Study: Americans Can Learn from Swiss, Dutch Systems

Les Masterson, for HealthLeaders Media , January 16, 2009

Two European nations with public-private healthcare systems that provide near-universal coverage could serve as inspiration for U.S. policymakers debating healthcare reforms, according to a study released today by the Commonwealth Fund.

The healthcare policies of those two countries, Switzerland and the Netherlands, have created systems in which a mere 1% of their populations are uninsured because of an individual mandate that requires everyone to purchase health insurance. In contrast, 15% of the U.S. population is uninsured, according to Robert E. Leu, PhD, executive director of the department of economics at the University of Bern, Switzerland, and four colleagues, who wrote the study. (The individual mandate mirrors the system in Massachusetts, which requires health insurance and offers a program that connects citizens with health insurers taking part in the program.)

"The Swiss and Dutch health systems provide real-world prototypes for a regulated competitive model with multiple insurance plans, which many believe is the most likely route to universal coverage in the United States. Both countries' systems are in transition, with ongoing reforms focused on improving cost and quality performance. Tracking and understanding their experiences—both challenges and successes—offers potential insights for U.S. policymakers," wrote the authors of The Swiss and Dutch Health Insurance Systems: Universal Coverage and Regulated Competitive Insurance Markets.

Both European systems feature cost-containment measures, which result in lower administrative costs. The Swish and Dutch health systems spend 5% of healthcare costs on administrative costs, compared to an average of 7% for private U.S. insurers, the authors reported.

The systems also feature patient choice, broad access to care, low rates of care disparities, and premium assistance to those who can't afford it they added.

Karen Davis, president of the Commonwealth Fund, which supports independent research on health policy reform and creating a high-performance health system, said the two European nations should serve as "idea labs" for U.S. health reforms.

"There are examples of universal, comprehensive, high-quality, efficient healthcare systems that can show us the path to high performance," said Davis.

U.S. policymakers could learn from Switzerland and the Netherlands in four ways, according to the study:

  • The universal mandate requires every individual to purchase basic health insurance.
  • National standards require private insurers to offer a certain baseline services and protections.
  • Tight regulations of basic health insurance markets include requirements for open enrollment and community rating, which lead to lower overhead costs.
  • Risk equalization systems help reduce incentives for insurers to seek healthier enrollees.

As a result, the two European nations spend a lower percentage of their gross domestic product on healthcare than the U.S. and benefit from better health outcomes, including life expectancy, than Americans, according to the study.

The study's authors acknowledged that the Dutch system is still "a work in progress" because it was implemented only three years ago. The Swiss program, on the other hand, has been around since 1996. The authors wrote that some of the Swiss program's "shortcomings" are in the areas of risk adjustment and provider contract, which have been difficult to address, partly "because of split responsibilities for healthcare under Switzerland's federal system of government."

"This may have important implications in considering the right balance of federal and state responsibilities in health reform in the United States," the authors wrote.

Les Masterson is senior editor of Health Plan Insider. He can be reached at

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