The popular votes of 2024 are of particular interest to those interested in Swiss political life. To take a closer look at the issues put to the vote on 9th June, DeFacto asked Philipp Trein about the results of the three popular initiatives at federal level.
Three of the four federal issues put to the vote on 9th June concerned healthcare, and all were popular initiatives. How do you explain the fact that this issue is occupying so much space in the public debate? Are the authorities devoting enough energy to it?
Philipp Trein: First of all, rising health insurance premiums against a backdrop of inflation are further eroding household purchasing power. This dynamic is putting pressure on political decision-makers to take measures to reduce costs, even though this is not a new issue.
However, I believe that it is difficult for the authorities to introduce far-reaching reforms in this area, since responsibility for the Swiss healthcare system is particularly divided: The Confederation is responsible especially for compulsory health insurance, drug approvals and health policy; the cantons are responsible for other aspects, i.e. they are responsible for organising the provision of healthcare and financing healthcare expenditure through taxation; and finally, interest groups, and in particular professional associations, negotiate and define the tariff system and the price of healthcare services. There is, so to speak, no one true driver of the healthcare system, but several players with different interests.
In addition to these structural elements of the Swiss healthcare system, healthcare policy reforms are difficult to implement because political decision-makers are faced with four often conflicting objectives: quality care, guaranteed access to care, freedom of choice of insurance and providers, and the financial viability of the system. Against this backdrop, the initiatives of the SP and the Centre have both focused on one of the four strategic goals of Swiss healthcare policy, with the aim of obtaining a response from the people in order to prioritise one of these elements. These initiatives, which come from different parties, each aim to prioritise a specific goal to the detriment of the others.
Both the initiative put forward by the Centre and that of the Socialist Party on the financing of the healthcare system were rejected. How can convincing reforms be envisaged if neither the bourgeois nor the left-wing political parties manage to rally a majority around their respective proposals?
On the one hand, the launch of the two initiatives is proof that the public wants to see politicians provide solutions to the problem of healthcare costs, but on the other, the results show that the proposals on the table had too many disadvantages to convince a majority.
As far as the Socialist Party is concerned, previous initiatives on a single health insurance fund have garnered significantly less support at the ballot box than the one on 9th June – turnout was also higher in 2024. The initiative on which we voted was based on a similar argument, namely to facilitate access to healthcare by strengthening the redistributive nature of the payment of health insurance premiums. The discussion is still open, since the SP may be relaunching the idea of a single health insurance scheme, and a pilot project for a public health insurance scheme will be launched in the canton of Geneva.
As far as the Centre is concerned, it’s clear that the Swiss people are not prepared to compromise on access to healthcare. In my opinion, people feared a reduction in healthcare provision if the initiative were to pass.
The question of the cost of the healthcare system has been clearly put to the Swiss people. Is it fair to say that, on average, they attach more importance to the financial health of the cantons and the Confederation than to their own wallets?
The acceptance of a 13th AHV pension last March may, paradoxically, have made voters more reluctant to endorse new federal spending by accepting the initiatives on the healthcare system. In my view, the two votes are linked, and it is likely that the initiators would have had more success if the votes had been held at longer intervals.
Based on the results of the vote on 9th June, it is clear that the Swiss people do not want a brake on healthcare costs along the lines of the debt brake – which is also very popular in the German-speaking part of Switzerland. Nevertheless, there is a slight trend towards a more redistributive healthcare system, even if it is premature at this stage to achieve a double majority of the people and the cantons. In order to understand the rejection of the two initiatives by the SP and the Centre, it would be necessary to analyse the acceptance rate for each commune according to the average income of its inhabitants and the amount of its average premium.
With a clear “Röstigraben” over the results of the initiative to cap premiums, isn’t it ultimately the question of the role of the welfare state rather than the issue of health that divides the German-speaking and French-speaking Swiss? What explains the majorities in favour of the two initiatives specifically in the cantons of Fribourg, Jura, Neuchâtel, Valais and Ticino?
Historically, there have been different ideas on either side of the Sarine about how the Swiss healthcare system should be financed. When the Health Insurance Act (KVG/LAMal) was introduced in 1994, there was a great deal of debate about the role of the market and the individual’s free choice of whether or not to take out insurance, and about the role of the state in this new insurance system. The left-wing initiatives on the single health insurer and the most recent vote on capping premiums return to this debate. The results of the vote suggest that people in French-speaking Switzerland were more in favour of state intervention, while people in German-speaking Switzerland were very much opposed to the idea of limiting the choice of health insurer and/or doctor.
In general, political proposals that appear to strengthen the role of the state in health insurance policy have had difficulty gaining acceptance because voters are sensitive to the argument for securing individual freedom in a context where the state is reinforced. During the vote on healthcare networks in 2012, the FMH successfully used this very argument to oppose the project. However, compared with previous votes on a single health insurance fund, the vote on 9th June 2024 shows growing support for a stronger role for the state and greater redistribution in health insurance policy.
As far as the initiative launched by the Centre is concerned, I’m not convinced by the Röstigraben. The fact that it was largely rejected in the cantons of Geneva and Vaud is the most telling illustration of this. If we look at the communes, the results are rather close and there is no strong majority. I hypothesise that the cantons with a historically strong Centre party tended to support the initiative. Perhaps the population of rural cantons visit specialist doctors less often, which could also explain the lower level of rejection in these regions.
After the failure of the three referendums against the COVID-19 Act and the end of the pandemic-related measures, one might have thought that the social movements and popular reluctance towards health measures would fade away for good. The fact that we voted on an initiative to guarantee physical integrity in June 2024 proves that this is clearly not the case. What can we say about this consistency over time?
There is a section of the Swiss population that is opposed in principle to the way health policy is organised in the Law on Epidemics (LEp). The COVID-19 crisis was a very concrete example of its application and its most controversial measures – in particular the pressure to vaccinate without making it compulsory. Supporters of the initiative are generally individuals who distrust the bureaucratic state in the broadest sense, the federal administration and its duty to apply abstract rules.
With regard to the various votes on the COVID-19 Act, the people who rejected it are probably the same people who accepted the initiative. The issue remains on the political agenda also because the World Health Organisation (WHO) is planning to improve preparedness for pandemics, in particular by better organising the distribution of vaccines between developing and rich countries. The SVP, which is fundamentally opposed to international agreements, has therefore taken up the issue.
Do you think the issue of healthcare will remain as divisive in Switzerland in the future?
Swiss politics has been generally polarised for some years now (see the book by P. Sciarini, M. Fischer, D. Traber, “Political Decision-Making in Switzerland: The Consensus Model Under Pressure” , 2015) but this doesn’t necessarily lead to inefficient or less legitimate reforms. Moreover, the cantons are currently working on various projects to reduce healthcare costs, and the “laboratory” aspect of federalism is likely to encourage the other cantons to take action. I don’t think that the Confederation will be able to take the lead in healthcare policy in the long term, as this would probably divide the population even more than the actual system.
Otherwise, rising costs and premiums remain the predominant issue dividing Swiss society. We will be watching to see whether the Socialist Party brings back its idea of a public health insurance fund, with the possibility of linking the amount of the premium to income – which would effectively turn it into a tax. As I said earlier, the issue of redistributing healthcare costs is an ongoing debate. In my view, the liberal ideal of the individual being solely responsible for his or her own condition is only partly valid:
The risk of getting ill depends not only on individual behaviour but also, to a very large extent, on factors beyond human control, in other words, by chance. That’s why a general, redistributive insurance makes sense. As long as healthcare costs continue to rise at the current rate, issues such as redistribution and the catalogue of medical benefits will remain an important topic in healthcare policy. The fate of the indirect counter-proposals to the two initiatives will have a major influence on this debate.
Philipp Trein is Assistant Professor for Public Administration and Policy at the University of Lausanne. His areas of research are policy integration, digitalization, health policy and crisis politics.
Picture: unsplash.com
