Edited by Luigino Bruni and Pier Luigi Porta
Chapter 22: Federalism Versus Social Citizenship: Investigating the Preference for Equity in Health Care
Luca Crivelli, Gianfranco Domenighetti and Massimo Filippini* 1. Introduction Switzerland does not have a National Health Service like Italy and Great Britain, nor is its system based on a public insurance scheme such as in France and Canada. The Swiss health-care system is based upon a mixed insurance model. On the one hand, competing private non-proﬁt companies are responsible for health insurance, and on the other hand, the system incorporates some elements that are normally adopted within the context of a social insurance, such as mandatory insurance for all residents, regulated and risk-independent premiums, public subsidies to the less wealthy for the payment of the insurance premiums. In an unusual healthcare context such as the Swiss one, the decision-making autonomy of the single cantons, reinforced by ﬁscal federalism, has led to a highly heterogeneous system. This heterogeneity applies both to the production capacity and to the speciﬁc weight which each canton attributes to the various forms of health-care provision (for example to public versus private hospitals or nursing homes). Instead of being a single health-care system, Switzerland can therefore be considered an ensemble of 26 subsystems, connected to each other by the Federal Law on Health Insurance (FLHI). In contrast to the majority of European countries, where the ﬁnancial contribution of the state to health-care expenditure is signiﬁcant, the Swiss system provides for a rather limited public participation. Moreover, the mandatory health insurance premiums are independent of income, and citizens ﬁnance 42 per cent of total health...
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