Health insurance premiums: discounts for foregoing end-of-life treatments (cross-border guide)

Context

In brief

• Slembeck proposes reduced premiums for those who forgo end-of-life treatments.
• The idea comes after yet another premium increase.
• Three factors drive costs: demographics, technology and demand.
• The model would be voluntary and individual.

Key facts

• Proponent → Tilman Slembeck, healthcare expert and economist
• Institutions → ZHAW, University of St. Gallen, Confederation and cantons
• Source → interview with NZZ after the premium increase
• Proposal → more affordable premiums in exchange for forgoing therapies
• Costs → demographics, medical-technological progress and maximum care
• Scope → life-prolonging therapies at the terminal stage

Tilman Slembeck, a healthcare-sector expert and professor of economics at ZHAW, the Zurich University of Applied Sciences, has proposed lower premiums for those who voluntarily forgo life-prolonging therapies at the terminal stage. The idea was outlined in an interview published by Neue Zürcher Zeitung (NZZ) following yet another premium increase.

Slembeck also teaches at the University of St. Gallen and has followed the sector for years, advising the Confederation and the cantons. His thesis is that the Swiss healthcare system has not yet reached its limit: it is designed to expand and resembles a self-service store. People continue to pay their own premiums, while the state eases the burden on more than a third of low-income families through premium subsidies worth billions.

“The pain threshold is still far from being reached,” the academic argues.

The cost argument starts from three elements. Demographics weigh heavily because the population is aging and the baby-boom generation is entering an age in which it makes more frequent use of medical services. Medical-technological progress makes more effective treatments available, including those in cancer therapy, but also very costly ones. Finally, those who pay premiums for years expect the maximum level of care when they need it and do not want to give anything up.

The limit on care, according to the expert

The most delicate point concerns the end of life and the relationship with cassa malati. Treatments can become very costly, and Slembeck doubts that it is possible to set a collective limit accepted by everyone. Even within a family, he observes, it is difficult to decide whether to adopt life-prolonging measures and which ones to choose. Cost-driven rationing seems to him almost impossible to accept at the social level.

The proposed approach shifts the level at which the decision is made: the insured person voluntarily forgoes life-prolonging therapies at the terminal stage and receives more affordable premiums in exchange. Slembeck considers this individual self-rationing feasible in principle. The proposal is linked to his idea of healthcare networks beyond cantonal borders, competing with one another and based on flat-rate amounts per insured person.

Operational details

What would change for the insured person

For the reader, the practical point is not an already quantified discount, but the mechanism being considered. The reduction in premiums would be linked to a specific renunciation: not using life-prolonging therapies when the condition has reached its terminal stage. The financial benefit, therefore, would not be separate from the healthcare decision, but would be the trade-off for it.

Two levels of decision-making

In the first scheme, the limit would concern society as a whole and would require social agreement. In the second, the decision would remain with the person who chooses to join the model. It is this shift that makes the idea different from a generalized cut in benefits: the incentive is not imposed on everyone, but would accompany an explicit renunciation by the individual.

The trade-off is stark. Anyone who pays premiums for years tends to expect maximum coverage when they need it; the imagined model instead asks them to accept foregoing those therapies precisely in the terminal phase, in exchange for more affordable premiums. The source does not indicate the amount of the discount, the enrollment formula or a start date. It therefore does not make it possible to estimate the savings or determine which insured persons would fall under the model.

Which part of the costs would be affected

The proposal would act on the willingness to give something up, not on the aging of the population or the price of new treatments. In other words, it would intervene on the third factor identified by Slembeck, leaving the other two unchanged. This is also why the issue enters costo della vita as a choice between lower recurring expenditure and a voluntary limitation of future care, not as a general solution to rising costs.

The organizational dimension remains national and cantonal. The healthcare networks envisioned by Slembeck would have to cross cantonal borders, compete with one another and operate with lump-sum amounts per insured person. The model of more affordable premiums fits into the same logic: if no one wants to give anything up, the financial incentive would become the lever for curbing growth.

Recommended tools

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Key points

How to read the proposal and follow its developments

Anyone who wants to assess the idea can start from a simple distinction: the source describes a model suggested by the expert, not a process to be activated for insured persons. The conditional formulas used in the text indicate a hypothesis. This avoids turning the benefit described into an already available right or looking for a deadline that the source does not indicate.

A five-step check

1. Define the scope. The waiver concerns life-prolonging therapies in the terminal phase. It should not be extended to every medical treatment or every choice concerning premiums: the connection described is between a specific decision and more affordable premiums.

2. Separate the objective from the instrument. The objective is to ease the growth of health insurers' costs; the instrument hypothesized is individual self-rationing supported by a financial incentive. Keeping the two levels distinct prevents presenting the discount as a general reform.

3. Verify who decides. The text contrasts the collective limit, which is difficult to share for cost reasons, with the individual's voluntary choice. This is the question to use when reading any possible development: is the decision proposed for everyone or only for those who opt in?

4. Isolate the spending factors. Demography, medical and technological progress, and demand for the highest level of care play different roles in Slembeck's reasoning. The proposal concerns only the willingness to waive treatment; it does not replace analysis of the other two factors.

5. Consider the organizational dimension. Slembeck links the issue to healthcare networks extending beyond cantonal borders, competing with one another and capable of working with lump-sum amounts per insured person. The Confederation and the Cantons are already identified in the source as stakeholders whom the expert has been advising for years.

For a responsible reading, it is advisable to separate what is described from what still needs to be defined: the amount of the premium, the method of enrollment, and practical implementation are not set out in the text. There is no need for estimates based on missing data. Instead, it is important to keep clear the link between individual choice and financial incentive, which is the heart of the proposal.

To organize the weight of personal expenses, use the calcolatore stipendio.

Source: tio.ch