing and transparency, two are aimed at increasing the catalogue of services, and only one is concerned with cost control", he points out in 19:30h.

While he is well aware of the importance of addressing the financing issue, which weighs heavily on household budgets, he also insists that the problem must be tackled at its root. "So we have to take care of the costs. And I don't think Parliament is acting fast enough, given the rate at which costs are rising."

The head of Groupe Mutuel "agrees" with Alain Berset on this "paralysis of parliament caused by lobbies." "The main lobby in parliament today are the cantons", he says.

We need to solve the problem of rising healthcare costs. There is a real urgency

"In any case, they're in a position that smacks of a conflict of interest: they own hospitals, therefore they have a vested interest in ensuring their profitability. At the same time, however, they define the rates that will be reimbursed on the bills. Hospitals are holding back on a number of issues. They have watered down the project on premium financing, and the financing of outpatient services has been dragging on in Parliament for 13 years because the cantons don't want to take over part of the costs.

Finally, the director insists: "We need to deal with the problems of rising healthcare costs. It's a real emergency".

"Parliament is not doing enough"

The political parties are stepping up their proposals to lower health premiums

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In the run-up to the Swiss federal elections, and just a few days before the announcement of premium increases, proposals to reform or even completely dismantle the Swiss healthcare system are piling up. Here's a small selection of the ideas put forward by the various political parties.

To cut costs, last May the Radical-Liberal Party proposed limiting the benefits provided by health insurance. The party refers to a "low cost" insurance. The idea is to replace the current fixed-premium system, which entitles policyholders to "consume everything", with an "à la carte" menu.

A reduction in medical tariffs is also being discussed, with tarmed being replaced by tardoc.

The left, for its part, has put its plan for a public health insurance scheme back on the table. A project that had already been rejected twice by the people. Finally, there's the Centre's popular initiative for a cost brake. The latter requires the Federal Council, the Federal Assembly and the cantons to intervene when healthcare costs rise too steeply in relation to wage trends.

Other proposals aim to distribute healthcare costs differently, with the constant objective of lowering premiums for policyholders. The Swiss Trade Union Federation is calling for an increase in cantonal subsidies. The Fédération romande des consommateurs (FRC) is calling for a freeze on health insurance premiums.

Shock proposal from Swiss People’s Party's Nathalie Rickli

Then there's the Social Democratic Party's initiative, which calls for no policyholder to have to pay more than 10% of their disposable income on health insurance premiums.

The latest proposal comes from the Swiss People’s Party. Zurich State Councillor Nathalie Rickli proposes to abolish compulsory insurance. A shock proposal that calls into question one of the basic principles of the health insurance law. In 1995, Switzerland's largest party had already opposed the Federal Health Insurance Act (KVG/LAMal).

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Parties' plans against premium increases

Costs and measures in the health care system will cause discussion

The National Council's Health Commission demands that health insurers be given access to the medical data of insured persons in order to recommend personalised and less expensive treatments

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How can the rising costs in the health care system be contained? Parliament has put forward new proposals that will cause debate. The starting point for these proposals is Health Minister Alain Berset's second package of measures to contain costs. This package aims to avoid unnecessary services, strengthen collaboration between the various professional groups, limit direct access to specialists and prevent double consultations.

However, the majority of the National Council's Health Commission does not want to go in this direction and instead proposes a number of other measures. The most controversial proposal is the possibility for health insurers to use the data of their insured persons to provide them with personalised information on possible savings or more suitable treatment models. This could be the case if a patient is taking several medications, not all of which are considered appropriate. The right argued that this would be in the interest of patients in order to optimise care. For the left, on the other hand, this step would give too much power to health insurance companies which are not medical organisations.

Among other things, the commission proposes reduced premiums for those who commit to the same insurance for several years and also a strengthening of the role of pharmacies by allowing them to charge more consultation and prevention services to the basic insurance. However, it remains to be defined exactly which services this should include and what this means in terms of costs.

Controversial proposal

‘Just back for a short visit’: politician wants to end healthcare tourism

The Swiss Abroad can end up being expensive to Switzerland. If they fall ill, they often return to the Swiss healthcare system. Things could be done differently, says politician and Swiss Abroad advocate Elisabeth Schneider-Schneiter. Her idea is to get broad support in parliament.

The Swiss population is groaning under the weight of soaring healthcare costs. According to an opinion survey by Tamedia press, this is the major problem the country’s leaders need to tackle. For Elisabeth Schneider-Schneiter, the Swiss Abroad need to be part of the solution.  

Among them are many retirees, who often need costly treatment. Retirees resident abroad often come back to Switzerland to get their health needs looked after. Especially if surgery or a major course of treatment is planned.  

“Swiss Abroad register for a half-year’s residence back in Switzerland and get costly surgery here,” says Schneider-Schneiter, “which is a real challenge for the system.” The Centre Party member of the House of Representatives is also on the board of the Organisation of the Swiss Abroad (OSA).  

There is a problem with this kind of healthcare tourism. Patients get services paid for by the Swiss health insurers, services which – at first sight anyway – they have not contributed to.

People who take up residence abroad have to exit the Swiss healthcare system with its rights and duties. They pay no more health insurance premiums, but they lose the right to healthcare in Switzerland.

As it happens, there is an easy way around this. If they take up residence in Switzerland again, they have to start paying health insurance contributions – and thus become entitled to receive the full range of healthcare.

All you have to do is take up residence again for a minimum period in Switzerland and you’re back – at no cost to  you – in one of the most expensive and high-quality healthcare systems in the world. It’s all quite legal. The fault, if there is one, lies in the system itself.  

"If someone is treated in Thailand, the treatment costs are significantly lower."

How often this happens is hard to determine. There is evidence, however, that it is actually quite common. The Swiss health insurance company KPT, which traditionally handles most of the health insurance requirements of Swiss expats, finds no great difference in the costs they have to assume whether their customers live in expensive countries like Japan or countries where healthcare is cheap, like Tunisia or Brazil.

That suggests that Swiss Abroad, living in a country where healthcare is not really top-quality, tend to come back to Switzerland for medical treatment, as SWI swissinfo.ch found out in a 2019 investigation.  

Talk around the community of Swiss Abroad definitely suggests that healthcare tourism is mainly resorted to by people in Thailand and the Philippines.

The issue seems to arise only when the health insurance system in the country of residence is so different that there is a strong incentive for homeward-bound healthcare tourism.

In EU and EFTA countries this is not the case. Thailand, on the other hand, is a special case, because it has a strong appeal for Swiss pensioners and early retirees, mostly men. Low cost of living, tropical climate and easy availability of visas are all factors in its favour; another draw is widespread prostitution.

As many as 6,000 Swiss seniors and early retirees live in Thailand. Many of these have come up against an unforeseen problem since the pandemic.

Since December 2022 residence in Thailand requires them to have a health insurance policy to cover treatment costs up to $100,000 (CHF87,539). When Covid-19 was at its height, Thailand’s healthcare system was stressed to the limit – and it is now stuck with a lot of unpaid bills.  

The private-sector health insurance cover available in Thailand can be quite expensive for foreign residents over 70. The older the customer, the higher the premiums. An 80-year-old might end up paying up to CHF40,000 ($45,693) a year.  

Retirees who go abroad because their budget can’t cope with the high cost of living in Switzerland tend not to be in a position to absorb these new costs. If there was a previous history of illness, they may not even be able to get health insurance at all.  

In Thailand these cash-strapped retirees now have a choice between continuing to reside illegally under the radar – or having to go back home. For some time now the Swiss community in Thailand has been lobbying on the political level for a solution to be found.  

Schneider-Schneiter has taken up this issue as a member of the House of Representatives. She proposed in a parliamentary initiative that Swiss Abroad should have the option of maintaining their Swiss basic health insurance cover. This is certainly not cheap. But compared to private-sector insurers abroad, it has the advantage that the premiums do not keep rising with the person’s age. 

Schneider-Schneiter thinks the government should allow this option, as she finds it “appalling that a Swiss citizen has been paying into the basic health insurance scheme their whole life and may never have received benefits” before they retired and went abroad. 

Her argument can actually be quantified: Swiss retirees in Thailand relieve the burden on Swiss health insurers to the tune of CHF250 million. This calculation was made by Josef Schnyder, vice-president of the Swiss Society of Bangkok.

Schnyder notes that younger contributors to the insurance plan are really paying for healthcare in advance as a kind of compulsory solidarity with older contributors. They are paying premiums for services that they won’t consume, or will only consume when they are old.  

If someone emigrates before the age of 60 – which is just when high healthcare costs typically begin to be incurred – they have paid up all their contributions, but won’t get anything back. “As it stands, based on statistical data, the insurer makes a profit of almost CHF42,500 per insured person,” concludes Schnyder. If there are 6,000 retirees living over in Thailand, that comes to CHF250 million. 

Schnyder tells of Swiss people who have had to leave family behind in Thailand for health reasons to go back to Switzerland for treatment. He knows of people who can’t get a long-term residence permit any more, because they can’t show proof of insurance. 

As a member of the Swiss Abroad Council, Schneider-Schneiter is in close contact with Swiss in other countries. However, her initiative in parliament is mainly targeted at bringing down Swiss healthcare costs. “If people get their healthcare in Thailand, it will cost a lot less,” she points out. 

Schneider-Schneiter has been able to persuade politicians in all the main parties of her position. Already 35 of them have endorsed her initiative, including some party leaders. “They all realise that this will mean a reduction of the burden on the Swiss healthcare system,” she says.

She is now waiting to see how the government responds to her proposal. Meanwhile, there is a further cost argument: if elderly, impoverished Swiss people in Thailand have to travel back to Switzerland, they are also likely to become a burden on the social welfare system. 

Therefore, their return means extra costs not only for the healthcare system but also for Swiss taxpayers generally.  

Update: ‘Missing a great opportunity’ 

The objective of the postulate signed by 35 members of parliament is the following; for the time being, their demand is just for a report that shows how offering the Swiss Abroad the option of retaining Swiss basic health insurance could be achieved. 

The government has now published its statement on this issue. It stresses two principles. The first is that health insurance is based on residence. “As a rule, premiums are paid in the country where medical services are used,” the government writes. The second principle is Switzerland’s balanced annual health budget. “The premiums of one year must cover the expected costs of the same year,” it says. According to the government, the result of these  principles is that “there is no individual health account”.  In its response, the government refers to private insurance as an option. However, it does not address Schneider-Schneiter’s observation that private insurance is “difficult to impossible” to obtain.

Schneider-Schneiter is disappointed. “The government hasn’t addressed the real problems,” she says. “It is missing a great opportunity for a simple measure that would be a significant improvement and would have little negative impact on the health system in terms of costs.” In its response, the government refers to an interpellation with similar content submitted in 2014. Since then, nothing has changed, it says. “The report requested by the postulate is not necessary at the current time.”

No more healthcare tourism

From a single fund to no fund at all - health care systems vary from country to country.

The hospital stay after an accident, the usual visit to the family doctor or the medication for pain - people in Switzerland rarely pay the costs for these themselves and directly. Many things are covered by the health insurance.

In the 1990s, the new health insurance law promised a solidarity-based system and low costs. However, there was also criticism. The change of system is always up for discussion.

Denmark: In the Scandinavian Kingdom, everyone is basically covered by the Danish public health insurance system. The system is highly centralised. There is only one, state-run health insurance fund. The benefits are financed through income tax. Denmark relies in particular on so-called super-hospitals and the digitalisation of the health system. In addition to the basic state health care, private health insurance can be concluded, as in most countries. Just under half of the population is also privately insured.

Italy: In our southern neighbour, a national health service was created in 1978. The system is mainly financed through regional taxes. Local public actors are responsible for the organisation. In most cases, only predetermined doctor's offices are available. General practitioners and pediatricians as well as emergency cases are free of charge. For specialists, there is a deductible. Long waiting times and regional differences in the quality of services are repeatedly criticised.

Germany: The German system is comparable to Switzerland in certain respects. There is a statutory health insurance system operated by around 100 health insurance funds. These are organised as corporations under public law and compete with each other. Most insured are free to choose their health insurance fund. Apart from federal subsidies based on taxes and other revenues, the system is financed by contributions, half of which are paid by employees and half by employers. Contributions depend on income (with an upper limit) and vary from fund to fund. Unlike in Switzerland, the region, age or an alternative insurance model usually has no influence on the contributions.

France: In our western neighbour, the health care system is also based on mandatory health insurance. However, there are different health insurance funds for employees, farmers, the self-employed or, for example, civil servants. The system is financed by taxes, social contributions and premiums. The latter depend on income (with no upper limit) and are set by the state. The contributions are currently mainly paid by the employers. In France, the general practitioner is generally the first point of contact.

US/UK: The health care system in the US is the most expensive in the world. Millions of Americans cannot afford health insurance. This is in vast contrast to the British National Health Service (NHS). Although it too has its quirks, it is more popular with the population than fish and chips or the King. In the podcast #SRFglobal (short version), former SRF US correspondent Matthias Kündig and UK correspondent Patrick Wülser discuss the major differences between the health care systems.

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How healthcare systems work abroad

Find out where you stand

Physician tariff: The President of the health insurance association Curafutura is counting on Alain Berset.

Konrad Graber has only been president of Curafutura for a hundred days, but he was involved in the founding of Curafutura from the very beginning. The then Lucerne member of the Council of States sat on the board of directors of CSS, which together with Helsana, Sanitas and KPT had split off from the umbrella organisation Santésuisse. A necessary and correct step, as Graber says in retrospect.

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This is because Curafutura has been able to provide important impulses for health policy in recent years. "I think it is easier when you only have four members. You can bring up ideas like uniform financing. You don't just give opinions, you can also give one or two inputs. Tardoc was an important issue there."

However, it is clear that whether it is about the details of the Tardoc physician tariff, the unified financing of outpatient and inpatient services or the increased use of generics - in the end, politics must set the course and make the decisions.

Curafutura President Konrad Graber hopes that Health Minister Alain Berset will make a final effort in these dossiers in his four remaining months in the Federal Council. "If that doesn't succeed, we are practically at point zero as far as reforms are concerned. A new Federal Councillor would have to familiarise himself with the issue. It takes two or three years for something to be ready to put into practice."

They say competition stimulates business, but here it has rather blocked business.

Politics decides, but the health insurance funds come up with innovative ideas, this is the motto of Curafutura. Michael Jordi, General Secretary of the Swiss Conference of Health Directors, is sceptical whether the umbrella organisation always lives up to this claim. "At first there was a certain enthusiasm. Not any more. So far I have not experienced any advantages of the competition. They say competition stimulates business, but here it has rather blocked business."

For example, the tariffs for doctor's offices and hospital outpatient clinics often have to be negotiated twice, Jordi says. He regrets that the health insurers are split into the two associations Santésuisse and Curafutura. In this split, Jordi sees mainly disadvantages. "It has made life more difficult and complicated for everyone in the world of health: for us cantons, for the Confederation, for politics under the federal dome and for the service providers. But also for the health insurers themselves."

Because of the split, there would be more bureaucracy in collective bargaining and more legal disputes. Konrad Graber, who has turned 65 but has only recently taken over the presidency of Curafutura, naturally sees things differently. He believes in the innovative power of his association and doesn't want a fusion with Santésuisse for the time being.

It seems central to me that we work together, that we share the same opinion on essential issues.

But he says: "It seems central to me that we work together, that we share the same opinion on essential issues. We can still improve on that in the future. One advantage is that the two presidents know each other well from their previous political activities, and I have high hopes for this.

Curafutura President Konrad Graber and Santésuisse President Martin Landolt are both experienced parliamentarians and both members of The Centre. In November, the two want to meet to discuss the major issues of the future in the health sector.

The ball is passed to politicians

Dreifuss on the Health Insurance Act: "We're still improvising!"

The former Federal Councillor, who introduced the law in 1994, criticises how it has been handled as well as the broken promises made by the cantons.

Former Federal Councillor Ruth Dreifuss laments the development of the Health Insurance Act, which she introduced as Minister of the Interior in 1994. "For 30 years we have improvised and we are still improvising," says Dreifuss. "When we won the election, I told my staff that we had to start revising the law because it had deficiencies that had to be corrected step by step", she told Le Matin Dimanche. "But the ground was never really levelled for that."

She describes the federal law metaphorically as an aeroplane: "There is no pilot in the aeroplane. Or rather, there are too many, and they are all pulling in different directions. True, the plane won't crash. But the passengers will be shaken."

Dreifuss points to a promise that has not been kept: Subsidies should keep pace with health care costs, with costs shared between the Confederation and the cantons. "The Confederation has kept its promise, but many cantons have not", she explains. An article published in Tamedia shows that ten cantons actually cut their subsidies between 2012 and 2022.

The Social Democrat Dreifuss rejected Swiss People’s Party politician Natalie Rickli's proposal to abolish compulsory insurance. Among other things, she said, it was an attack on the principle of solidarity. "You have to remember that before the Health Insurance Act, there was no solidarity between the sick and the healthy or between the young and the old", emphasises 83-year-old Ruth Dreifuss. In conclusion, however, she adds: "I am not completely hopeless: Some of the existing proposals make sense." As an example, she mentioned public health insurance, which the Social Democratic Party would like to introduce. However, this should be unique: "Otherwise it will have to adapt to the competition."

Dreifuss criticises handling of LAMal

Rising health insurance premiums are a political challenge. In 2023, they are expected to rise by up to 9 percent - last year it was 6.6 percent.

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