In Switzerland, A Health Care Model For America?
Cecile Crettol-Rappaz (left) with her daughter, Anais, - Cecile Crettol-Rappaz, seen here with her daughter, Anais, says she had high-quality, but expensive, health care while living in the United States. Her family's insurance in Geneva isn't cheap, but she likes that some of what she pays into the system helps others in need. (Rebecca Davis/NPR)
At first glance, Switzerland's health care system looks like it could be the perfect political compromise for the United States.
As Republicans would prefer, individuals — not employers or the government — choose from a broad array of health plans, sold by private insurance companies.
And as Democrats urge, everyone in Switzerland has health coverage (it's required by law), with the government providing generous subsidies for those who couldn't otherwise afford it.
(Rebecca Davis/NPR)
So does it all run, to use a Swiss cliche, like clockwork? Yes and no.
Switzerland's 7.5 million citizens are, by and large, quite happy with the system.
"I wouldn't trade it for the world," says Nicole Bieri, an adult vocational education instructor from Lucerne. "I think it's a very good system."
But, as in the United States, just about everyone is quick to complain about one thing: rising costs.
"The costs have increased in the last 10 years by 50 to 60 percent," says Roland Brunner, a banker from Baden.
Rising Costs
Indeed, while individuals feel that pain, so do Switzerland's politicians.
"They see it in their budget," says Peter Zweifel, a professor of health economics at the University of Zurich. "It's very visible because it's that budget chunk that needs to be reserved for the subsidization of premiums."
And the fact that that chunk of the budget grows each year has been particularly frustrating for members of the Swiss parliament, Zweifel says, because "those poor [who get the subsidies] are not those that go to the polls and give you the votes."
Still, Zweifel says that in the 1990s, when the current law was being drafted, it was the Swiss populace, by referendum, who insisted that the subsidies be included if there were going to be a requirement that everyone purchase health insurance.
"Surveys showed the population was skeptical," says Zweifel, who helped government officials write the law. "They began to figure, 'Hey, now the poor are forced in a system that quite likely will become more expensive as time goes on. They don't have a way to opt out anymore.' So pressure began to increase that the poor shall have [a] subsidy; personalized subsidy of the health insurance premium."
One Price
But even with the subsidy, there's still a regressive aspect of the Swiss system: health insurance premiums are not linked to income. So everyone pays the same.
"I pay what I pay, but my neighbor pays 400 francs also, even though she has a salary which is half mine, and that's unfair," says Cecile Crettol-Rappaz, who works in corporate communications for Migros, the country's largest supermarket chain.
Rappaz is in a particularly good position to compare the U.S. and Swiss systems. Not only did she live in the United States for several years — her husband is a videographer for Swiss TV — but they have a daughter with juvenile schizophrenia, so they have been heavy users of health care in both countries.
In the United States, she says, care was of high quality, but expensive. "What we found in Washington, D.C., was that it was easy to get good care, but everything costs a lot."
Once back in Geneva, she said it took some scrambling to get Anais, then age 11, settled into treatment, but once she did, things were much better.
"What we have found here is the best of what the public system can give to us." For example, when Anais needed to be hospitalized for five months, they were able to get her into a special facility for young psychotic children.
"That was paid by our insurance. And everything that has to do with her health is paid by that insurance."
Anais, who is now 17, also qualifies for Switzerland's disability insurance program, which is even more generous, says Rappaz.
"For example, our daughter gets three-times-a-week psychotherapy, and it's her fourth year," she says.
Twice a week, her daughter has therapy with horses, using repetitive body motions. And unlike the Swiss health insurance, which requires the family to pay 10 percent of the cost, the disability plan pays 100 percent.
Considerable Price Tag
Still, the coverage takes quite a bite out of the family budget. Rappaz keeps the bills in a three-ring binder. She pays 400 Swiss francs per month for her basic coverage; her employer contributes 60 francs toward that.
Under Swiss law, insurers may not make a profit on the basic plan, which is quite comprehensive. Individuals, however, can adjust their premium up or down by choosing a larger or smaller annual deductible, or by joining an HMO-type plan that requires them to choose a doctor in a network.
Since her husband, Bernard, rarely goes to the doctor, they have chosen a network plan for him; his monthly premium is only 298 francs. Children also cost less, so Anais and her brother Lucien's premiums for basic coverage are 89 francs each.
Where Swiss health insurers can and do make profits, however, is on supplemental coverage. This is for things like dentistry, alternative medicine (which is popular in Switzerland), and semiprivate or private hospital rooms. For 30 francs per month, Cecile and her husband have a supplementary policy that covers, "for example, all kinds of prevention, not-on-the-list medication, help at home, glasses, transport, alternative medicine. That's a good one," she says.
For another 105 francs each, they have another supplemental policy that guarantees them a semiprivate hospital room — and the possibility of a private, rather than a public hospital.
"We decided, Bernard and me, that if we have a huge accident or cancer, we want to have the best care or hotel room, so we can get into it because we pay these 105 francs a month. That's amazing how expensive it is," she says with a laugh.
The children also have supplemental coverage, although theirs costs far less — 14 francs per month for Lucien, and only 8 for Anais. That is because Anais was not able to get much extra coverage — insurers do not have to sell beyond the basic package to people with pre-existing health conditions.
So, all together, the Rappaz family — which is upper-middle-class, but far from wealthy — pays just over 1,100 francs per month for their health insurance. That's over $1,000 U.S. dollars.
Worth The Cost
Yet Rappaz looks puzzled when asked about people in the United States who say that it would be intrusive to mandate health insurance.
"I'm not sure that I get you," she says, cocking her head.
When the question is put another way, she laughs. "Oh, I see. That's really an American question. You are so used to having this individualistic way of thinking, and that's why you don't have these social [safety] nets. You still have this pioneer mentality where everyone has to take care of themselves."
That's not how people in Switzerland think about it, she says. That pioneer mentality, "is good for people who have no problems, but there are a bunch of people who ... need a social net.
"I'm really happy to give part of my salary to a solidarity system," she says.
Produced by Rebecca Davis
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MICHELE NORRIS, host:
Over the past several weeks, we've been reporting on health care in European countries. In the U.S., health care is one of the top issues for voters this year. As lawmakers prepare for another round of health reform, the system in Switzerland has drawn a lot of attention in health policy circles. Like in the U.S., Swiss people spend a lot on health care, but there are some fundamental differences.
Everyone in Switzerland is required to buy insurance, and the minimum package is more comprehensive than many U.S. insurance policies. NPR's Julie Rovner met a Swiss family that's experienced the health care systems on both sides of the Atlantic.
JULIE ROVNER: Cecile Crettol-Rappaz is Swiss, but she was actually living in the U.S. when her daughter Anais began having emotional problems. Anais was seven at the time.
Ms. CECILE CRETTOL-RAPPAZ: In Washington, D.C., we find extremely well-trained people who worked with Anais, but everything costs a lot.
ROVNER: There was a lot of testing, some psychotherapy and medication. Crettol-Rappaz was luckier than many Americans. Her Swiss insurance covered at least some of her daughter's psychiatric bills, even while her family was here in the States. Many Americans have far less coverage for mental health than for other types of conditions. After four years in Washington, the Rappaz family returned home to Geneva.
Ms. CRETTOL-RAPPAZ: And then she had this huge breakdown because she changed into middle school. And then she was hospitalized.
ROVNER: Anais was ultimately diagnosed with a rare form of childhood-onset schizophrenia. That's when Cecile says she was most thankful for her Swiss health and disability coverage.
Ms. CRETTOL-RAPPAZ: For example, her hospitalization, she was five months hospitalized in the special care for young psychotic children. And that was paid by insurance. Our daughter got three-times-a-week psychotherapy. She has therapy with horses two times a week.
ROVNER: That horse therapy is popular in Europe. It's to help children with emotional problems learn to use their bodies. Today, Anais is 17. She goes to a special school. Soon, she'll start another program offered by the hospital in Geneva that will provide a wide array of services, including art therapy. She's quiet but otherwise friendly, as she shyly poses for a photo with her mother in their comfortable Geneva apartment.
Later, sitting on the terrace that overlooks a lush courtyard, Cecile explains that their generous health care coverage doesn't come cheap.
Ms. CRETTOL-RAPPAZ: We have, like, a luxury system of health, but it costs a lot.
ROVNER: Almost $1,000 a month just in mandatory premiums in the case of the Crettol-Rappaz family. That's pretty typical for this part of Switzerland. Cecile brings out the family's health insurance bills. She keeps them in a three-ring binder. Here's how it breaks down.
Ms. CRETTOL-RAPPAZ: For me, it's 400.
ROVNER: That's 400 Swiss francs per month, about $390. Her employer, the Swiss grocery chain Migros, pays 60 francs towards that, although in Switzerland companies don't have to contribute to their workers' insurance.
Cecil turns to her husband Bernard's bill. He pays less because he chose a plan that limits his choice of doctors. Next page. Now she's on to the extras. In order to get some of the few things that aren't included in the basic Swiss package, the family also buys supplemental insurance.
Ms. CRETTOL-RAPPAZ: Okay. For me, 30 francs. That means that I get, for example, all kind of prevention, help at home, glasses, alternative medicine, all these things.
ROVNER: Cecile and her husband also have added policies to provide them with semi-private rooms if they need hospital care. Those are another 105 francs a month each.
Ms. CRETTOL-RAPPAZ: That's amazing how expensive it is.
(Soundbite of laughter)
Ms. CRETTOL-RAPPAZ: I just realized that.
ROVNER: Well, not that amazing. Selling supplemental insurance is the only way Swiss health insurers are allowed to make a profit. By law, they can't profit on the basic insurance package - that's the part everyone is required to buy. Insurers can't discriminate against sick people in the sale of the basic plan either. But they can refuse to sell supplemental coverage to people who are already sick, people like Anais.
Still, Cecile says about the only thing that really bothers her about the Swiss health system is not how much she pays, but the fact that health insurance premiums don't vary according to people's incomes.
Ms. CRETTOL-RAPPAZ: I pay what I pay, but my neighbor, you know, she pays also 400 francs, even though she has a salary which is half mine, for example. And that's unfair.
ROVNER: There are efforts underway to change that, but what about the insurance mandate? Does she object to the fact that she's required by law to buy insurance? Cecile laughs.
Ms. CRETTOL-RAPPAZ: Oh, that's really American, your question. No, because you are so used to have this individualistic way of thinking, this pioneer mentality, where everybody has to taking care of themselves. It's good for people who have no problems, but there is a bunch of people who have fragilities, who have problems. And these people need a social net.
ROVNER: In the end, says Peter Zweifel, a Swiss health economist, that may be the biggest difference between the Swiss and American health care systems - that Swiss willingness, even eagerness, to provide for one another and why passing a law to cover everyone, as the Swiss did in 1994, remains such an uphill battle in the U.S.
Professor PETER ZWEIFEL (University of Zurich): If you'll permit my remark, I don't see American voters forcing their politicians to write anything like this into law. It's in your genes. Your ancestors emigrated from European countries because they did not believe in redistribution, but they heavily believe in everyone is responsible for his own luck, or unluck - whatever. That's not a criticism. It's just a fact that the mindset of the U.S. population is a slightly different one from the Swiss.
ROVNER: Which may help explain why a universal coverage system - even one based on private insurance like Switzerland's - still seems a long, long ways off. Congress just may, however, pass a law in the coming weeks to require health insurers to cover mental illness to the same extent they cover physical ailments. It's been 12 years in the making. Julie Rovner, NPR News. Transcript provided by NPR, Copyright National Public Radio.
