The new system of care financing that came into effect on 1 January 2011 reflected the political will to achieve two major goals: firstly, to avoid placing an additional financial burden on mandatory healthcare insurance (OKP), which had previously taken on more and more of the rising costs of age-related care, and, secondly, to improve the difficult social situation of certain groups of people who are reliant on care. The core element of these new arrangements, and thus the main factor in attaining the stated goals is the capping of OKP and patient contributions to care, with responsibility for the remaining costs being transferred to the cantons. Additional social policy measures include: increasing the eligibility threshold for supplementary benefits to the old-age and survivors' insurance (EL), introducing an attendance allowance for people demonstrating a slight degree of disability (‘helplessness’) who wish to receive care at home, and obliging the cantons to ensure that admission to a care home does not result in the patient becoming dependent on social assistance. These rules will inevitably – and as desired by the policymakers – result in the cantons and communes shouldering an increased burden of costs. The evaluation report on these new arrangements, published in July 2018, shows that the first major objective of limiting the additional financial burden on the OKP has been achieved. Spending on care under mandatory healthcare insurance has stabilised and the share of costs funded by premiums has not increased. The second main objective, of improving the difficult sociopolitical situation of persons in need of care, has been only partly achieved. Shortcomings in implementing the reform, and therefore a need for action, can be found in particular with regard to flaws in the financing of the uncovered care-related costs by the cantons and the failure of service providers to delineate properly between care-related costs that fall under the KVG and those that do not. In addition, the restrictions on the patient’s share of these costs is not always observed. The cantons have mostly complied with their duty to avoid persons becoming dependent on social assistance because of a stay in a care home, yet there are still indications of this happening in individual cases that should no longer be occurring, which suggests uneven implementation by individual cantons.
Two decisions handed down by the Federal Administrative Court in 2017 (C-3322/2015 and C-1970/2015), condemned the customary practice of agreeing payments for nursing supplies in service agreements with health insurers as unlawful. This has made the situation worse for service providers, especially those providing outpatient services, although payments in this area would be ensured without any actual funding gap arising if the cantons would simply comply with their legal obligation (Federal Supreme Court decision (9C_446/2017) to cover the remaining costs.
The Federal Council wishes to change the law and introduce new rules for the payment of medical care products, making them fully coverable under mandatory healthcare insurance (OKP), regardless of whether the products in question are being used by the insured persons themselves or by a healthcare professional. At present, the KVG provides for payment by the health insurance company only if the medical care product is being used by patients themselves or non-professional helpers. This payment is not available for care or nursing supplies that are used in homes or by Spitex. According to the draft act that has been presented, the new rule should now also apply to retirement and care homes. However, CSS does not consider any amendment of the law to be necessary in this respect, as the medical care products in question are being used by professionals in 95% of cases. The effort required to delineate the remaining 5% of cases is minimal and bears no relation to the additional costs of around CHF 100 million a year that the OKP would have to pay out. The cantons and communes would save the same amount. As CSS sees it, burdening the premium payers with these additional costs is neither justifiable nor defensible. Therefore, the planned rules should be restricted to the one area in which it is difficult to clearly distinguish between use of medical care products by professionals or by patients and their non-professional helpers, i.e. in outpatient care.
Growing cost pressure, which is system-based, has caused cantons and communes to voice greater criticism of the financing system as we know it, publicly question its viability and step up the political pressure for system changes, if not a complete overhaul. This is also reflected in the political initiatives that are regularly launched. Nevertheless, there is no need to amend the legislation at present or to make any fundamental changes to the financing model (e.g. by making nursing insurance compulsory). According to a Federal Council report on the outlook for long-term care, the current method of contribution-based financing remains legitimate in the medium term. Not until 2030 onwards does the Federal Council see a need for reform driven by cost trends.
Arrangements for financing care of the elderly and long-term care remain within the remit of the state and its social policy. Regardless of the financing model, the sources of funding used thus far (taxes, premiums, direct co-payment / self-financing) cannot be extended. Alternative financing models would merely change the share of costs to be borne by the individual parties. Therefore, before any change to a new model takes place, the question of social compatibility and solidarity must be answered.