Misaligned

The tenor of the health-care slapfight (I’ll not dignify it with the word debate) in the United States of late is… well, frankly, embarrassing. Y’all are really making yourselves look bad. Death panels? Really? When a walking vapidity whose prime qualification for the job is that she can see Russia from her house gets up on the tee-vee and starts improvising science fiction so terrible that even L. Ron Hubbard wouldn’t stick his name on it, you do what the rest of us do, and you ignore it.

[People](http://www.nytimes.com/2009/08/17/opinion/17krugman.html) who have a bigger audience than I do (but who, alas, don't know that the Swiss don't wear lederhosen, or that most of the cheese here is relatively hole-poor) have already drawn the parallel between the American system and the Swiss one, and wondered why you can't reap the benefits of moving to a more Swiss-style system. Well, let's have a look. The main differences I've noticed between the Swiss health-care system and the American trainwreck are:
  • Health insurance is mandatory; when you register your residence (which you must do within 8 days of moving to a new city or district), they give you 45 days to select a carrier, sign up, and send proof of insurance to the district. If you can't pay, the government subsidizes you. Consequently, you can buy insurance retroactively. I purchased coverage from 1 June 2008 on about 20 June; had I had any claims during that time, they would have been paid.
  • Health insurance carriers must accept any patient, cannot deny coverage for "pre-existing conditions", and have a relatively limited set of variables on which they can set rates.
  • Health insurance is paid directly by the patient, who pays 100% of the premium. The company doesn't have anything to do with it. For me, here, this works out that I pay about twice as much out of pocket every month, but that the total cost is about half what it was, compared to UPMC in Pittsburgh. The particulars of my coverage here are about equivalent.
  • Health insurance covers those things insurance generally does, not purely elective (e.g. cosmetic surgery) or routine (e.g. dental cleaning) things.
  • I'm told health insurance usually operates on a reimbursement basis: you pay the doctor, the insurance pays you. However, all my experience with my carrier so far has the doctor or hospital billing the insurance company, and the insurance company billing me for anything under the deductible. In any case, I see the bills, and the bills are the same regardless of who you have coverage through.
  • Medical expenses incurred as a result of an accident are handled by a separate accident insurance system, paid by the employer. This accident insurance covers you whether or not you were at work or doing something work-related at the time. Accident insurance premiums are "pre-tax", and are shown on your pay stub. I'm not sure who covers accident insurance for the unemployed; I'm guessing it's the city's or district's responsibility.
  • Testing and treatment seem to work differently. At least in my experience, they're much slower than American doctors to prescribe antibiotics or advanced diagnostics, and somewhat more willing to let you heal, under supervision. I attribute this to relatively less angst over malpractice lawsuits, which comes from a less litigious culture in general.
  • Billing and care are handled completely separately; this allows the medical people to focus on caring for the patient, not shaking them upside down waiting for a wallet to fall out. I walked out of the emergency room after a bicycle accident in July (resulting in a thankfully not-broken-but-badly-sprained left hand), without having to convince anyone I would pay them. It felt odd.
I'm not sure you could run this system with American patients.
First, Americans like suing their doctors when things go wrong much more than Swiss do. It's [not clear](http://blogs.reuters.com/great-debate/2009/08/06/reduce-the-high-cost-of-medical-malpractice/) whether this makes things significantly more costly in the first order; most of the effects (diagnostic and ultimately-unnecessary treatment costs) are second order, and these are probably much more significant. Of course, one of the reasons Americans like suing their doctors is that when something goes wrong, it usually goes wrong in some expensive way, and the insurance company sure as hell won't help you out; the Swiss are more calm in part because they know the system will do a reasonable job of taking care of them if something does happen. But litigation is a part of American culture in a way that it isn't part of Swiss culture.
Second, Americans and Swiss have rather different ideas on end-of-life care. Contrast Terri Schaivo, who was basically kept alive by executive order, with [Dignitas](http://www.dignitas.ch/), where people from all over Europe who might die painfully someday in the future fly for legally assisted suicide. (Okay, it's more complicated than that; I've not talked to an actual Swiss person who's completely comfortable with what Dignitas does, but they do what they do without the Federal Council sending the Swiss Army to force feeding tubes into people, which is my point.) A Swiss person who is likely to live out the last few days of a terminal illness in a morphine haze would be kept alive for a few expensive and excruciatingly painful weeks in an American hospital.
Third, Swiss are healthier. They eat somewhat less (but not necessarily healthier — this place is serious about its sausage and ice cream, though, ah, not at the same time) and exercise a lot more, both in the order of the day and for fun. Zürich, at least, can be crossed on foot in a little over an hour, is excellent for bicycling as long as you pay proper attention to the tram tracks, has ridiculously usable public transit, and is absolute murder to drive in. Transport alone knocks five kilos off the average. And there are lots of lakes to swim in and mountains to climb and ski down. Additional costs in airlifts and broken bones (which you see a lot of; the trams are packed with crutches in April and May) are more than offset by the savings of an entire generation not sitting out the three-month heart-disease endgame in a hospital.
The real problem, of course, is that the United States is saddled with a giant health-finance industry that eats kittens, shits evil, owns your senator, and employs your neighbors. Monoliths with money, power, no sense of ethics, and a bunch of normal people who you kind of like on the payroll are tedious to get rid of. But let's sidestep that for a moment, and pretend we can fix things, shall we?
Now, those of you who know me know I'm not a free market fundamentalist by any means. But I have to say that from the ground here, it appears that the core advantage of the Swiss system is alignment, in the form of choice. This element is missing from the American public health insurance system (i.e., Medicare), the American private health-finance industry (i.e., the aforementioned evil-shitting kitten-eaters), and everything I've read about what's going to come out of this particular partisan health care reform sausage-factory.
In Switzerland, I pay for my insurance. I am free to change my insurance carrier if my insurance carrier does not please me, without changing doctors (or worse, jobs); consequently, they're actually quite pleasant to deal with. I pay my doctor, and am free to change my doctor as well, without changing insurance carriers. So doctors' offices are pretty pleasant to deal with, too (of course, this may have something to do with the fact that the front office's main job isn't yelling at insurance-company back-office people all day).
In Switzerland, the patient (me) and the payer (me) have aligned interests (at least, assuming I don't have multiple personality disorder): in this case, getting well without getting broke. Add in good access to information to make informed decisions (I see the bills) and this is one of those depressingly rare situations in which the free market actually does what it says on the tin.
In the dystopian death-panel future that has the American right whipping its minions into showing up at health care rallies [packing heat](http://videocafe.crooksandliars.com/heather/cnn-assault-rifles-spied-openly-phoenix-ra), of course, interests are misaligned: you (the patient) want to get well, and some GS-3 in a giant nameless government agency (the payer) just wants to go home. (Actually, in the dystopian death-panel future, that GS-3 is actively trying to kill you, because you're the only person who realizes the [truth](http://en.wikipedia.org/wiki/Barack_Obama_citizenship_conspiracy_theories), that the President is a Kenyan-built, Indonesian-programmed cyborg sent from an even more dystopian future to enslave the American people in Teh Soshalizum, but in the dystopian death-panel future, you need to adjust your tinfoil hat.)
This misalignment is the core of the problem with the current system, too: the patient, who wants to get well without getting broke, has no information and no mechanism by which to use that information to make an informed choice. The payers all have different interests. Medicare: GS-3 indifference, your employer: cost control, your insurance company: making enough sweet, sweet cash to fuel the [private jet](http://djmrswhite.livejournal.com/415594.html) for a weekend of kitten-eating in the Caymans.
Sadly, though, it's all about a bunch of Reaganists who believe Government Is Evil using the noise machine to win the slapfight versus the indignance of what's left of the Left at the injustice of leaving ten percent of people uninsured and more liable to fall into medical bankruptcy. Alignment isn't even part of the discussion, probably because it's too simple and not profitable enough. Without proper alignment, reform won't work. Personally, I've given up hope for this time around; maybe when it hits the agenda again in 2025, you'll have figured this out.
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Brian Trammell
Bike Dad, Photographer, Management Trainee

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