• So how’s that health care in Switzerland turning out?

    Many of my more conservative counterparts like to point to Switzerland as an example of a system they would favor more. It’s a private-insurance system that is all run at the level of the individual. You don’t get insurance through the government or your job; you buy it on your own. There’s a mandate, but there are also subsidies for the poor, aiming to keep everyone’s contributions to health care below 10% of their income. there are also fairly high co-pays and deductibles.

    It’s a fairly expensive system, although still cheaper than ours. It performs decently in terms of quality. There are plenty of things that today’s conservative will find unappealing, but it’s probably closer to ideal for them than what we have today.

    But there’s a study that I just saw coming out in Preventive Medicine, entitled “High prevalence of forgoing healthcare for economic reasons in Switzerland: A population-based study in a region with universal health insurance coverage“:

    Objective: To investigate the determinants and the 4-year evolution of the forgoing of healthcare for economic reasons in Switzerland.

    Method: Population-based survey (2007–2010) of a representative sample aged 35–74 years in the Canton of Geneva, Switzerland. Healthcare forgone, socioeconomic and insurance status, marital status, and presence of dependent children were assessed using standardized methods.

    Results: A total of 2601 subjects were included in the analyses. Of the subjects, 13.8% (358/2601) reported having forgone healthcare for economic reasons, with the percentage varying from 3.7% in the group with a monthly income ≥ 13,000CHF (1CHF ≈ 1$) to 30.9% in the group with a monthly income < 3000CHF. In subjects with a monthly income < 3000CHF, the percentage who had forgone healthcare increased from 22.5% in 2007/8 to 34.7% in 2010 (P trend = 0.2). Forgoing healthcare for economic reasons was associated with lower income, female gender, smoking status, lower job position, having dependent children, being divorced and single, paying a higher deductible, and receiving a premium subsidy.

    As I said above, co-pays and deductibles are high. They have a lot of “skin in the game“. They are exposed to the cost of health care. And the results shouldn’t suprise readers of this blog. About 14% went without health care because of cost in 2010. Women were more likely to forego care, as were people who were divorced or who had dependent children. Those who had insurance with higher deductibles were more likely to forego care. And here’s the money shot:

    That’s the percent of Swiss that have foregone care for economic reasons by year and income. What you’re seeing is that almost no people in the upper class forego care. But as you get poorer and poorer, more and more people do. In the lowest group, more than a third of them went without care because of the cost.

    When you expose people to more of the cost, they go without. That’s by design. But you’re totally depending on them to go without unnecessary care, not necessary care. What we’re seeing is that poor people are much more likely to forego care than rich people. I’d want to make sure – really sure – that we weren’t negatively affecting their health before I got comfortable with that. Research shows that’s unlikely.

    • I live in Switzerland, and would like to make a few comments.

      First of all, most everyone who has a job makes more than CHF3,000 per month. That’s a bit below the starting salary for someone working in a restaurant. I know that seems high by US standards, but this is a high-cost high-wage society.

      Second, I don’t find out-of-pocket costs so high by US standards. The basic, mandated insurance coverage has a required deductible of CHF500 per year, though adults can choose higher deductible levels to get a decreased premium. There may be an additional deductible if you are hospitalized, again you can trade off the deductible against a lower premium. A lot of procedures and medications have no co-pay, and most others have a 10% co-pay.

      None of this detracts from your point that “skin in the game” doesn’t necessarily lead to good decision-making by patients. I think that’s clearly true.

      The other sad part of medicine in Switzerland is not economic — the large and growing number of vaccine deniers. Each year seems to bring a bigger outbreak of measles. I worry that even worse diseases (polio, e.g.) will regain a foothold.

      • In actual comparative currency, you are correct that your out-of-pocket costs may not be much compared to ours. But as a percentage of health care spending, your OOP costs are about the largest in the world.

        • I saw your graph on this, and have no evidence or references to refute it. It doesn’t feel right, i.e. correspond to my personal experience. I wonder if there is some confounding factor we are missing.

    • I have one more thing I would like to add about health insurance in Switzerland. It came from the quarterly newsletter that I received from my insurer today. Forgive an amateur translation:

      “Among the most important positive aspects [of the Swiss health insurance system] is the … solidarity between males and females, young people and old people, as well as healthy and sick persons…”

      I might add, solidarity between rich and poor. There really is a “we’re in this together” attitude here.

    • A few comments:
      a) I would say that the vast majority of Foregone Healthcare is done so for economic reasons. If there were no real costs, then who wouldn’t do it, excepting the issue of Access.

      b) the definition of ‘necessary’ and ‘unnecessary’ care is nebulous, and varies by person – risk, age, and gender are big determinants.

      c) your post relies heavily on the ‘money shot’ to condemn the realities of forgoing health care in Sweden because of costs, yet you don’t specify how many Swedes fall into each of those buckets. For example, a dual-axis graph showing cumulative % of population on the right would clarify just how many people are affected by this (currently, one might even assume that the buckets represented equal portions of the population! they’re the same width, after all). This rings with the first commenter’s point that virtually all Swedes with jobs make > 3000 Swiss francs/mo.