A Swiss Miss…Or Maybe Not?

By  |  August 7, 2010 | 

Public Policy Contributor Brad Flansbaum writes…

Oft cited as a template on which to base U.S. health reform (along with the Dutch system), I have always found the Swiss model of great interest.  I read with allure an interview with Switzerland’s former health minister, Thomas Zeltner, in the latest edition of Health Affairs (firewall).  As a primer for those unfamiliar with the Swiss system, I commend this nice review written by Uwe Reinhardt from JAMA in 2004.  They transformed their system in 1996 using a highly regulated model of managed competition—with an all in approach encompassing exclusively private payers.

Frequently, reformers tout the Swiss model as an “all juice, no squeeze” affair, blemish free and a win-win for all.  The candor and honesty expressed by Dr. Zeltner is rousing and a necessary read for those interested in our reform law, its evolution, and the stumbles we might face.

Of note, his proudest achievement is the slow conversion of the country’s populace to the social solidarity model (the interviewer tees up one of her questions with a telling sentiment: “The Swiss are known for jealously guarding their individual freedom, too, yet they accept their own mandate to have adequate health insurance”).  The individual mandate is currently a contentious debate in our country, but I was heartened to see that change is possible in a nation similar to ours, at least as individualism goes.

Surprisingly, he cites lack of transparency, poor QI infrastructure, little in the way of preventive care, and real dissatisfaction amongst primary care docs as disappointments under his tenure.  This was news to me, and again, given all the positive press, it was refreshing to see how far they have to go and what still needs accomplishing.

Regardless, the give and take is terrific and you can glean a lot from this piece.  I will leave you with what I thought was the money passage:

“Reforming the health care system is like fixing an airplane that is in the air. It’s repairing an engine at full speed, and you’re not allowed to let the airplane crash.

That’s the reason why I believe you have to advance very carefully, step by step. You can’t make a revolution in the health care system, because a revolution would, at least for a couple of months or years, block a system expected to function 24 hours a day and 365 days a year. It’s like a Swiss watch. It has to function day by day with a high degree of precision. But when it needs repair, you can’t just drop it at the watchmaker’s shop and wait until it is fixed in three, four weeks. That’s, I think, the big challenge.

Two parallel processes need to be handled: working on a national consensus about the long-term perspective, and implementing measures along the way. Our experience is that people in the trenches can’t absorb too many reform steps at once. So when it comes to implementation of universal coverage, if you succeed in getting 92, 93 percent of your population into the system, that may already be OK. Then do the rest later. Maybe the problem of your illegal immigrants is just something you can’t solve in the first step. But you have the vision of universal coverage at the end—you keep that as your objective, but the end can be 2020.

I’m convinced that a country like the U.S., with the incredible assets you have, needs a health system with equal and fair access for all citizens. And finally, in your case, it’s true, too: You need to invest in a healthy population to remain prosperous.”

Very wise words indeed!

Extra credit: What is a canton?


  1. steve August 8, 2010 at 9:33 am - Reply

    I am surprised that right of center health writers would want this kind of system. I would have thought the cost controls unacceptable. They are also currently suing to do away with the individual mandate.


  2. Jairy Hunter, MD, MBA, SFHM August 23, 2010 at 2:52 pm - Reply

    Good post. This exact topic (indeed Switzerland was specifically discussed) in a documentary from a couple of years back called “Sick Around the World.” It hit the high (and low) points of the six richest nations’ healthcare systems, including the US, which, by the way, is the only one without some sort of universal coverage. I found it fair and relatively even handed despite being a PBS piece. In those countries, no one goes bankrupt because of health care bills. On the other hand, several of the aforementioned nations’ systems are broke.

    Although the challenges are great–the dissemination of misinformation, mis-perception, and even the American Dream notwithstanding–I have come to believe that how we handle the legions of uninsured individuals says a lot about our society.

    I am conflicted professionally, however, in that no one with any clout seems to be discussing tort reform which most physicians cite as a reason for escalating costs and defensive practices.

    The PBS program can be viewed online here: http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

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About the Author:

Brad Flansbaum
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education. Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates. Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University. He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.


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