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. Regardless of this, the Federal Council has made changes to the laws and ordinances and an amendment to the aids and appliances list (MiGeL) that introduce new rules for the payment of medical care products as of 1 October 2021. The provisions state that, in future, medical care products in accordance with MiGeL – whether used in outpatient care or nursing homes – are to be fully covered 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. These new rules will burden the OKP with an additional CHF 65-100 million a year and relieve the canton of costs of the same magnitude.
Growing cost pressure, which is demographically driven, has caused cantons and communes to voice greater criticism of the financing system as we know it, question its viability and step up the political pressure for system changes, if not a complete overhaul. This is reflected in the political initiatives that are regularly launched. In CSS's view, especially given the amendments that have already been enacted, there is no need to amend the legislation further or to make any fundamental changes to the financing model (e.g. by making nursing insurance compulsory).
Ensuring arrangements for providing and financing care of the elderly and long-term care are and 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 do nothing to change financing requirements. They merely change who pays and the share of costs to be borne. Therefore, before any change to a new model takes place, the question of social compatibility and solidarity must be answered.
The possible integration of care financing into EFAS calls for a reassessment and repositioning. It is clear, however, that the burden placed on the cantonal and local authorities as a result of the growth in volume and rising costs is disproportionately high. This is stretching the maintenance of the current contribution system more and more to its limits in political terms. Integrating care costs into EFAS would largely silence the recurring demands for a fundamental system change (care insurance, care savings account, etc.) and thus enable a financing model to be maintained that is still based on solidarity (premiums financed from tax revenues, and insured persons making a contribution to costs).