Effective and efficient health care systems offers quality and enhanced healthcare to the community through improving the health care outcomes of all people. Countries can ensure the provision of effective health care systems by implementing people-centered health care using approaches that solve accessibility and inequity issues while supporting shared decision making. They must also evaluate and monitor these approaches to ensure the continuity of an effective health care system (WHO, 2015). Health care systems across the world react to the needs and expectations of people independently based on their locations and have their strengths and weaknesses. The health care system in the United States is not a universal system as it consists of both privately and publicly funded programs. Private and public health insurance programs cover Americans in which private insurance plans cover the bulk of the population through employers. The government also funds insurance programs such as Medicare and Medicaid, which insure vulnerable groups. The military and the Indian Health Services also receive public funding from the government. The Swiss health care system comprise a universal health care system with private programs and without public programs. People select their health insurance plans from different private health insurance firms with guarantees for total coverage for all people. The government also offers subsidies for people who cannot afford health care.
The present paper compares two health care systems, namely the United States and Switzerland. The paper focuses on the design and functioning of the two systems to examine how each system addresses Triple aim of care, the differences between them, their similarities, and their strengths and weaknesses.
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Structure and Functioning
The Swiss Health care system is based on the principle of equality and universality that mandates all citizens to obtain a private health insurance plan while subsidizing healthcare for low-income earners. The system also regulates the insurance market to protect the people (De Pietro & Crivelli, 2015). According to Rapaport (2018), while Switzerland is the second-highest health care spender across the world, 99.5 percent of its population have private health insurance cover. Switzerland offers a universal health cover based on the 1996 Federal Health Insurance Act. The act mandates people to purchase statutory health insurance plans from different private insurers. The effect of this act is the absence of uninsured citizens in the country (Rapaport, 2018). All citizens in the country have insurance plans. For immigrants, they must purchase insurance plans within three months after arriving. The plan applies retroactively to their arrival date.
The country’s statutory health insurance covers citizens without external sponsorship by employers. Citizens must purchase different plans for their dependents (Tikkanen & Abrams, 2020). The consumers influence the Switzerland insurance market in which the providers offer insurance to avoid compelling consumers to continue working to continue benefiting from employer-based plans. Government laws prevent private insurers from earning profits when citizens purchase mandatory plans even though they earn profits by selling additional insurance plans such as hospital rooms or alternative medications. The extra plans are private and have specialized providers. In the Swiss model, citizens incur the country’s health care cost. According to Eggli, Stadelmann, Piaget-Rossel, and Marti (2019), the Swiss model is divided into three levels, which are communal, cantonal, and federal. The model is also decentralized in which the cantons contribute significantly to health care provision. The model comprises of 26 cantons including 6 demi-cantons. The cantons focus on licensing, hospital planning, and subsidizing health care costs. They also operate independently and function like states even though the Federal constitution regulates some matters. Cantons and demi cantos have individual regulations.
The health care system in the U.S. is non-uniform and is not universal. The country only enacted the Affordable Care Act in 2010 that mandates health care coverage for nearly all citizens. Despite its passage, however, about 10 percent of the population lacks health insurance (Tikkanen & Abrams, 2020). The system does not operate as a national system, a single-payer national system, or a multi-payer universal system. Rather, the system functions as a hybrid model that receive funding from the government, private plans, and households. The contributions from each group include about 20 percent by private businesses, nearly 30 percent by households, about 30 percent by the federal government, and about 17 percent by local and state governments (Department for Professional Employees, 2016). Private organizations deliver most health care regardless of the source of funds. Health insurance covers about 90 percent of the U.S. population in which private insurance plans cover about 60 percent of workers who depend on their employer contribution.
The government cover health care insurance for nearly 37 percent of the citizens through military care, Children’s Health Insurance, Medicaid, and Medicare programs in which a person can be covered by both plans. Nearly 10 percent of people in the U.S. lack health insurance (Department for Professional Employees, 2016). The government does not offer health benefits to migrants or citizens, people must purchase health insurance plans from private companies. After purchasing a plan, people select a primary health provider approved by the insurance company. The provider will be the one to offer health care services to the person. The country is the topmost spender on health care across the world followed by Switzerland. Medicare program covers nearly all the elderly while Medicaid covers low-income earners.
Triple Aim
The decentralized nature of the Swiss health care system helps it address the issue of health care costs, enhanced health, and enhanced care. For instance, each canton in each jurisdiction sets a fixed insurance premium price. Cantons also cap premiums at about 10 percent on average to preventing health care costs from becoming too high and unaffordable (Eggli et al., 2019). Citizens can select from different insurance companies in their cantons and choose benefit packages and providers from four main insurance plans based on quality or cost (Eggli et al., 2019). Each insurance plans has a minimum annual deductible unless the consumer selects a higher deductible but lower premium plan. Consumers must also cover a yearly deductible and integrate a 10 percent coinsurance percentage after the deductible reaches a yearly ceiling.
The model also has a cost-sharing element in which all citizens incur a 10 percent coinsurance cost for all services or per visit in addition to a 20 percent coinsurance cost for drugs. The model excludes several preventive services and maternity services from deductibles while insurers can lower or wave co-pay costs for consumers using managed care programs (Eggli et al., 2019). Enrollees reaching chf700 receive co-pay waivers in one year to protect consumers in case of severe illnesses (Eggli et al., 2019). The model also uses a central fund to redistribute costs between insurers based on a risk equalization program that considers gender and age. Previous premiums and hospitalization may remain the same for pre-existing health issues or other social matters.
The United States Health care system enhances care through the Affordable Care Act that integrates accountable care organizations (ACOs) in the system. ACOs comprise of several health care providers as new payment models that provide coordinated health care by working together to harmonize care management and data collection (Albright, Lewis, Ross, & Colla, 2016). These organizations mostly work with Medicare in which the insurer sets different quality measures that ACOs must implement. The measures focus on prevention by emphasizing vaccinations and screenings (Albright et al., 2016). Other measures focus on performance improvement with an emphasis on coordination of care, patient experience, and chronic disease management.
The insurer also sets measures that concern clinical outcomes such as satisfaction and readmission rate. The government offers fixed finances per patient to the ACOs every month to cover all expenses to improve population health while reducing the use of healthcare, which in turn decreases costs relative to profits and revenues. The objective of the payment changes is to enhance health besides treating illnesses. The U.S. currently has over 520 ACOs that serves over 17 percent of the population (Smith, Palmer, Martin & Fitch, 2016). It is, however, vital to note that a majority of the payers in the U.S. do not offer prevention-based reimbursement.
Differences
The main difference between the Swiss health care model and the United States model concerns the presence of Medicare in the United States. The model in Switzerland does not compel people to leave their private insurance plans to join a public plan after turning 65 years. This enables the Swiss model to operate under a risk equalization program and competition. The Swiss model pools premiums and divides them between insurers based on the insured population including both the old and the young (Eggli et al., 2019). Balancing risk equalization would be challenging if the elderly are detached from the system. All the citizens in Switzerland purchase insurance plans the same way including the elderly and are subsidized if the need arises the same way. The system also covers home visits, inpatient care, and nursing homes using basic health care programs, which meets the needs of the elderly without the need for a specific plan for them. In the U.S. system, Medicare encompasses a massive public health insurance plan that specifically targets the elderly besides other private and public health insurance programs. The systems are similar in a way because both systems have adopted Diagnostic Related Groups (DRGs) that involve paying hospitals for procedures, not length of time.
Strengths
The Swiss model focuses on individualized insurance programs, which include the health insurance coverage of the people regardless of their life situations (Eggli et al., 2019). All citizens in Switzerland aged 18 and above must enroll in their selected health care plan, maintain coverage independent of wealth or employment across their lifetime unless they change plans voluntarily. The system also calculates the required subsidies for people whose income decrease below the minimum living standard every month and award extra subsidies if needed.
Individualized coverage is also stable, supportive, and direct compared to the employer-based plans that are expensive. Additionally, the individualized insurance plans in Switzerland offers insurance firms the incentive to engage in competition with each other. Citizens can select the plans they want, which gives them an incentive to economize. In turn, the insurance market in the country has balanced costs in which demand and supply are balanced.
The passage of the Patient Protection and Affordable Care Act is one of the strengths of the United States Health Care system. The act forced competition on insurance companies, which has the potential to enable health insurance programs based in states to become more affordable individually. Before the act, the country had an expensive individual insurance program that only a few could afford (Patrick & Yang, 2019). The expansion of Medicaid and the initiation of premium tax credits for the U.S. citizen ranging from 133 to 400 percent of the poverty line reduced the cost of health insurance plans.
Weaknesses
One of the weaknesses of the United States health care system is its confusing and overwhelming nature. Before the passage of the ACA, the system had different private and public health insurance programs and the act increased the confusion. For instance, Medicare covers the elderly, Medicaid covers the poor, and then there are employer-offered plans for workers, subsidized programs for people who cannot afford exchange insurance programs, the uninsured's exchange availability, and different exchanges for small firms. The programs overwhelm the system and lead to confusion (Patrick & Yang, 2019). Many benefits may overlap, which leads to waste.
Another weakness is that the many programs of the U.S. health care system encourage the susceptibility of people who are at risk of being left out of the system. People who lose their job, for example, must apply for an insurance exchange to obtain coverage. Citizens must also apply for premium tax credits if their job loss declines their income to less than 400 percent of the poverty level. Besides, citizens must search for new jobs and deal with losses related to unemployment. People who fall below 133 percent of the poverty level must apply for Medicaid while those reaching 65 years old must change their insurance to Medicare (Patrick & Yang, 2019). The risk of being left out of the system is high because of the disjointed nature of the U.S. system.
The employer-based coverage in the U.S. is also expensive given the increasing premium trends above earnings, which increases the cost of insurance whether paid by the employee or the employer for most workers. The self-employed in the U.S. also must purchase insurance plans from State-based exchanges. While exchanges aim to reduce the cost of individual health plans, they encourage inequality. For instance, competition between exchanges does not lead to low insurance costs that match the cost-sharing and premium rates achieved by large firms (Patrick & Yang, 2019). Large companies can also negotiate with insurance firms.
The Swiss model lacks managed care plans that help in controlling costs. Managed care programs achieve reduced costs by managing access to providers and needing approval before visiting a specialist. The U.S. system already has managed care plans since most employers favor them. Additionally, the reliance on individual contributions of the Swiss model without the contribution from the government makes the model to be expensive (Tikkanen & Abrams, 2020). Substantial challenges to the citizens emerge, particularly given the high number of the aging population. The increasing cost of technology and experts is another disadvantage because the cost will be passed to consumers. Without programs to address health care cost and centralization of insurance regulation, the public may face a costly health care system.
Conclusion
The present paper explored the structure and function of the Swiss healthcare system and the United States healthcare system. The paper compared the two systems based on their triple aim strategies, consumer participation, and government involvement. The paper highlighted that the two countries have different health policies based on their specific situations, although they have similarities in aspects such as DRGs. The two systems also addressed the Triple aim of care differently, had their strengths and weakness and differed in the way they address elderly insurance coverage. While the U.S. system has Medicare plans that specifically address elderly insurance coverage, the Swiss model is a single model without specific programs for specific population groups.
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