The history of professional medical bodies begins with cantonal medical societies. The Swiss Medical Association (FMH) only developed into a strong political stakeholder over the course of the 20th century.
Professional medical policy was largely run at a cantonal level in the 19th century. The Helvetic Republic did attempt to standardize health policy nationwide in 1798, particularly by means of a national license for professional practice. However, after the end of the Helvetic Republic, the new constitution of 1803 stipulated that health and medicine were matters for the cantons – setting the future course. In just a few years, medical societies were set up in the cantons of Aargau (1805), Bern (1809), Zurich (1810) as well as Fribourg and Lucerne (1811). They not only acted at a cantonal level, but also nationally within the concordat of cantonal medical societies.
Medical education was gradually standardized across the country in the second half of the 19th century. The concordat diploma was introduced in 1867, followed in 1877 by the state examination that continues to exist to this day. Professional medical bodies defined the requirements for these qualifications. It was not until 1901 that the Swiss Medical Association (Foederatio Medicorum Helveticorum or FMH) was established. At the time, being a medical doctor was already a highly professional and academic occupation. The curriculum design for the study of medicine and access to medical qualifications thus lay in the hands of professional medical bodies. The medical profession also benefited from very good political networks. When doctors became politically active, they mostly did so in line with the liberal creed that dominated national policymaking during the 19th century. This elective affinity between the doctor’s profession and the Free Democratic Party’s persisted until well into the 20th century.
The Swiss medical profession enjoyed a privileged position compared to other countries. For example, Germany did not introduce the necessary approval of medical licenses. As the most powerful individual state in Germany, Prussia abolished professional medical privileges in 1869 and introduced the freedom to practice medicine. Anyone who felt called to offer medical services could indeed do so. In Switzerland, too, individual cantons – particularly Appenzell Ausserrhoden – adopted similar regulations. In most cantons however, medical societies were able to prevent such a liberalization of access. Nonetheless, the economic position of doctors varied somewhat. Whereas medical practices with a bourgeois or wealthy rural clientele typically had sound finances, practices in poorer rural or industrialized regions often had to make do with meager fees. Most of the medical profession feared a ‘plethora’ of medical services – an excess supply of doctors’ surgeries with ruinous competition between physicians.
Tariff Conflicts in the First Half of the 20th Century
Because a steadily growing proportion of medical services were paid for by health funds since the end of the 19th century, the development of doctors’ incomes depended increasingly on the tariff contracts between medical societies and health fund associations. The medical income situation came to a head during the First World War and in its aftermath. Inflation during the war had eroded real earnings. Medical societies therefore insisted on an adjustment to medical tariffs in the interwar period. However, their contractual partners – the health fund associations – opposed these demands and argued that the tariffs were already set too high. The Great Depression that arrived in 1931 exacerbated the pressure on doctors’ tariffs. In 1932, the FMH gave in to this pressure and proposed a temporary ‘crisis discount’ to cantonal medical societies amounting to up to ten percent of the doctors’ tariffs. This proposal was approved by most cantonal professional medical bodies and was implemented accordingly. Tariff tensions intensified again after the Second World War due to an increase in tariffs as a result of the improved economic situation and greater financial leeway.
In the decades following the Second World War, medical doctors benefited from the accelerated expansion of healthcare. Hospital infrastructure was improved substantially between 1950 and 1980. The number of independently practicing doctors also more than doubled between 1945 and 1975, while the general population grew by less than 50 percent in the same period.
Controversies Surrounding Compulsory Health Insurance
The influence of medical societies in healthcare policy remained substantial after 1945. This is evident from the protracted debates concerning the reform of the Health and Accident Insurance Act (KUVG) of 1912 that regulated the propagation of compulsory health insurance. A full revision of the KUVG had been demanded by health fund associations and left-wing parties since the 1940s in order to expand the application of state health insurance, eventually leading to a national obligation for health insurance. The medical societies were skeptical of this policy as compulsory health insurance funds paid them at a lower rate than private providers. In 1949, a planned national tuberculosis bill failed at the ballot box, with 75 per cent of voters opposing the proposal. It would have included statutory insurance for low-income groups. Opposition came in no small part from the FMH. It was not until 1964 that, in the context of rising healthcare costs, a partial revision of the KUVG was passed. Yet it addressed only minor issues. These included the expansion of statutory minimum benefits, the reorganization of cost sharing (co-payments and deductibles) and improving health fund finances by means of increased federal subsidies. At the beginning of the 1970s, the Swiss Social Democratic Party pressed ahead with another attempt to introduce a national health insurance obligation by means of a popular initiative. The medical societies were among those who opposed compulsory insurance. They successfully defeated the proposal with the support of the health funds. Both initiative and a parliamentary counter-project were strongly rejected by voters in 1974.
In the 1980s and 1990s, debates surrounding a reform to the KUVG were increasingly focused on the rising costs rather than compulsory coverage. This was not least because health insurance had since reached almost all of the population – even without a nationwide obligation. In 1945, the proportion of people with health insurance amounted to 48 per cent of the overall population; this number increased to 89 per cent by 1970 and to over 95 per cent from 1980 onwards. Following a failed attempt in 1987, a new health insurance bill (KVG) was adopted in 1994 and introduced in 1996. It pursued two main objectives: to introduce both cost-saving measures as well as a nationwide obligation. The legislature pledged cost reductions by expanding co-payments for treatment costs (deductibles) and by introducing ‘managed care’ insurance models limiting the choice of doctors (HMO or family doctor insurance schemes for example). The KVG likewise stipulated a tariff structure for individual medical services, standardized nationwide. This gave rise to Tarmed – the first tariff structure introduced in 2003/2004. However, managed care models and Tarmed were highly controversial within the medical profession. The medical profession was also split regarding calls for the introduction of a national universal health fund (Einheitskasse) as a means of tackling the health funds’ hunt for customers with low risks and in order to restrict cost increases in health insurance. This has been a demand of the Swiss Social Democratic Party and others since 2003, taking the form of two consecutive popular initiatives. Although the FMH largely rejected the universal health fund popular initiative in 2007, several cantonal medical societies spoke in favor of the project.
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; Braun, Rudolf (1985), Zur Professionalisierung des Ärztestandes in der Schweiz, in: Conze, Werner, Kocka, Jürgen (Hg.), Bildungsbürgertum im 19. Jahrhundert, Stuttgart 1985, S. 332-357; Vuagniaux Rachel (2002), «Le ‹médecin libre› contre le ‹bolchevisme médical›: le Bulletin professionnel des médecins suisses et les premières tentatives de révision de la LAMA (1920–1951)», Aspects de la sécurité sociale: 3, 2–9.