In the course of life, everyone falls ill multiple times. Though this may happen with greater or lesser frequency and severity for any particular person, everyone is at risk. Many diseases are also considered social problems, as was long true for infectious diseases like cholera, tuberculosis or – more recently – AIDS. This is true as well for chronic conditions such as cancer or cardiovascular disease. Here it is not just an individual whose life is at risk but rather entire groups that are affected, which is why it becomes a political issue to take precautions against these illnesses. Health and individual well-being have become social goods, and it is in the public interest to safeguard them.
When a person falls ill, the priority today is to provide medical care to that person. This is a view that has fundamentally changed over the centuries. Improvements in hygiene and nutrition as well as medical progress have made it possible for once fatal diseases to now be cured. In Switzerland, life expectancy between 1880 and 2010 doubled from 40 to 80 and 84 years for men and women, respectively. The health professions have likewise changed. Prior to 1800, health care was provided only to a limited extent by qualified doctors. Barbers, surgeons, midwives and other healers without academic training also attended to the health of the population. It was only in the course of the 19th century that doctors, in the modern professional sense, emerged. The certification, through examination, of doctors has been regulated nationwide in Switzerland since 1877, helping to cement the monopoly position they hold. Infirmaries initially took in quite specific segments of the population, and only developed into modern hospitals and clinics over the course of the 19th century. Special facilities also arose, including women's clinics, sanatoria, and nursing homes for those with mental illnesses, or sanatoria for tuberculosis patients. At the same time, nursing – traditionally considered a women’s profession, with the care often provided by nuns – underwent both professionalization and specialization; nurses were increasingly came under the supervision of trained doctors. During the second half of the 20th century, the development of new medicines, surgical techniques, and examination procedures resulted in an unprecedented expansion of medicine, including greater specialization and much increased use of technology. Today, health care is considered one of the most important sectors of the economy. In western industrialized countries at least 10 percent of GDP goes into health care.
New Forms of Provision: Relief schemes and Health Insurance
Until the end of the 19th century, it was largely up to families to care for their sick members, and it was the families which had to find the means to pay for doctors and medications. If the illness was severe, the community of residence might provide some support. For a long time, it was therefore only the wealthy who could afford professional medical care. Starting in the mid-19th century, industrialization led to an expansion in wage work, hence in a greater ability to pay for medical care, and thus to a new constellation in health policy. Wage-dependent workers of both sexes were relatively unprotected from health risks, not least because if they fell ill for longer periods, employers generally stopped paying their wages. Many of those with prolonged illnesses became impoverished and had to seek welfare benefits from their municipality. As the industrial sector grew, a range of private organizations, occupational associations, as well as trade unions and individual entrepreneurs established sickness funds intended to alleviate social hardship. These funds were based on the principle of mutual solidarity: members paid premiums and, in return, received a modest daily allowance if they fell ill. This provided a degree of protection from loss of income, initially the priority. Over time, such funds started to reimburse the costs of treatment, and the number of funds began to expand rapidly before the First World War. By 1914, ten percent of the population were already covered by a health insurance fund – although significantly more men than women. From the doctors' point of view, this increased the share of health insurance fund patients who paid medical fees according to the tariff agreements concluded with the health insurance funds.
The German Reich introduced a new form of risk provision in 1883 that applied the model used by the private sickness funds to the whole population. After this point in time, health insurance became compulsory for a large part of the population. A constitutional basis was created for introducing compulsory health insurance in Switzerland in 1890. The relevant legislative bill, however, was clearly rejected in a popular referendum in 1900. The Swiss voters thus rejected the German model of compulsory insurance, with government-established health insurance funds and wage-based financing with employer co-payment. Following this setback, the revised Health and Accident Insurance Act (KUVG) of 1912 did not include a general obligation for individuals to carry health insurance.
Subsequently, the Confederation then indirectly promoted the idea of insurance. Recognized health insurance funds were able to apply for subsidies from the Confederation. Additionally, the KUVG allowed cantons to introduce compulsory health insurance schemes within their jurisdictions, and about half the cantons subsequently did so. Individual cities also decided to introduce compulsory health insurance. Most such regulations were limited to at-risk groups such as children or those with low incomes. As a rule, such insurance only covered the cost of treatment rather than the loss of earnings. In theory, the cantons could have established public health insurance funds. However, the implementation of compulsory health insurance schemes was delegated nearly everywhere to the many existing funds. This led to a fragmentation in coverage, one which exists still today.
The numbers covered by health insurance slowly but steadily increased after the First World War, so that by 1940, half the population was insured against illness, and nearly all by 1980. Despite this progress, gaps in insurance coverage with respect to hospital care or daily sickness allowances still existed at the end of the 20th century. Only half of the working population in 1990 was insured against a loss of earnings in the event of illness.
The Long Road to Compulsory Health Insurance
Efforts to introduce a general obligation to carry health insurance failed time and time again in Switzerland throughout the 20th century. During the Second World War, and under the influence exerted by the Beveridge Plan, greater demands were made in Switzerland to introduce comprehensive social insurance that would also address the risk of illness. However, the corresponding political proposals did not stand a chance, as both federalist and fiscal reservations about expanding the power of centralist institutions were simply too strong. Once the war ended and countries like France or Great Britain introduced comprehensive social security system, Swiss authorities restricted their socio-political activities to expanding the AHV. After a moderate proposal for tuberculosis insurance foundered in 1949, plans to expand health insurance had to be put on hold. At another crossroads in 1974, the electorate voted against both an obligatory national scheme for health insurance as well as better protection against costly health risks (such as longer hospital stays or loss of earnings). Compulsory health insurance was only finally achieved in 1994. The new Health Insurance Act (KVG) now provided complete coverage for hospital care. However, daily sickness allowance was still not included in the compulsory insurance – a significant difference between Switzerland and most European countries. Continued pay in the event of illness, for a limited duration, remained a matter of labor law and collective wage agreements. Uninsured workers could also cover the risk of loss of earnings by taking out voluntary supplementary insurance, provided they paid the premiums themselves.
Due to the late introduction of compulsory universal health insurance and the large proportion of direct payments made by the insured, the Swiss health care system developed in manner similar to the United States, where private health insurance predominates and compulsory coverage was introduced even later than in Switzerland. In contrast to the United States, the KUVG regulated the services and financing of private insurers as early as 1912. In contrast to the United States, governmental financial contributions in Switzerland provided benefits to all those who were insured by a health insurance fund and not just those in need. Due to the traditionally significant role private and civil society institutions such as sickness funds and welfare associations have played, Switzerland is also comparable to Germany and France. In Switzerland and Germany, is has mainly been the health insurance funds, and ultimately the insured persons, who were responsible for the financing. The health care systems in France or Great Britain rely more on fiscal contributions of the state. Switzerland differs most strongly from centralized systems like the National Health Service in the UK. Overall, Switzerland distinguishes itself in international comparison by the very heavy role private institutions play, as well as the federal nature of the health care system. The cantonal health directors are responsible for overseeing the provision of health services, though their competence is limited by the KVG. While the federal government enacts the framework laws, the cantons are responsible for implementing regulations and for enforcement. One consequence of these features is that premium rates differ from canton to canton.
Over the longer term, the introduction of health insurance resulted in an increasing demand for medical services. Early compulsory insurance schemes at the cantonal and communal level were the primary reason that lower-income groups, who previously could only afford a doctor in emergencies, gained greater access to health care. One side effect was that health care costs rose, a cause of complaint already in the interwar period. The health insurance funds responded by restricting the benefits they offered and increasing the share the insured had to provide. Costs soared further after the Second World War due to rapid developments in medical technology, the expansion of the pharmaceutical industry, and to the expansion in hospital care. From 1966 to 1989 alone, health insurance fund expenditures increased by a factor of 8.6, while workers’ wages only grew by a factor of 3.6, and consumer prices by a factor of 2.4.
Until the mid-1960s, however, the rise in health care costs was considered a byproduct of economic growth. It was felt that increasing prosperity should be reflected by providing modern health care. Serious attempts to contain costs were not taken until the economic crisis of the mid-1970s, as when the Confederation froze its subsidies to health funds in 1977. This resulted in further increases in the premiums individuals paid, a trend intensified by the Health Insurance Act of 1994. This Act enshrined the notion of cost containment and marketing-based thinking of health care in law. It sought to promote alternative, cost-reducing insurance models, to substantially increase the contributions of the insured (such as cost-sharing minima and deductibles) as well as to improve cost transparency and the efficiency in economic terms of medical care. These measures, however, soon proved insufficient. Furthermore, it became increasingly difficult to reconcile the political interests of the various stakeholders (including cantons, health insurance funds, the pharmaceutical industry, doctors, hospitals and patient organizations). A number of proposals aimed at achieving cost savings were therefore unsuccessful. The Federal Parliament rejected a set of measures for containing costs in 2010. In 2012, the managed-care bill was defeated in a referendum. Following a different agenda, left-wing initiatives tried to establish a unified health insurance fund, but this idea was rejected at the ballot box in 2014. In 2013, the Federal Council presented its "Health2020" package of measures, aiming to improve care for the elderly, strengthen prevention, and introduce more transparent and more readily controllable structures into the healthcare system. Stabilizing health care costs without risking significant cuts in benefits continues to be a key challenge for social health insurance.
Literatur / Bibliographie / Bibliografia / References: Lengwiler Martin, Rothenbühler Verena (2004), Macht und Ohnmacht der Ärzteschaft. Geschichte des Zürcher Ärzteverbands im 20. Jahrhundert, Zürich; Alber Jens, Bernardi-Schenkluhn, Brigitte (1992), Westeuropäische Gesundheitssysteme im Vergleich. Bundesrepublik Deutschland, Schweiz, Frankreich, Italien, Grossbritannien, Frankfurt am Main 1992.