Explaining Policy Stability and Change in Swiss Health Care Reforms

© (2009) Swiss Political Science Review 15(2): 205–40

Explaining Policy Stability and Change in Swiss Health Care Reforms Björn Uhlmann and Dietmar Braun University of Lausanne

The article investigates recent health reforms and reform attempts in Switzerland. A substantial reform, the revision of the health insurance law in 1994, is followed by a long period of refused reform proposals and incremental change. In order to explain policy change and policy stability in health policies, we apply veto-player theory to partisan and parliamentary debates on reform proposals of the health insurance from the end of the 1980s until today. Shifts in ideological positions of parties, especially with regard to the objective of solidarity, allowed for a new win-set in the 1990s that was at the base of the law revision. Since then, the win-set is empty as parties did not change their preferences. New and substantial reforms will only be possible, it is concluded, if the pivot player, the Christian-democratic party, changes its ideological positions to a significant extent. Keywords: Health Policy • Veto-Player Theory • Switzerland • Parties

Introduction The “health insurance law” (LAMaL; Loi de l’Assurance Maladie) adopted in 1994, ended almost 30 years of political debates on how to reform the existing “health and accident insurance law” valid since 1911. Though Gilardi and Bertozzi (2008) do not see the change as “path-breaking”, the strengthening of equity and solidarity in the system can be seen as a structural change towards a health care system with different dynamics than the previous one (for a similar conclusion see Schenkluhn 1992: 673). For the OECD, Switzerland has “blurred the boundaries between private and public health insurance” (OECD 2004b: 28). In terms of Hacker’s “modes It became an example of a system where the “regulation of private health insurance increases the degree of cross-subsidisation across risks and enhances the “social” nature of such schemes” (OECD 2004a: chapter 2, footnote 4).

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of policy change” (Hacker 2004), one can qualify the reform of the health care system in Switzerland, as we will demonstrate below, as a “revision” of existing policies, i.e. a “formal reform”, though it still needs to be debated to what extent this reform can be seen as “sweeping” or “incremental” (see Wilsford 2000: 977). We are – this is our first objective – interested in explaining how this “blurring of boundaries” between a private and public health insurance system came about. The “revision” is the more astonishing as Switzerland offers many veto-points (Immergut 1992a) and has an important number of veto-players, which would rather suggest “policy stability” (Tsebelis 2002a) than a formal reform of health insurance governance structures and principles. The opposite is true for the period after the new law was accepted, despite of high cost pressure and the obvious lack of effectiveness of many instruments adopted. One finds a number of fundamental reform attempts that all failed. Only “incremental modifications of the system” (Gilardi and Bertozzi 2008) or “conversion” (Hacker 2004), i.e. “internal adaptation of existing policy” now seemed possible. It is our second objective in this paper to explain this “policy stability” of the Swiss health care system after the adoption of the new LAMaL in 1994 and its becoming effective in 1996. Our explanatory model for policy stability and policy change in Swiss health care focuses on party struggle in political decision-making, a variable, which is only seldom taken into account when explaining reforms in health care systems (but see Döhler 1990) and even welfare state development in general (Green-Pedersen 2001). Green-Pedersen underlines that though economic development and institutional factors are certainly most influential in welfare state development in general and welfare state retrenchment in particular, “party politics matters as well” (ibid.: 964; see also Huber et al. 1993; Kitschelt 2001). Structural pressures on the welfare system must be mediated and party politics and party struggle play a most See also Kittel and Obinger (2003). The authors conducted a quantitative analysis on the role of politics as a driving force behind the empirical variation of social expenditure dynamics in twenty-one OECD countries in the expansionary phase and the shift to retrenchment during the period of 1982 and 1997. According to their findings partisan and institutional effects provide a possible explanatory model for the time of expansion but less for the time of retrenchment. However, Kittel and Obinger underline that their findings don’t mean that politics doesn’t matter anymore, but that the analysis has to be designed differently to find explanations on a less aggregated level with more focus on qualitative differences (39–40).

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important role for the “extent” to which retrenchment policies can take place. This also holds for the extension of services in health care systems. In order to explain “policy change” and “policy stability” in health care reforms, we think, moreover, that party politics and party struggle must be linked to “veto-player” theory. This theory has the advantage of, first, being modelled for explaining policy stability and change and, second, being able to integrate both institutional elements (in the form of “institutional veto-players”) and “politics” (in the form of “partisan veto-players” Tsebelis 2002a). Its main elements are the distribution of preferences of actors on political issues, which is influenced by the “ideological stance” of actors and their “distance” as well as by the “internal (ideological) cohesion” of (collective) actors. In order to overcome the status quo it needs a majority of veto-players, i.e. those actors the approval of which is needed for a legislative change, otherwise the status quo cannot be defeated. In our opinion, the analysis of veto-players in the context of the Swiss political system allows to understand both the revision of health care policies in the 1990s as well as the policy stability thereafter. We are aware that there is at least one prominent competing explanatory variable in order to explain change and stability of health care reforms that is often discussed in the literature, i.e. the influence of “vested interests” (insurance agencies; doctors’ associations; trade unions; see Immergut 1992a and for their role in welfare reform in general Oliver and Mossialos 2005; Orloff and Skocpol 1984). Interest groups have “voice” in Switzerland because of several “veto-points” (Immergut 1992b) in the decision-making process: during pre-parliamentary procedures where interest groups may present their written opinions on a law proposal; in parliament by party representatives that are at the same time affiliated to interest groups and in the referendum process by mobilising the people for their purposes. Immergut’s explanation of policy stability in health care policies in Switzerland before 1994 was largely based on the role of vested medical interests that were mobilised in various referendums. We believe that we can demonstrate that, though interest group representatives exercise influence on discussions among parties, party consensus and party conflict are equally important in order to understand “stability” and “change” in health care reforms. Our argument is the following: With regard to the referendum process, which is the final hurdle to be taken in most legislative reforms in Switzerland, we contend that law proposals that are not defended by a large majority of parties during the parliamentary process will have fewer chances to be accepted by the people

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than in the case of a large party consensus. A large party consensus does, however, not guarantee referendum success because vested interests may have a crucial role in influencing public opinion. It is therefore neither a sufficient nor a necessary condition for referendum success. But, as a study evaluating voting behaviour in all referendums in Switzerland since 1874 demonstrates, a large party consensus raises the probability of winning a referendum or avoiding referendums considerably (Linder et al. 2008: 109–12; see also Kriesi 2005). If we can, therefore, demonstrate that a large majority of political parties was in favour of a successful fundamental health reform in the 1990s and that later such a party consensus was lacking and reforms failed, we can make a strong case for party struggle as an explanatory variable sui generis for explaining reform capacities without disconfirming the influence of vested interests. This argument has made us focus on processes of party struggle as a precondition of successful reform processes. The article is structured as follows: We will first discuss the partisan veto-players in the Swiss political system and then present the characteristics of the health care system in Switzerland before the formal reform in 1994 in order to judge on the degree of policy change that has taken place. Chapter 4 gives an overview of preferences of partisan veto-players and possible winning coalitions concerning the health care reform. Chapter 5 discusses the time after the introduction of the new law in 1996 and demonstrates why several fundamental reform attempts failed. In the final part we assess the current status quo in health care policies and predict to what extent we can expect further change or stability. Veto-players in the Swiss Political System Veto-players are actors that have the power to reject law proposals. According to Tsebelis, we can distinguish between institutional and partisan There is of course also the influence of vested interests on decision-making in Parliament as indicated by way of lobbying and representation of such interests by political representatives. We agree that such influence exists but in order to become effective, such influence must be taken up by parties in their struggle for ideological dominance and majorities in parliament. In other words, it must become part of preferences of parties. For our analysis it is not important where “ideas” come from but only to what extent the ideas and preferences of parties are compatible or incompatible and how consensus is constructed in the process of parliamentary debates. This is our focus of analysis.


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veto-players (Tsebelis 2002a). Institutional veto-players are defined within the constitution of a country, e.g. the parliament (a collective veto-player) or the president (an individual veto-player) the consent of which is needed to adopt a law because otherwise it would fail. Partisan veto-players are “generated inside institutional veto-players by the political game” (ibid.: 79). The parties composing a government for example are veto-players as government cannot act without the consent of its coalition partners. And if an opposition party is needed to win a majority in a chamber of the States as it is often the case in Germany, it becomes a partisan veto-player next to the coalition parties holding a majority in the People’s chamber. Switzerland has three institutional veto-players at the federal level, the two chambers (National Council and Council of the States) and – as a direct democracy – the referendum (see Tsebelis 2002b). It has the particularity, though, that its government, the “federal council”, is not built on a coalition of parties that act on the base of a coalition contract. Federal councillors are elected as individual persons, though their choice is strongly motivated by their party affiliation. Once elected, they are relatively independent of their party base. The federal council itself is working on the base of ad-hoc majorities, in principle striving for a large consensus in structural policy decisions. Each of the seven federal councillors is responsible for a different department and can manage daily affairs relatively independently. Within the government he or she has agenda-setting powers to define subjects and their contents. No councillor can, however, count on stable majorities in parliament, where the two chambers hold completely equal rights. The four major parties, that have since 1959 the prerogative to propose federal councillors out of their ranks, are not bound by coalitional agreements which gives them the possibility to vote according to individual preferences. Parliaments with unstable majorities cannot be “reduced” to partisan veto-players and are considered being one collective institutional veto-player each (ibid.: 19). This does not mean that parties in parliaments do not play a role. The federal councillor must, in order to make his or her proposal pass in both chambers, find majorities in each chamber. The composition of both chambers does not differ in types of parties but in the distribution of seats for parties, above all because electoral systems differ. This makes different The National Council is elected on the base of proportionality, the Council of the States recruits two representatives from each canton – except for half-cantons who have on representative – mostly on the base of the majoritarian electoral system.

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“win-sets”, i.e. majority coalitions possible. How the institutional vetoplayer votes depends therefore on the majority coalitions that are possible inside each chamber. They define the “win-sets”. The role of the federal councillor who has to represent the government is one of an “agenda-setter”, as the government has no veto-rights but the possibility to propose laws and put them on the agenda of the parliament. In our study we will take only account of the four parties that are represented in the federal council because they hold large majorities in both chambers. Winning majorities based on the addition of the remaining smaller parties almost never occur. Win-sets in both chambers are therefore a matter of finding majority coalitions between the four major parties. The relative power of the four parties in terms of parliamentary seats has varied. In the National Council the SVP and the SP are the strongest parties at the moment (62 and 43 seats of 200), with the FDP and the CVP following (each 31 seats). There is one remarkable trend in the development of relative powers that is the growing strength of the SVP after Switzerland refused in a referendum to join the European Economic Area in 1992 (being the weakest party of the four at the beginning of the 1990s) and a corresponding downward trend for the FDP and Christian-democrats which had been the two strongest parties in the beginning of the 1990s. This downward trend has not really had an effect on relative powers in the Council of the States where the CVP and the FDP are the strongest parties (15 and 12 seats of 46 in 2007 (SP: 9; SVP: 7)). The other two parties have gained some seats in relation to the centre parties since the beginning of the 1990s without changing the power relationships. This distribution of power demonstrates that today all parties have considerable influence on voting decisions: the SVP and the SP above all in the National Council and the FDP and the CVP in the Council of the States.

See König et al. (2003) who elaborated a similar argument for the case of Germany.

These four main parties – the Socialist Party (SP), the Christian-Democratic Party (CVP), the Radical Party (FDP) and the People’s Party (SVP) – had a majority of votes between 72.5% (1991) and 86.5% (1999) in the National Council with an average of 82% since 1971. Majorities were even clearer in the Council of the States: the lowest percentage was 89% in 1999 and the highest percentage 100% in 2003.

Since the last election in November 2007.


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The Swiss Health Care System before the Introduction of the New Health Insurance Law The governance of the Swiss health care system was for a long time based on a federal health insurance law dating from 1911, which introduced the right of the federal government to regulate health insurance swiss-wide. Except for one minor revision in the year 1964, the law on health insurance remained practically unchanged until 1994 when the so-called LAMaL (“Loi sur l’assurance maladie”), the new health insurance law, was adopted by the federal parliament and the people. How can the pre-1994 Swiss health insurance system be classified? There is no consensus on how to define and measure health care systems (see Blank and Burau 2007: 10–15). The OECD (OECD 1987) uses a taxonomy that establishes a continuum between a “free market system” on the one hand and “government monopoly” on the other, with the degree of government involvement as the underlying classification dimension. Freeman (Freeman 2000) integrates “mechanisms by which health care is coordinated” (Blank and Burau 2007: 12). Others base the taxonomy above all on financing modes. Moran (Moran 2000) uses the distinction among institutions related to the governance of consumption, provision and production. A more recent taxonomy of the OECD (OECD 2004a) proposes a mix of financing sources, level of compulsion of the scheme, group or personal health insurance, and methods of premium calculations. It is not our intention to discuss the “ins” and “outs” of these classifications but will propose our own taxonomy that remains strongly related to both OECD taxonomies but highlights the elements we believe crucial for understanding above all the party struggle about the governance of health care systems. In our view, basic political decisions with regard to the health care order and its governance have overwhelmingly been taken along the lines of the “left-right cleavage” in the party system. This means that the main debate has been indeed on the question if the system should be centralised, controlled and financed by government or if market mechanisms should prevail at the detriment of government involvement. This concerns the “organisation” or general set-up of the health care system. A second dimension in political discussions that one also finds – often implicitly – in the various taxonomies, is “social justice” or, in other words, the question of how “equal” the health care system should be and how much “solidarity” the system needs. The degree of government involvement and equity are therefore the main issues of conflict that have influenced the political

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struggle for health insurance and health care. We have elaborated both dimensions in the appendix to this article. In terms of “organisation”, Switzerland had a system based on profit-oriented, private health companies that were competing for wealthy and healthy clients. Insurance agencies were not completely free to act but not excessively restricted in their actions. The federal legislation prescribed some minimal standards like for example the obligation to accept any insurant within five years of inscription who fulfilled the statutes of the health insurance company. Some prescriptions were made about the benefits that insurance agencies had to offer when concluding contracts. In addition contracts between insurance agencies and service providers had to be uniform and did not allow for differentiation. Financing was mainly based (85%) on individual premiums and co-payments. 15% were spent by the federal government and cantons in order to introduce some compensatory mechanism for disadvantaged persons. But this payment was given to health insurance agencies per enrolee without any further differentiation. In terms of equity Switzerland had a voluntary insurance system, which nevertheless covered more than 90% of the population. Insurance agencies were obliged to offer some limited benefits that were defined by the federal government. Finally, insurance agencies were free to vary premiums according to “risk groups”, i.e. according to age, sex, health risk and regions. No solidarity existed between people exposed to bad risk and those who were young and healthy. This makes for a low degree of equity in the system. If we use the classification of health insurance systems in the appendix, Switzerland clearly belonged to the countries with a liberal health insurance system that put emphasis on a minimum of government involvement and individual responsibility, i.e. a low degree of solidarity and equity. Since the 1960s, this liberal system was under increasing pressure. In fact, there were constant reform attempts since the first revision in 1964. The reasons for this were soaring costs and rising premiums on the one hand and demands for an extension of equity in the system on the other. The government had already twice attempted to solve the conflict between the objectives of cost containment, access to health care and an extension of the mandatory health benefit package. A first reform attempt failed in 1977 and a second one in 1987. Both times government proposals were rejected in a referendum. In both cases it was clear that the propositions that the government made were only incremental steps and could not solve the problems of financial viability and equity in a more substantial way. In 1987, the parliament accepted the proposals almost unanimously


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in both chambers as they were considered at least as minimal steps towards cost containment and an increase in equity. This consensus pointed already to the general shift of party positions with regard to the status quo. There was a general willingness of all partisan veto-players to reform the existing system. The real confrontation was, however, only postponed, as a more fundamental reform was already announced by the federal government in response to the urgent problems and the two popular initiatives, which needed a more profound answer than given until then. During the years 1987 and 1994 several things happened: the federal government tried to construct a law proposal that could find a large majority in parliament and that could resolve the fundamental structural problems that were still on the table. To this aim, it first asked the advice of a number of health experts. The recommendations of the expert group were discussed in a parliamentary committee that had to prepare the law proposal of the federal government. On the base of the recommendations of the committee the federal government developed its own law project, which was presented to parliament in 1992. Deliberations in parliament took about two years but did not lead anymore to substantial changes with regard to the original proposal of the government that had well used its agenda-setting prerogatives. The law proposal was finally adopted in the National Council by a large majority (124 to 38) and in the Council of the States almost unanimously (35 to 1). A 51.8 majority accepted the law in an obligatory referendum with 43.7 per cent of the registered electorate taking part. We want to know two things: First, how this compromise was possible given the manifest party struggle that had taken place and, second, to what extent the adopted law can be seen as a fundamental policy change. Though we do not focus on these reform attempts in this article, it is worthwhile to shortly explain these failures: in 1974 people had to decide over two proposals, one was launched by the Socialist Party as a popular initiative and the other was the government counter-proposal which had found a majority in parliament but both proposals were heavily contested. It comes as no surprise – following our initial statement on the importance of party consensus for fundamental reforms – that both proposals were rejected in the referendum. In 1987 the government proposal failed despite of a large party consensus. This demonstrates that, as we pointed out, a large party consensus is neither a necessary nor a sufficient condition for referendum success. However, one can also argue that the party consensus did only come about because the essential points of conflict were excluded from the proposal. The stakes of the existing proposal were therefore not very high and might have led to a mitigated investment of parties in defending the proposal in the public.

http://www.admin.ch/ch/d/pore/va/19941204/index.html.

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With regard to the first question, we use veto-player analysis to see if and which “win-sets” were possible in parliament. On the base of parliamentary discussions and other sources in the 1970s and 1980s,10 we have endeavoured to define the party preferences concerning the health reform on the organisational and equity dimension. These two dimensions constitute the “policy space”. Overlapping preferences between parties can demonstrate the possibility of creating winning coalitions. The distribution of seats in both chambers determines which coalitions are winning coalitions and which ones are not. The Preferences of Parties Partisan struggle about a reform of health insurance hovered around two questions: 1. How could financial viability be reinstated? In order to find the answers, fundamental ideological questions about the organisation of the health care system were raised: Should the solution be inspired by the private insurance, a social insurance or a national health service model? Was it right to continue in organising the health care system in terms of competition amongst private insurance agencies or should the state take over the responsibility to organise the system and abolish market instruments? 2. To what extent a fair or equal distribution of costs had to be realised? One answer was to leave choices, as before, to the market and individual responsibility and accept an unequal distribution of the costs in the system and of benefits and access to health services. Another answer was to develop policy measures that would at least support the most precarious social groups and at a maximum guarantee an equal distribution of costs in the system and universal and equal access to health care. The parties did not disagree on the need of a reform but rather how to position themselves on these two reform dimensions – organisation and equity. Our data on party positions are based on party manifestos, party positioning papers concerning health affairs, interviews with party opinion leaders in health policies and protocols of speeches of party spokesmen in the two chambers of the federal parliament. The various statements were used to place each party into one of the “groups” in each of the six variables we defined in the appendix. 10


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In order to estimate the chances for a reform on the base of ideological affinities and differences in the early 1990s, e.g. the period of intensive consultation and negotiation for the new law, we have measured the position of parties in health care reform more precisely to see to what extent these positions allowed new majority coalitions that could overcome the status quo. To this end we used the variables we discussed to reveal the basic characteristics of the Swiss health care system (see the appendix). We endeavoured to position each party on each variable and to put these positions into a two-dimensional space consisting on the one hand of the “organisation” dimension and on the other of the “equity” dimension. We have drawn policy spaces for each institutional veto-player, one for the National Council and one for the Council of the States. The policy preferences of parties in both chambers are, we assume, identical, though one can observe some variation in opinion between party representatives in both chambers. This variation remains, however, small. Because of different winning coalitions that are possible given the different power distribution in the two chambers, indifference curves should be drawn for both chambers.11 As the figures demonstrate, all parties wanted a shift away from the status quo, though to different degrees. The FDP, CVP, and the SP were prepared to accept shifts that contained both more state involvement and more solidarity. The SVP remained the most liberal party but was willing to agree to minor changes in favour of equity. What are the�� “win-sets” �� given this distribution of preferences of parties? Win-sets have been different in the two chambers. If we take the distribution of seats in the government period 1991–95 the Council of the States allowed three win-sets, the ones defined by coalitions between the FDP/CVP, FDP/SP, and FDP/SVP (see Figure 2). This is equivalent to the In the National Council, the distribution of seats for the four parties was the following: FDP 44, CVP 35, SP 41, SVP 25. This allowed, for the following minimum winning coalitions: FDP/CVP; CVP/SP; FDP/SP. These three coalitions are shaded in different ways in Figure 1. In the Council of the States the following distribution hold: FDP 18, CVP 16, SP 3, SVP 4. All minimum winning coalitions needed the FDP: FDP/CVP; FDP/SP; FDP/SVP. The win-sets are therefore smaller than in the National Council. All coalitions are shaded in different ways in Figure 2. The scales are calculated on the base of “membership” in “groups” on the dimension of organisation and equity, as indicated in the appendix. On each dimension the value of each party is calculated by summing up the value attributed to each group the party belongs to and dividing it by the number of variables that define the dimension. The scale is therefore the average of group memberships of parties on each dimension. It can vary between 1 as a maximum and 0 as a minimum. 11

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indifference circle of the FDP. One can therefore expect that all solutions that could be found must fall in one way or the other into this circle. Winsets in the National Council were larger as here the coalition between FDP and SVP is replaced by a coalition between CVP and SP while the two other coalitions were also options. In this case (see Figure 1) the win-set does in addition comprise large parts of the CVP indifference circle. Possible compromises could therefore deviate from compromises in the Council of States. However, given the fact that it needs the consent of both institutional veto-players, the number of possible win-sets is defined as those majority coalitions that are equal in both chambers,12 which in this case was equivalent to the FDP indifference circle. So, any solution having a chance to find a majority in parliament should be situated at one point or other within the FDP indifference circle. It was the prerogative of the Christian-democratic Minister of Health as the “agenda-setter” to make a concrete proposition where exactly to locate a feasible reform proposal. In order to do so, he not only had to respect the preference distribution in parliament but also the preference distribution within the government. Though the responsible minister has also agendasetting rights within the federal council, important structural decisions like the health reform need the consent of a majority of government members. One can guess, as there is no information on this, about the options that were available for the minister given the voting power in the government. In the government at this time the CVP, FDP and SP each held two seats and the SVP one. No coalition without the responsible minister and his party seems possible under these circumstances which make minimumwinning coalitions of CVP and FDP or SP possible. Two additional restrictions entered into the calculation of the Minister: one is that he had to take the preference distribution in the parliament into account, which means that he could not define any solution outside existing win-sets and, two, for electoral purposes he had an interest in locating any proposition as near as possible to the “ideal point” of his own party, the CVP. After listening to an expert group that made first propositions in 1990s and to a parliamentary committee – the “Schoch committee” – that discussed a preliminary outline of a proposal of the Minister and made recWe do not need to treat the win-sets of each chamber as different preferences of institutional veto-players like Tsebelis does it when he discusses bicameral systems as vetoplayers (Tsebelis 2002). The reason is that we assume that the preferences of parties are identical in both chambers. In this case the distribution of preferences in the policy space is the same and it suffices to identify those win-sets that have the majority in both chambers. 12


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ommendations in the same year, the minister presented the official law proposal in 1991 (Botschaft Krankenversicherungsgesetz 6th of November 1991, No. 91071). The proposal was at the edge of the FDP indifference circle (see Figure 3 below) and nearer to the CVP ideal point than to the FDP ideal point. In this sense the minister had taken all constraining variables into account: In principle all major parties except for the SVP that had no veto-powers could agree to this proposal; it still fitted into the FDP indifference circle which was a necessary condition to find a majority that not only held a majority in one but both chambers; it was very close to the party of the Minister. There is no need to go into details concerning this proposal as it contained almost all essential reform points that were accepted – after 2 years of intense debates in parliament – without major changes in 1994.13 This means that the Minister had indeed found the right compromise given the preference distribution in parliament. No party rejected the proposal in parliament, though the SVP recommended a refusal to the population during the referendum campaign14 which was taken though not by the party itself but by a referendum committee consisting of several health insurers and associations of medical practitioners.15 In the following Figure 3 the preferences of parties as shown before, the proposal of the federal government, and the new health insurance law status quo are all indicated.16 The health reform brought significant changes. In a nutshell, the most important agreements made were: • The maintenance of the premiums per capita to finance the bulk of We refrain from elucidating the debate as the final result did not deviate substantially from the initial input given by the federal government. The debate is extensively taken into account in our book on the LAMaL (Braun and Uhlmann 2008). 13

Such a policy stance can be explained by the distribution of preferences in the policy space: the compromise was outside the indifference curve of the SVP so it seems almost natural that the party did not support the law in the referendum. In the parliament, however, the progressive wing of the SVP prevailed. As a consequence the party supported – against the will of its hawks – the bill. Once the referendum was launched by other actors and the party’s member basis had do be included in the process of the referendum campaign the hard liners gained ground and the SVP decided – in accordance with the indifference curve – to vote against the bill. 14

15

Swissvotes: online 8 February 2009 on http://www.swissvotes.ch/votes/view/428/list.

The operationalisation of the government law proposal and the new law was effectuated in the same way as the policy preferences of party before. We used the classification in the appendix to position the law proposal and the final law. 16

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health costs and the preservation of the private competitive insurance system; • The systemic change from an optional to a mandatory health insurance; everyone applying for compulsory health insurance had to be accepted by insurance agencies; • The change from subsidies per enrolee to means-tested subsidies; • A substantial extension of benefits covered by the compulsory health insurance; • The suppression of different premiums per capita between men and women of the same age and with the same insurance policy; • The introduction of a risk compensation funds between insurance agencies to raise equity; • The abandoning of obligatory uniform contracts between insurance agencies and service providers; allowance of introducing health maintenance schemes. If we try to measure the degree of policy change this agreement meant, we can refer to the variables presented in the appendix: 1. “Organisation”: With regard to the management of the health care system Switzerland passed from a free market system to a system with considerable regulation of insurance agencies;17 in terms of financing Switzerland remained in the same group (system based on individual premiums with additional state subsidies or contributions) though it changed the way of distributing subsidies (see below income equity). This means that concerning the organisation of the health care system, changes have been modest. 2. “Equity”: Access equity was changed from a voluntary private inIn detail this meant that insurers had to accept all citizens without differentiating according to risks; a referential premium for each region was introduced that insurers had to take into account when formulating their price policy; insurers were obliged to pay into the compensatory funds for equalising differences in the competition of insurance agencies’ membership; a uniform tariff structure nation-wide was mentioned but not yet made obligatory; measures to control the efficiency of organisation and management were introduced; see for the measurement the appendix. 17


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surance system to a system with a mix of compulsory and voluntary, complementary insurance; the compulsory system became however, given the number of benefits included, clearly predominant; income equity was gradually changed as subsidies remained the instrument for compensating the negative effects of premiums per capita but subsidies were not any longer paid per enrolee but to means-tested groups which increased equity and solidarity; benefit equity was changed as the “reduced benefit package” that insurers had to offer before the introduction of the new law was clearly increased and became part of the mandatory insurance; finally, risk equity was changed dramatically, as Switzerland passed from no risk compensation to a system where only age differences were any longer accepted for premium differences within the mandatory insurance. No risk compensation continued to prevail in voluntary insurance. It was here, if one regards equity as an aggregate index of all four types of equity, that Switzerland demonstrated therefore a substantial shift that allows speaking of policy change with regard to the revision of the health insurance system. In fact, if one calculates the average value on each dimension before and after the reform,18 one can give a more precise picture of the different “pace of change”: If 1 is the maximum that can be reached on each dimension and 0 the minimum, the reform brought a change in the organisation of health insurance from 0.15 to 0.33 while the change on the equity dimension went from 0.23 to 0.61. It is the equity dimension therefore that justifies to speak of a “blurring of boundaries between private and public insurance”. The degree of solidarity and equity has been substantially increased and can be compared to social security systems while the organisation dimension remains more oriented towards a preference for the market than for a state-run system. It is this very combination that made the compromise possible: the far-going shift on the equity dimension only found approval by the three bourgeois parties SVP, FDP, and CVP because the liberal organisation of the system remained intact and because another condition of the bourgeois parties, cost containment, seemed to be achieved by the new system: The financial base of insurance agencies was considered to be sound from now on because premiums were substantially increased (while out-of-pocket payments were reduced) at the same time when the new law was introduced. In addition, parties like the FDP and the By adding up the values of the different indicators of each dimension and by dividing them by the number of variables on each dimension. 18

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SP

0.6

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Figure 1: Party Preferences and Win Sets National Council about 1991

0.4

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0.0 low

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SVP could more easily agree to the strengthening of equity in the system as it was supposed that above all risk equity measures also had a positive spill-over effect on the efficiency of health insurance agencies: as these agencies could no longer compete on the base of risk premiums they needed to improve the efficiency of their functioning in order to have competitive advantages on the insurance agencies. This in turn should contribute to a better cost containment. One can speak therefore of a new health insurance system that shifted the existing liberal system into the direction of a social insurance model with its stronger emphasis on a fair redistribution within the health system. However, one should be aware that this outcome was still a compromise between conflicting objectives – financial viability versus equity and solidarity – and it needed only sufficient “stress” on this system to flare up


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party struggle. It was, however, much more difficult now to react to such a stress and to apparent shortcomings of the compromise by political reform because the new status quo makes it almost impossible to find new winning coalitions. The reason is that – as shown in Figure 4 below – the new status quo is almost identical to the position of the CVP, which therefore has no interest to change the status quo. As long as win-sets demanded the participation of the CVP – and given its strong position in the Council of the States this is the case until today – the room for manoeuvre for any minister to launch more substantial reforms were extremely limited and so it was for any party trying to use the referendum path for support by the population.

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Reform Steps and Failures 1996–2008 Health care costs, already high, continued to rise steeply after the adoption of the new health insurance law: from CHF 37.5 billion in 1996 (10.1% of GDP) to CHF 51.7 billion in 2004 (11.6% of the GDP) (Bundesamt für Gesundheit 2007: 166).19 In 2008 they are estimated to rise over CHF 59 billion (Bundesamt für Statistik 2007: 6). This has led to soaring insurance premiums, which increased over the last decade much stronger than the price rise of the consumer basket of goods (Bundesamt für Statistik 2007: 6).20 Therefore the objective of financial viability was and still is clearly not attained and becomes the predominant concern of all parties. It are the bourgeois parties, however, that underline in particular that the system might have reached its financial feasibility and that everything needs to be done to prevent the system from collapsing. It is said that new and stronger instruments of cutting down costs and expenditures are necessary. At the same time, equity remains on the political agenda: the enormous rise of insurance premiums begins to weight not only on lower but also on middleincome groups. It seems that the existing compensating mechanisms, the subsidies, which are only paid to lower income groups, are not sufficient to compensate the rise in premiums. The debate that started after 1996 and continued in the new century is therefore one between those bourgeois parties or factions of parties that had agreed to the substantial reform in favour of equity because they expected positive side-effects of the reform for cost containment, i.e. the SVP and the FDP, and the centre and left-wing parties CVP and SP that saw equity and solidarity endangered by soaring health care costs but also by cost containment measures that were discussed in parliament. The period after 1996 is characterised by several reform attempts both by the government and parties. The last ones used the referendum as a venue to succeed. In the following part we will shortly present the different reform attempts and explain why they had to fail. First, we demonstrate how the SP and the SVP intended to transform the health insurance system in favour See also Bundesamt für Statistik: Online: http://www.bfs.admin.ch/bfs/portal/de/index/ themen/14/05/blank/key/leistungserbringer.html [accessed: 18.05.09]. 19

There has been a slowing down of the rise in premiums in recent years due to a decree of the health minister urging the insurers to use their savings in order to keep premium rises at a lower level. However, in the meantime savings are used up and a steep rise in premiums of 10 to 20 percent is again foreseen in 2009 (NZZ 27th January 2009: 14). 20


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of their ideal positions by various referendum attempts. In a second step we point out how the CVP and the FDP argue on the foundations of the existing health system to move the future status quo towards more market economy and more personal responsibility. Reform Initiatives Launched by the Socialist Party Though the SP had agreed to the LAMal, their ideal point was by far still the most distant from the new status quo (see Figure 4). The party had therefore an interest to change the status quo especially after it became visible that the rising premiums caused further equity problems and existing compensation methods were insufficient. The SP had two means to shift the status quo, given that new winning coalitions in parliament were not available: first, it could influence the new socialist minister of health, who took office immediately after adoption of the LAMal in 1994 and stayed in office until 2002, and try to launch incremental reforms21 or, second, to bet on a referendum though it was clear to the party that a referendum without the backing of the other major parties would have extreme difficulties to win (see above). If the party thought about such an option, it was probably not because it believed in success but to reveal to its electoral clientele its “ideal position” in the policy space.22 Concerning the first option, one notices that the new minister of health introduced a number of minor, incremental changes especially with regard to a further extension of the benefit package – as for example the inclusion of new medicaments against illnesses – in the mandatory basic insurance. Such incremental steps could be achieved relatively easy on the base of governmental decrees without even consulting the parties. In juxtaposition to these “fine adjustments”, the social-democratic health minister launched in 1999 a first reform process, which aimed at increasing income (increase of federal and cantonal subsidies for economically weak households) and We consider incremental reforms as reforms the outcome of which remains near to the status quo. In terms of our classification of the “organisation” dimension and the “equity” dimension this means that an incremental reform cannot entail a shift from one “group” to another “group”. Only variations within the group are possible. 21

Ideal positions are often hidden in parliamentary debates, most of all because parties have to present their points of view with an eye on possible coalition partners, i.e. they make propositions that seem to win majorities but that are not any longer identical to the ideal point of the party. Referendum initiatives can serve to remind the electoral clientele of the “true” position of their party. 22

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benefit (provisions) equity as well as state regulation in the system’s financial organisation (global budgets) (Bundesrat 1999). This reform attempt can also be labelled as incremental because change happened only occasionally and not fundamentally: against the vote of the SVP, additional federal means for subsidies were granted, whereas global budgets for cantons to intervene into the health market were successfully rejected by the three bourgeois parties and the extension of the benefit package was curtailed. Although the final reform proposal of the federal council was re-near the status quo of 1994, the bourgeois parties considered the reform as a move away from the status quo. This led to growing resistance in parliament and an isolation of the socialist minister who quit office in 2002 and was replaced by a radical minister.


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The loss of the health department together with soaring premiums and rising health care costs were reason enough for the SP to go the people twice, in 2003 and in 2007, with fundamental reform propositions. The referendums aimed to both revise the organisation of the health care system – the abolishment of the competitive system of insurance agencies by creating one single national health fund for the mandatory basic insurance in order to increase income and risk equity – and to improve equity by the financing of the health insurance by income-related premiums. Both propositions were not new and demonstrate that the party had never abandoned its ideal position even if it had approved the LAMaL. The stressing of the strong role of the state and the even higher degree of equity stood – it is almost needless to say – in sharp contrast to the preferences of the bourgeois parties which recommended in both cases a refusal together with the government. Without a majority of partisan veto-players, the Socialist Party had no chance to convince a majority of the population or the cantons. Both referendums were clearly rejected: in 2003 with a majority of 72.9 per cent23 and by all cantons24, in 2007 with one of 71.2 per cent25 of the population and by 18 cantons and 6 half cantons26. The fact that the SP tried to shift the status quo unilaterally by way of referendums and consecutive reactions of the SVP, which was the other party that had an incentive to shift the status quo more into the direction of its ideal position (see Figure 4), raised the conflict intensity concerning health reform issues considerably. The polarisation of points of view contributed without any doubt also to the failure in parliament of a revision of the LAMal in 2003, launched by the new liberal minister of health, which dealt in particular with the financing of hospitals, the (reduction of) individual premiums and the freedom of insurance agencies to contract providers.27 Not satisfied with the result of the deliberation, especially with the missing financial support for families, a substantial number of CVP representatives 23

“SP-Gesundheitsinitiative” http://www.admin.ch/ch/d/pore/va/20030518/index.html.

24

http://www.admin.ch/ch/d/pore/va/20030518/det499.html.

25

“SP-Einheitskrankenkasse” http://www.admin.ch/ch/d/pore/va/20070311/index.html.

26


See Amtliches Bulletin Ständerat (2001: 629). Until then and this has remained unchanged, insurance agencies did not have the right to select certain providers and refuse others in order to be more competitive and lower premiums. The proposition was to give insurance agencies the right to select, a proposition that came back in the latest referendum on health reform in 2008. 27

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regarded income equity as jeopardised28 and voted with the SP against the government bill. For the SP the revision as a whole and in particular the regulation about the contractual freedom were too liberal. It would, in their view, have altered the status quo of the health system’s organisation too much towards market forces.29 Reform Initiative Launched by the SVP As demonstrated in Figure 4, the ideal policy position of the SVP, not only on health but also on many other political questions, was and still is diametrically opposed to the one of the SP. To get a grip on the rising costs in the health care sector and consequently to secure the systems financial viability, the party argued strongly in favour of transforming the prevailing health insurance system back into a more liberal one, which meant essentially to come back to the decision of a mandatory health insurance system and replace it by an optional one with detrimental effects on access, benefit and income equity. The party launched a referendum in 2004 going into this direction. It, however, quickly realised that the proposal had no chance to be accepted, not by the radical minister of health nor by the other three parties. In contrast to the SP the SVP did not want to continue a pure confrontation strategy with the other parties. Instead it decided to moderate its claims in order to find allies. It demanded to not only take back most of the extensions of the benefit package that had taken place under the socialist health minister – something which had some sympathy in the FDP and CVP – but even more to reduce the benefit package of the mandatory basic insurance to such an extent that in the future the majority of health services would have to be bought by membership in voluntary insurance schemes. Even though these demands were more moderate in comparison to the initial proposal, it would have meant a substantial reduction of benefit equity30 with negative effects also on income equity. The proposition remained therefore incompatible with the preferences of the other parties. The Radical Party initiated a direct counter proposal in parliament at the end of 2007, which was in the end accepted by both chambers by 133: 63 and 29: 13 respectively (Bundeskanzlei 2008: 29). This counter propo28

Amtliches Bulletin Nationalrat (2003: 2052).

29

Amtliches Bulletin Nationalrat (2003: 2052).

This would indeed be more than an incremental reform as it would have meant to switch from group “b” in benefit equity to group “c” (see the appendix). 30


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sal allowed the SVP to withdraw its chanceless initiative because the proposal attempted to liberalise the existing system in a moderate way though not with the same focus as the SVP. The FDP wanted above all to increase the efficiency and effectiveness of the system by introducing more competition among providers and among insurance agencies. In contrast to the SVP, the FDP did not want to cut down the benefits in the basic health insurance scheme and left benefit equity therefore untouched. Nevertheless, the FDP’s counter proposal too was without a chance before the people and was as a result rejected with about 70 per cent in June 2008.31 The reasons for this were not linked to the equilibrium established since 1994 concerning the organisation and equity but to other controversial subjects: First of all, the proposal attempted indirectly as a constitutional frame and guideline for bills to introduce the free choice of insurance agencies of contracting with providers, which meant nothing less than a strong deregulation of the health care market and therefore met the resistance of the doctors’ association. Second, it wanted to introduce a “monistic financing” of the system, which meant that the money that cantons spent on their hospitals should be managed by insurance agencies. This obviously led to harsh resistance by the cantons. Last but not least the proposal could not convince other parties or the people that it would really lead to a surplus value in reference of equity and/ or cost containment of the system. In all its other parts, concerning for example efficiency measures like for instance HMOs, it built on what already existed in practice. A revision of the LAMal seemed therefore not necessary. Except for the resistance of doctor’s association and a large number of cantons, the CVP and the SP recommended the refusal of the referendum, above all because it handed over to much (financial) power to the health insurances with its inherent risk of a substantial loss of equity. Under such a combined resistance, the proposal of the FDP had no chance. Reform Proposals of Parties near the Status Quo: FDP and CVP The FDP held a position near the status quo and the ideological position of the CVP was identical with the status quo. Their indifference circles were therefore very small and so was their capacity to search for solutions to the problems.

31


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It is obvious, however, and the indifference circles in Figure 4 demonstrate it, that the FDP with its minister of health32 was and is bowing more into the direction of liberal solutions (reducing equity to some extent while promoting cost containment measures), while the CVP remains fixed on a position maintaining the status quo in matters of equity and also in matters of organisation. What does this mean in terms of policy preferences and reforms that these parties propose? In order to demonstrate the positioning of both parties in the reform process we will take only one prominent example that has nevertheless been a frequent point of discussion, i.e. the regulation of health care consumers by the instrument of deductibles and co-payments. These instruments were not directly touching upon the organisation of the health care system but could have effects on the equity in the system. The liberal minister made above all two proposals in the aftermath of his failure to introduce the more comprehensive reform package that failed in 2003: • The first one was to raise the mandatory deductible (from 230 CHF to 300 CHF) and co-payments (from 600 to 800 CHF per year per person) and later on to increase the levels of the optional annual deductibles; • The second one was a measure compensating in part the negative effects that these measures could have on lower incomes by reducing the discount on premiums an insurant could get, thereby reducing the incentives for higher incomes to profit from higher optional deductibles while lower incomes could not afford to use such high optional deductibles. The position of the FDP was consequently in favour of more liberal solutions: It welcomed the rise of the mandatory deductible because this could recalibrate the system after the extension of benefits introduced under the authority of the socialist health minister towards the status quo of 1994. But it criticised the reduction of the discount on premiums and did not folOne has to take into account that the position of the government in Figure 4 is not anymore the position of the government since 2002, when a radical minister took office. He used his agenda-setting powers in favour of a stronger liberal outlook. Possible majorities within the government at this time were – with the FDP, SVP, and SP holding two seats and the CVP one seat – a coalition of the FDP minister with the SVP or the SP. By choosing the support of the SVP it was possible to develop a policy with a more liberal outlook. 32


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low its own minister. The party proposed instead to think about optional deductibles related to income with a maximum limit defined by law, which would have meant, if adopted, a strong reduction of income equity. Its centre position near the status quo, the CVP demonstrated by its refusal of both the increase of the mandatory deductibles and of the reduction of the discount on the premiums. It voted against the increase because if feared like the SP detrimental effects for lower and middle incomes. It refused the reduction of the discount because this could create a wrong incentive punishing those who take over personal responsibility even if this meant more equity. These contradictory positions are explained by its interest in defending above all the status quo, leaving little room in one or the other direction.

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Conclusion Switzerland revised its health care system in 1994 by raising the degree of equity substantially and – to a slighter extent – by introducing more regulation into the governance of the system. It remained a private insurance system if one refers to its organisational foundations – degree of government involvement and financing – but it blurred the boundaries with public insurance systems in general and social insurance systems in particular by the strengthening of solidarity and equity. The reasons for the revision were twofold: On the one hand, Switzerland’s private health insurance system suffered from a particularly low degree of equity and solidarity in relation to other states. This can be seen in the context of Switzerland being in general a latecomer in welfare state development (Armingeon 2001, 2003; Bonoli, 2007). The demands for more equity and solidarity were in part influenced by this general positive climate for welfare state reforms in the 1980s and 1990s. On the other hand, cost containment was a problem in Switzerland as it was elsewhere and the main motive for above all the right-wing parties SVP and FDP was to reform the health insurance system to reduce the cost increases that were also – all parties agreed on this – detrimental to equity. Given the strong voting powers of the FDP in both chambers at this time, no consensus could be found without the introduction of a number of efficiency measures and of instruments to increase the competition within the system. But it was above all the expectation that the risk equity measures would have a pay-off for efficiency that convinced these parties to agree to the reform package in the end. Our analysis, inspired by veto-player theory, demonstrated that all parties were shifting away from the status quo ante and this most prominently with regard to an amelioration of equity in the system. Preference intensity between parties concerning this dimension differed of course as the “distance” between the “ideal point” of each party and the status quo ante demonstrates (see Figure 1). On the base of our model we could demonstrate, first, that a revision was possible because win-sets existed that could defeat the status quo and, second, we could predict to a certain extent the position of the compromise in the policy space. The reform introduced a new status quo, which meant that further revisions would only be possible if some partisan veto-players would change


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significantly their position in relation to the status quo and allow for the creation of new win-sets. This, however, has not taken place until today and this explains the relative stability we find after 1996 despite of numerous reform attempts. Analysing this period, one notices that reform attempts (by the SP and SVP) that tried to shift the status quo near to their extreme ideal points in the policy space were without a chance to succeed, not in parliament and not in a referendum. All four referendums that were started – three of them were executed – confirm our expectation that it needs a large party consensus in parliament to have a fair chance of winning a referendum. As this was not the case, all referendums failed, though especially in the last referendum, initiated by the FDP, the left-right cleavage was not the decisive factor explaining the rejection. One can speak of “relative” policy stability because some incremental changes have been possible. Incremental change means in our context that no change in “group membership” of the various variables defining the “organisation” and “equity” of the health care system has taken place. One finds therefore for example an extension or a curtailing of benefit packages in the mandatory health insurance, introduced by decree powers of the federal government, but this did not add up to a shift in “group membership” of the variable “benefit equity” (see the appendix). But even incremental reform attempts were not uncontested: It was in particular – but not in general – the polarised climate in 2003, when the SP and in the next year the SVP launched their radical reform propositions that prevented the adoption of the encompassing but rather incremental reform package of the liberal minister. And it was difficult for the minister to make propositions of cost containment that seemed to have some negative consequences for the degree of equity, as in the case of the reforms of deductibles and co-payments. The FDP finally had to learn that incremental reforms do not pass if they are packed into a constitutional reform parcel. The status quo is therefore very stable under the existing distribution of powers and party preferences. The parties near the status quo, the FDP and in particular the CVP, have a pivotal role in the maintenance of the status quo.33 By using our model we could demonstrate that the FDP has an interest in abandoning the status quo concerning equity in order to achieve At the moment, in 2009, the CVP can build a coalition in the Council of the States with any of the three other parties to have a majority. The only other possibility is a three party coalition of FDP, SVP and SP, a very unlikely coalition. This demonstrates the pivotal position of the CVP. 33

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more cost containment but the possible shift remains limited given the relatively small indifference circle. The CVP has – given its almost identical position with the status quo – almost no room for manoeuvre and hovers around the status quo. This leads to the prediction that one can only expect fundamental health care reforms in the future if the CVP – the consent of which is still needed given its dominant position in the Council of the states for building minimum-winning coalitions – changes its preferences concerning the equity dimension and joins forces more closely with the FDP and the SVP. As long as this is not the case, new fundamental revisions of the health insurance law are not to be expected. Appendix: Classification of Health Insurance Systems

In order to classify countries concerning the type of health care system

they have installed we think that the OECD distinction (OECD 1987) between private insurance, social insurance, and national health service needs further refinement and is not yet satisfactory as also other attempts of systematisation demonstrate (Blank and Burau 2007: 10–5). We propose to use two dimensions, the general institutional set-up or “organisation” of the health care system, and the “degree of equity” as the main dimensions to classify countries. Organisation The underlying dimension of the OECD type (1987) is in fact “government involvement” in the organisation of health care and the three systems (private, social, national) are on a one-dimensional scale in between the “free market system” and “government monopoly”. Government involvement appears in two ways: first in the way the health care system is managed or run (with a strong/weak participation and/or control of the state)(1) and how it is financed (i.e. by government money or other financial sources)(2). The groups we have classed under each variable are rank-ordered from the highest value “1”, which indicates a strong government involvement or, in the case of the equity dimension, a strong degree of equity or solidarity, to the lowest value “0” that represents the group with the lowest degree of government involvement and equity or solidarity respectively. Each group in one variable is attributed a value that


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expresses the degree to which it belongs as a “member” to the variable in question.34 The value is found between brackets. (1) The first variable in the dimension “organisation” concerns the way the health care system is managed or run. We can distinguish four groups that run from a state controlled system without any independent insurance agencies to a free market system with freely operating private and profitoriented agencies: a. State-led unified agency or state bureaucracy that runs a mandatory health insurance and is responsible for collecting and distributing money for health care services (1) b. System with social security schemes run by multiple public and semi-public insurance agencies that are not competitive and which are strongly regulated (0.67) c. System based on private and competitive insurance agencies; competition is, however, strongly regulated (organisation, financing etc.) (0.33) d. Free market system based on private and competitive insurance agencies; only few regulations are found (0) (2) The second variable concerns the financing in the system where “government monopoly” means a tax-based financing system and a “free market system” individual premiums as the main financing source. Here we identified four groups: a. Tax-funded health insurance that is collected by a central authority (1) b. Mandatory social security contributions, which are incomerelated. Employers and employees participate in the financing. Usually there is a deficit guarantee by the state (0.67) c. System based on individual premiums with however additional state subsidies or contributions (0.33) The values in between are calculated simply by dividing 1 by the number of remaining groups (for example in this case four groups remain and we have a value of 0.25). In going down from the highest value 1 we then attribute the next group a value of 1–0.25, the third group a value of 1–0.5, the fourth group a value of 1–0.75. 34

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d. Individual premiums as the main financing source; no participation by the state (0) Equity In addition, we think it necessary to introduce a second defining dimension of health care systems, i.e. the degree of equity. All countries must develop a policy concerning different dimension of equity in health care. We make a distinction of four types of equity that are usually debated in political discussions: (3) The first type is access equity, which treats the question if all or some should have the right to profit from health insurance schemes. Four different kinds of institutionalisation are possible with regard to access equity: a. the most equitable kind would be compulsory membership for all citizens (1) b. the next equitable kind would be “mandatory participation in a health insurance scheme, but with freedom to choose across alternative schemes or carriers” (OECD 2004: 9). There is a mix of compulsory and voluntary insurance schemes, but the compulsory element dominates (0.67) c. a voluntary insurance system in which there is nevertheless some mandatory services that private insurances must offer (0.33) d. the least equitable form would be a system that offers only voluntary insurance without any prescription concerning the offers insurance agencies must make (0) (4) The second type is “income equity” which pays attention to the degree of equity in the contributions of citizens to health care. In general we can distinguish between a. A tax-financed system that is used to equalise contributions of citizens (1) b. An income-related premium system (0.75)


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c. A premium system with compensatory mechanisms for selected (means-tested) groups (0.5) d. A premium system with some subsidies to insurance agencies without differentiation of financial positions of insurants (0.25) e. Finally, a premium system without compensatory mechanisms (0) (5) Third, “benefit equity” means to guarantee that all citizens have equal chances of treatments and services. a. One way to do so is to introduce mandatory health insurance, which at the same time comprises all health services in its basic package (1) b. A second group includes a medium to high number of benefits in the mandatory health insurance while other services have to be “bought” in voluntary insurance schemes (0.67) c. A third group includes only few benefit services within the mandatory health insurance. Equivalent to this would be a system without no mandatory health insurance but the obligation of insurance agencies to offer a few number of services stipulated by the state in their insurance package (0.33) d. The final group would have no mandatory insurance and no regulations concerning the offer insurance agencies must make (0) (6) Finally, there is “risk equity”, which means the degree to which certain groups are subject to health risks does or does not enter into the calculation of premiums. a. The most equitable system would allow no differentiation in premiums among groups of people (1) b. The next equitable system would only allow to differentiate premiums on a very small number of categories like for example age or sex but not for health risks (0.67)

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c. The next system would allow to differentiate according to a large number of criteria including health risks (0.33) d. The final and not equitable system would make no prescriptions at all with regard to risk groups (“risk-related premiums”; see OECD 2004: 11)(0).

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Zur Erklärung von Stabilität und Wandel in der Schweizerischen Gesundheitspolitik Der Artikel analysiert die jüngsten Gesundheitsreformen und Reformversuche in der Schweiz. Auf eine grössere Reform, die Revision des Krankenversicherungsgesetzes im Jahre 1994, folgte eine lange Periode abgelehnter Reformvorschläge und inkrementeller Reformen. Um Politikveränderung und Politikstabilität in der Gesundheitspolitik erklären zu können, wenden wir die Veto-Spieler Theorie auf Parteidebatten und parlamentarische Auseinandersetzungen um die Reform der Krankenversicherung von Ende der 80er Jahre bis heute an. Die Verschiebungen in den ideologischen Positionen der Parteien, vor allem im Hinblick auf das Ziel Solidarität, erlaubten einen neuen Win-Set in den 90er Jahren und bildeten die Grundlage für die Einigung beim Gesetz. Der Win-Set ist seit diesem Zeitpunkt leer, da die Parteien ihre Präferenzen nicht mehr verändert haben. Neue und bedeutende Reformen wird es, so unsere Schlussfolgerung, in der Gesundheitspolitik nur geben, wenn die christdemokratische Partei als “Zünglein an der Waage” im parteipolitischen Machtspiel ihre ideologischen Positionen grundlegend revidieren würde.

Expliquer les continuités et changements dans les réformes de la politique de santé en Suisse Cet article analyse les récentes réformes et tentatives de réforme de la politique de santé en Suisse. Une réforme importante, la révision de la loi sur l’assurance maladie de 1994, fut suivie par le refus d’une longue série de propositions de réforme et de changements supplémentaires. Afin d’expliquer les changements et les éléments stables de la politique de la santé, nous appliquons la théorie du “veto-player” aux débats partisans et parlementaires depuis la fin des années 1980 à nos jours. Les changements des positions idéologiques des partis, particulièrement en ce qui concerne l’objectif de solidarité, permit un nouveau win-set dans les années 1990 qui fut à la base de la révision de la loi. Depuis cette période, le win-set est vide car les partis n’ont plus changé leurs préférences. De nouvelles et importantes réformes ne seront possibles que si l’acteur principal, le Parti Démocrate Chrétien, change ses positions idéologiques de manière significative.

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Björn Uhlmann is teaching and research assistant at the Institute d’études politiques et internationales (IEPI) at the University of Lausanne. Since January 2009 Ph.D. student. His main topics of research are governance, public policy, federalism, and constitutional design. Address for correspondence: Institute of Political and International Studies, University of Lausanne, Bâtiment Anthropole, CH-1015 Lausanne, Switzerland. Phone: +41 (0)21 692 31 77; Email: [email protected].

Dietmar Braun is professor of comparative political science at the Institute d’études politiques et internationales (IEPI) at the University of Lausanne and research councillor at the National Science Foundation. He has published on public policy topics, federalism, political theory and research policies. Address for correspondence: Institute of Political and International Studies, University of Lausanne, Bâtiment Anthropole, CH-1015 Lausanne, Switzerland. Phone: +41 (0)21 692 31 32; Email: [email protected].