Unbundling the reforms of the Health Insurance Act

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

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Abstract

The failure of the second revision of the Health Insurance Act, decreed by the Swiss parliament in December 2003, has pushed the Federal Council to adopt a strategy of unbundling. The new project of reform retraces the one rejected by parliament in its contents, but subdivides the legislative intervention into 6 small packages, which will have to be approved singly by parliament and which will be treated with the accelerated legislative procedure.

Purpose of health policy or idea

In December 2003, after a two long years of discussion, the Swiss Parliament rejected the second revision of the Health Insurance Act. The Federal Council, when analysing this result, reached the conclusion that the negative outcome of the parliamentary ballot did not put doubt on the strategic lines of the reform, but rather on the process of decision-making. In fact almost all the proposals included in the second revision of the Health Insurance Act, if taken singly, won the support of the majority of the members of parliament. For this reason the Federal Council decided not to modify the lines of the reform but to change the approach. 

The main novelty of the project presented at the end of the month of February 2004 consists, in fact, of unbundling. The main aspects of the second revision of the Health Insurance Act are proposed again, with minor changes, but instead of being integrated into a single draft bill they are now subdivided into small legislative packages, which will have to be approved one by one by parliament and which will be treated with the accelerated legislative procedure. 

The new project of the  Federal Council is subdivided into two distinct legislative acts, also from the point of view of time; overall these contemplate 6 reform proposals of the Health Insurance Act, to which a new draft bill concerning  long term care financing is to be added:

1. The first package, containing 4 partial, independent messages, was  put to discussion at the end of March 2004, should arrive in parliament by the summer session 2004 and come into force between 1 January and 1 July 2005 or, in the case of an optional referendum, on 1 January of the year following its acceptance in the popular vote.
   
   The surveys 2004/2 (National social target defined in terms of maximum incidence level for health insurance premiums), 2004/3 (Contracting freedom for health insurers) and 2004/4 (Higher share of co-payment and less regulated system of optional deductibles within mandatory health insurance) are devoted to the key points of this first package of reforms.
2. The second package of reforms, containing 2 partial messages, should be put to parliamentary debate starting from the autumn session 2004, with the aim of bringing them into force by 1 January 2006.

The working out of a new draft bill concerning the reorganization of the financing of long term care is to be added to the two reform packages; this should be examined by the Swiss parliament by December 2004.

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

The impact of unbundling on the organization of the procedure of the Swiss  health system will have to be evaluated in the light of its ability to encourage the reaching of a consensus between the parties on the more important and critical aspects of the reform.

Political and economic background

The Federal Council's decision not to abandon the course of  reforms undertaken in the recent past, but to organize the decisional process in a different way, that is giving up the idea of a unitary draft bill in favor of 6 separate messages, has to be interpreted on the background of the reasons which determined the rejection of the second revision of the Health Insurance Act (see Origins of Health Policy Idea) keeping in mind the impelling necessity to prolong some transitory measures (inserted into the Health Insurance Act or decreed by means of urgent federal laws) whose legal base expires in 2004 or 2005.

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The decision not to abandon the reform path followed in previous years but to break the reform health insurance down into small packages, to be approved or rejected separately, is linked to the reasons which led to the failure of the second revision of the Health Insurance Act in December 2003.

There are two possible keys to understanding that lack of approval:

1. The first key to understanding it is linked to the heterogeneity and large number of topics dealt with in the draft bill, which ended up dissatisfying all the political currents in parliament, on at least single points, thus creating the premise for a transversal coalition capable of blocking the whole revision of the law.
2. The second interpretation is linked to the role played in Switzerland by direct democracy (especially the right to referendum).
   Federal laws, generally binding decisions of the Confederation and State treaties concluded for an indefinite duration are subject to an optional referendum; in this case, a popular ballot is held if 50,000 citizens so request. The signatures must be collected within 100 days of publication of a decree. The referendum is similar to a veto and has the effect of delaying and safeguarding the political process by blocking amendments adopted by Parliament or the Government or delaying their effect - the referendum is therefore often described as a "brake" applied by the people.
   Since at least one of the reforms contemplated by the second revision of Health Insurance Act was strongly opposed (during parliamentary debates the associations of doctors and patients had expressed the will to launch a referendum against the suppression of the obligation to contract), on the horizon in any case there was the chance of the whole draft bill failing.
   However, it is necessary to underline that the consequences of this in the popular ballot of the second revision of the Health Insurance Act would have been much more serious, for at least two reasons: (a) the decision to reject the reform would have arrived at the end of 2004 and (b) it would have led to the necessity to start the legislative procedure from the beginning again with a new draft bill, thus setting any reform back by several years.
   Thus the decision of parliament not to approve the second revision of the Health Insurance Act can also be seen as the result of a shrewd political calculation, intended to prevent popular response from freezing the whole reform process for years.

Approach of idea

The approach of the idea is described as:
renewed: Second revision of the Health Insurance Act, 2000-2003

Stakeholder positions

The decision of the Federal Council to carry out the unbundling of the reform project of the Health Insurance Act is greeted in a positive way by all the stakeholders, especially by sickness insurers. The Cantons expressed some reserve concerning the accelerated procedure of consultation (through the Swiss Conference of Cantonal Directors of Public Health); they saw the risk of putting before parliament draft bills which, due to lack of the time necessary for proper coordination, do not enjoy the necessary political support.

Adoption and implementation

In particular the process of consultation involves: the cantonal  authorities (cantonal executives) and the various cantonal conferences (of the cantonal directors of finance, of the cantonal directors of public health etc.), the federal tribunals, the sickness funds (Santesuisse), the associations of the suppliers of services (doctors, physiotherapists, nurses), the associations of patients and consumers, political parties.

Expected outcome

The consequences which are expected from this unbundling strategy are:

• the approval of the more urgent and less problematic dossiers, which will enable the temporary measures in expiry to be prolonged for some years;
• the need to find political and social consensus on the more problematic dossiers, penalty their not being approved by parliament or in a referendum.
  In fact, the separate treatment of the dossiers in certain cases can be in favor of maintaining the status quo (the groups which are penalized by a particular measure are not compensated by another legislative intervention which favors them and whose coming into force is associated with the approval of the whole package), but implies a certain advantage from the point of view of democratic transparency and the search for political and social consensus.

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

It is not so much the policy of unbundling in itself as the content of the single proposals which has an impact on quality, equity and effectiveness. For an assessment of the impact expected from the single measures we refer to the surveys 2004/2, 2004/3 e 2004/4.

References

Sources of Information

About the rejected second revision of the Health Insurance Act:

The Federal Assembly - The Swiss Parliament, Krankenversicherungsgesetz. Teilrevision (00.079). Amtliches Bulletin 2001-2003, www.parlament.ch/ab/frameset/d/index.htm

"KVG-Revision hätte verschiedene Neuerungen gebracht", NZZ Online (17.12.03, 16:24), www.nzz.ch/2003/12/17/il/page-newzzDOBG5HF2-12.html

"Enttäuschung auf der einen, Freude auf der anderen Seite. Reaktion auf Scheitern von KVG-Revision", NZZ Online (17.12.2003, 16:20) www.nzz.ch/2003/12/17/il/page-newzzDOBJ35EK-12.html

Waber, B. (2003),"Kleine Schritte statt umfassende Operationen. Nach dem endgültigen Scheitern der KVG-Revision", Neue Zürcher Zeitung Nr. 294 (18.12.2003), p.13. www.nzz.ch/dossiers/2003/gesundheitswesen/2003.12.18-il-article9ATPU.html

About the new attempt to reform the Health Insurance Act:

Federal Department of Home Affairs (2004), Teilrevision der Krankenversicherung - in die Vernehmlassung gegebene Projekte.

Federal Department of Home Affairs (2004), "Krankenversicherung: Bundesrat stellt Reformplanung vor", Press Release of 2-25-2004
www.edi.admin.ch/presse/2004/040225_kvg-reformplanung.pdf

Federal Department of Home Affairs (2004), "Krankenversicherung: Bundesrat verabschiedet Vernehmlassungsvorlage", Press Release of 3-24-2004
www.edi.admin.ch/presse/2004/040324_kvg-vernehmlassung.pdf

Gerny D. (2004), "Vertragsfreiheit statt Ärztestopp. Couchepin will Selbstbehalt der Versicherten verdoppeln", Neue Zürcher Zeitung Nr. 47 (26.02.2004), p.13.
www.nzz.ch/dossiers/2003/gesundheitswesen/2004.02.26-il-article9FKRS.html

Schoch, C. (2004), "Happiges in homöopathischen Dosen", Neue Zürcher Zeitung Nr. 47 (26.02.2004), p.13. www.nzz.ch/dossiers/2003/gesundheitswesen/2004.02.26-il-kommentar9FKWF.html

Author/s and/or contributors to this survey

Luca Crivelli (proof reading by Iva Bolgiani, Gianfranco Domenighetti, Massimo Filippini and Mary Ries)

Empfohlene Zitierweise für diesen Online-Artikel:

Luca Crivelli (proof reading by Iva Bolgiani, Gianfranco Domenighetti, Massimo Filippini and Mary Ries). "Unbundling the reforms of the Health Insurance Act". Health Policy Monitor, 20/04/2004. Available at http://www.hpm.org/survey/ch/a3/4