How Switzerland delivered health care for all -- and kept its private insurance

JUDY WOODRUFF: We return now to our special series on universal health care. Since the pandemic began, a growing number of Americans think the U.S. health care system is below average compared to other nations. That is according to our latest "PBS NewsHour"/Marist poll. As the U.S. considers changes, William Brangham and producer Jason Kane travel to Switzerland, which has preserved the private insurance market, while still achieving universal coverage. Like this whole series, this story was filmed before the pandemic erupted. WILLIAM BRANGHAM: The Swiss shop for health insurance a lot like they do their groceries. There's a wide array of choices. This cheese or that one? One with the high deductible or one with the high premium? For all Swiss families, like the Prestons, it's a system that, in some ways, is even more market-driven than our own. But the big difference? Everyone here is covered.

The idea behind it is what's known as social solidarity, and it's what impressed American-born Jason, who's a teacher, when he moved here and married Sabine (ph), who is Swiss. JASON PRESTON, Switzerland: For me, it's just sort of a basic right, and they seem to appreciate that. WILLIAM BRANGHAM: Do you see it that way, too? I know that the Swiss talk about it that way. Do you buy that idea that health care is a right? JASON PRESTON: Yes, because, I mean -- yes, I mean, coming from where I come from, there's this sort of negativity in the States that, well, if you're poor, then it's almost like you deserve to die, right, for being poor. It's like you're being punished for circumstances that are outside of your control. It may not be said like that explicitly, but that's kind of the feeling, the vibe that's given off, that, well, if you can't afford it, well, you don't deserve to be well. WILLIAM BRANGHAM: Health insurance in Switzerland is costly. Jason and Sabine pay about 16 percent of their income on premiums. On top of that, the average Swiss pays more out of pocket for things like co-pays than the average American. But the Prestons like the care they get, and they like buying into

a system that protects everyone. JASON PRESTON: Here, it's a bit more humane. It's like, look, there's a basic level of care that people deserve. It costs, but you still deserve it. And I think that the Swiss government's commitment to that is spot on. WILLIAM BRANGHAM: This is one of the men who helped design that system. Thomas Zeltner was Switzerland's state secretary of health for many years, and is now a consultant to the government, and, until recently, chaired one of the country's private insurance companies. THOMAS ZELTNER, Former Swiss Secretary of Health: In the '90s, there was a debate on, is health care such an essential part of well-being, and feeling safe in your country and in your neighborhood, that you want that everyone has access to it? And, actually, it was something like 70 percent of the population who said, we want that. WILLIAM BRANGHAM: Wow. That is a resounding yes. THOMAS ZELTNER: Yes. WILLIAM BRANGHAM: Zeltner says one of the crucial innovations was separating health

insurance from employment, which has allowed the Swiss to keep their health insurance during the pandemic, while millions of Americans are losing theirs when they lose their jobs. They have been able to separate the two, but instead of making the government the single payer, like in the U.K., they have made it so that a wide array of insurance companies can flourish. THOMAS ZELTNER: And the fun thing is, you can choose. And I just told a friend, I can choose to go to the barber here or there. Since 30 years, I go to the same barber. (LAUGHTER) WILLIAM BRANGHAM: And he does a nice job. THOMAS ZELTNER: But the option -- but the option to be able to choose is kind of a freedom. WILLIAM BRANGHAM: This is all now baked into society, as Swiss as this country's famously punctual rail system. There are roughly 60 private companies selling plans, but the Swiss government does take a firm hand in regulation. It mandates basic coverage that all plans must include, and

the government sets the prices that can be charged for medications and procedures. Depending on the plan they choose, the Swiss can pick their own doctors and avoid needing referrals for specialists. Wait times for procedures are low, in part because doctors get paid well, there's a lot of them, and the system is competitive. I met up with New York University's Victor Rodwin. He's a health policy expert who's traveling across the country studying its health care system. VICTOR RODWIN, New York University: The Swiss have the lowest avoidable mortality rate. WILLIAM BRANGHAM: Avoidable mortality. VICTOR RODWIN: Which means -- which means mortality amenable to health care intervention. It means the lowest rate of people who die who shouldn't die. The U.S. has the highest. WILLIAM BRANGHAM: The Swiss live about five years longer, on average, than we do, and they're a lot healthier than we are, suffering far lower rates of asthma, diabetes, heart disease and hypertension. Rodwin credits part of that to Swiss health care, a system which polls incredibly well here.

VICTOR RODWIN: They express high confidence in the medical profession and high confidence that, if a problem occurs, they know they're covered. There's a sense of quality in this country which goes from chocolate to cheese to watches. And in health care, it's the same. They do things carefully and at generally high quality. WILLIAM BRANGHAM: Swiss officials say there's another main reason they achieve these results. It requires everyone, like Mel Hirsig, to have insurance, no excuses. It's similar to the individual mandate with the Affordable Care Act but, unlike the ACA, this mandate has sharp teeth. The government will garnish your wages if you don't comply. That's partly how they get universal coverage, but, for young people like Hirsig, who don't need a lot of medical care, it can seem like a big imposition. So, what happens? If you don't buy the insurance, what happens to you? MELANIE HIRSIG, Switzerland: Well, it's also like you have to be registered to get a job,

you have to have an address, you have to then show the local council office your proof of health insurance and blah, blah, blah. WILLIAM BRANGHAM: Oh, really? MELANIE HIRSIG: So, they can chase you down quite easily. WILLIAM BRANGHAM: Oh, really? MELANIE HIRSIG: Mm-hmm. WILLIAM BRANGHAM: And if the government wasn't forcing you to buy health insurance, do you think you would buy it anyway? MELANIE HIRSIG: No. I wouldn't have it for... WILLIAM BRANGHAM: Just because that monthly cost is too much? MELANIE HIRSIG: And because I don't use it. I don't get my money's worth out of it. WILLIAM BRANGHAM: The government offers premium subsidies for lower-income workers, and it caps yearly out-of-pocket expenses. So, unlike the U.S., people rarely go bankrupt from medical bills. WOMAN: That's the list of all your debt. WILLIAM BRANGHAM: But those premiums can sometimes lead to serious debt for middle-income families. This woman didn't want her name revealed because of the stigma around debt. Her husband had multiple surgeries, lost his job, and their income dried up. WOMAN: We were getting subsidies to help pay for the health insurance, but we still had

to pay a large portion ourselves. WILLIAM BRANGHAM: And even with the subsidy, it still was unaffordable? WOMAN: At the time, it was unaffordable for us, yes. I think it is expensive, but I think the health care is also very good. WILLIAM BRANGHAM: So, even though the costs put you at real financial peril, you still see some benefit to the system? WOMAN: Because I see that, if everybody pays into health insurance, it makes the quality of health insurance better for the population. DR. ASHISH JHA, Director, Harvard Global Health Institute: Intensive care is very expensive. WILLIAM BRANGHAM: Brown University's Dr. Ashish Jha studies health care systems around the world, and he traveled with us for this series as a collaborator. DR. ASHISH JHA: I think what's really remarkable about what we have seen here in Switzerland is, it's a totally different model for achieving universal health coverage, getting -- making sure everybody has access to health care, providing high-quality care, in a way that's so different from what the U.K. does, through the National Health Service, and actually, in many ways, pretty different from the U.S. approach.

WILLIAM BRANGHAM: Jha notes the U.S., of course, is a much bigger nation than Switzerland, has a higher poverty rate, and the Swiss have a more robust safety net. But there's more. DR. ASHISH JHA: And that is kind of the rule-following mentality of the Swiss, that the government says, you must buy health insurance, and everybody says yes, OK, we will buy health insurance, as opposed to in America, where we bristle when the government tells us we have to do anything. And we bring up the broccoli argument: What if the government made you eat broccoli? The Swiss don't worry about eating broccoli. They think, if the government thinks that's something we ought to do, we will do it. And in that way, it is very different, and it allows the Swiss health system to function differently than what we have been able to do in the U.S. WILLIAM BRANGHAM: For the record, the Preston girls not big fans of broccoli, but Sabine and Jason are fine with it. They also know the insurance mandate costs them a lot, but they see it as part of the greater good, part of being Swiss. For the "PBS NewsHour," I'm William Brangham in Oberhofen am Thunersee, Switzerland.