OBAMACARE ON STEROIDS:

For Republicans, 2009 was a tragedy founded on sins of omission. Barack Obama came triumphant into Washington followed by crowds of celebrities and admirers literally chanting his name as a hymn of praise, and his first order of business was doing something about health care -- or, more specifically, about health insurance. Republicans responded with something less than splendiferous wit and intelligence: "We have the best health-care system in the world!" they insisted, over and over, dozens of them, often using precisely the same words. Somehow, a political strategy based on the notion that Americans like health-insurance companies proved ineffective -- surprise.

The Democrats, for their part, couldn't quite decide what they wanted. They talked about "Europe," as though there were a single "European" model of health care. Some of them talked about the British and Canadian systems, rarely if ever giving serious consideration to the question of why so few of those admired European countries rely on such systems (Germany? No. Sweden? No? Switzerland? No!) or why these national monopolies produce so many complaints among citizenries that generally support them or so many documented failures when it comes to access and timely patient care. They thought they were being clever by taking as their starting point a model associated with Mitt Romney in Massachusetts -- "Call us irresponsible radicals, will they? Well, this is a Republican plan! Take that!"

Massachusetts had looked in part to the Swiss model of health care, which the legislative engineers behind the ACA had attempted to graft clumsily onto existing American practice. [...]

In Switzerland, health insurance and the delivery of health care are entirely private enterprises. There is no Swiss NHS, no single-payer, no "public option" -- none of that. Switzerland has health care that is by European standards 1) excellent and 2) expensive. Insurance coverage, though entirely private, is universal. It is also heavily regulated and sustained through various direct and indirect subsidies, and consumption is restrained not through the god-kings of political management but through substantial out-of-pocket costs. There is a great deal of consumer choice and competition across internal political jurisdictions -- as a result of which, Switzerland has one health-insurance company for every 100,000 residents. For comparison: In 2019, the United States is expected to have one insurance company on the ACA exchanges for every 1.7 million residents.

Switzerland has an individual mandate that has nearly 100 percent compliance, which is achieved through ruthless enforcement. That enforcement is made easier by Switzerland's extraordinary civic culture, but, still: If you fail to secure health insurance for yourself, you'll get a notice from the authorities reminding you of your obligations, and if you continue in noncompliance, they'll just sign you up for a policy and start charging you both forward-going premiums and retroactive premiums and penalties covering the period of your lapse.

There is a legally defined bare-bones insurance policy in Switzerland, rather like the ACA's statutory minimum coverage. Though there is no government-run insurance program in Switzerland, these programs sometimes are described as the country's "social insurance," and the insurance companies are obliged to offer them on a nonprofit basis. Premiums aren't fixed by law, though insurers must charge everybody the same rate; because Switzerland has had nearly 100 percent compliance with its mandates since 1996 (it had about 98 percent voluntary coverage before that!), "preexisting conditions" are not much of an issue. Practice varies from canton to canton, but Switzerland subsidizes its system in two main ways: by providing direct subsidies for the premiums of low-income citizens and by providing financial support to the hospital system in general.

Dr. Thomas Zeltner, Switzerland's former secretary of health, characterized the system this way in a 2010 interview with Tsung-Mei Cheng of Health Affairs:

In Switzerland, rich and poor share the same insurance plans, and physicians and hospitals are paid the same fees for rich and poor alike. But in the U.S., fees paid vary by type of insurance. Fees for the poor in your Medicaid are much lower than fees paid by commercial insurance.

I think that is an interesting difference. We don't want the poor to be stigmatized in associating them to a specific plan. So, indirectly, we come to the same result -- we help the poor -- but it makes a huge difference when it comes to personal dignity as a patient. In Switzerland, the doctor and hospital do not even know whether you're subsidized or not. They get the same fee, regardless of who you are.

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