By I. Guessous, J.M. Gaspoz, J.M. Theler, H. Wolff
In press – Draft published online August 23, 2012
Health insurance is compulsory for all citizens in Switzerland and insurance premiums are paid independently of income. Health insurance covers the costs of medical treatment and hospitalization for the insured. The insured person pays part of the cost of treatment: an annual flat deductible, called the franchise, chosen by the insured person (with premiums adjusted accordingly) and a 10% co-pay of the costs up to a stop-loss annual amount of CHF 700 (1CHF≈1$). Between 1099 and 2010, health insurance premiums increased by 77%, coupled with increasing out-of-pocket payments. Increasing out-of-pocket spending may, at least in some settings, reduce the use of clinically important services and drugs to prevent the onset and progression of chronic disease (Paez et al., 2009).
We aimed to determine the characteristics of participants who report forging healthcare and to describe the past 4-year trend for forgoing healthcare for economic reasons.
To investigate the determinants and the 4-year evolution of the forgoing of healthcare for economic reasons in Switzerland.
Population-based survey (2007–2010) of a representative sample aged 35–74 years in the Canton of Geneva, Switzerland. Healthcare forgone, socioeconomic and insurance status, marital status, and presence of dependent children were assessed using standardized methods.
A total of 2601 subjects were included in the analyses. Of the subjects, 13.8% (358/2601) reported having forgone healthcare for economic reasons, with the percentage varying from 3.7% in the group with a monthly income ≥ 13,000CHF (1CHF ≈ 1$) 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.
In a Swiss region with universal health insurance coverage, the reported prevalence of forgoing healthcare for economic reasons was high and greatly dependent on socioeconomic factors. Our data suggested an increasing trend among participants with the lowest income.
– Forgoing healthcare for economic reasons is frequent in a region of Switzerland.
– This prevalence varies with reported monthly household income category from 3.7% to 30.9%.
– Data suggest an increasing 2007–2010 trend among participants with the lowest income.
– Risk factors include gender, smoking, occupation, children, being divorced, and insurance status.
– Forgoing healthcare is associated with worse self-rated health status.
By Don McCanne, MD
Conservatives in the United States often praise the Swiss health care financing system largely because it is composed of a choice of private health plans (although they may not like the facts that it is compulsory, that it is heavily regulated, and that it is one of the most expensive financing systems in the world). So what is the policy lesson from this study of the Swiss system?
The out-of-pocket deductibles and coinsurance result in a high prevalence of forgoing health care for economic reasons. The prevalence is inversely related to household income, but even at the highest income levels, some do forgo health care for economic reasons. Forgoing health care is associated with worse self-rated health status, and reduces the use of clinically important services and drugs.
Other nations have shown that you do not have to have deductibles, co-payments, and coinsurance to control health care spending. Since these cost sharing measures do have the detrimental effect of reducing the use of clinically important services and drugs, they should be rejected as bad policy. The other measures inherent in a well designed single payer system obviate the necessity of patient cost sharing.