Passing Healthcare Reform- Key Politicians’ impacts with Regards to Switzerland and the U.S

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Sarah DeCloux

Comparative Politics

Professor Tom Villis

February 25, 2013

Passing Healthcare Reform: Key Politicians’ impacts with Regards to Comparison between

Switzerland and the U.S.

Healthcare reform has a historical background for being highly

controversial in politics. For starters, healthcare impacts entire populations

directly. Everyone has to live with the outcome, therefore, politicians need to

be successful the first time around; there are no second chances. In addition,

healthcare must be affordable for a diverse economic population. As the

cost of treatment goes up, so the importance of maintaining sustainable

prices becomes crucial. Healthcare is a complex creature and needs to be

handled with delicate consideration. Funding, systematic distribution of

services and quality are all important elements that must have priority in the

minds of policy makers when creating a healthcare system that contributes

instead of detracts from the national wellbeing.

So how do politicians pass healthcare reform while keeping the

multitude of factors in mind? The purpose of the paper is to explain the

politics involved in reforming two similar, yet very different, healthcare

systems in two dissimilar countries: the United States of America and

Switzerland. We will look at the political journey of reform in each state while

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paying specific attention to the key politicians who were instrumental in

positive and negative aspects of these transformations. As healthcare is a

politically charged issue, this comparison will show that the disagreement

between politicians and parties is the same for both nations, however; it will

also show that there is more than one way to pass healthcare reform.

On February 24, 2009, President Obama proposed health care reform

for the United States. Knowing there would be many obstacles to reform he

stated, “So let there be no doubt: Health care reform cannot wait, it must not

wait, and it will not wait another year.”1 President Obama was adamant

about passing healthcare reform and didn’t give much time to accomplish

such a difficult task. From the start when the Senate Finance Committee

began discussions regarding the budget deficit and how to reform healthcare

efficiently, there was enormous controversy surrounding it. Senator Max

Baucus (a Democrat from Montana) and Senator Chuck Grassley (a

Republican from Iowa) led the Senate Finance Committee in hearing ideas

for reform. While the Republicans listened to experts critically, the

Democrats had already come up with a plan. This was the beginning of the

battle between President Obama and his Democrat allies, and the GOP

resistance.

1 Emily Smith, "Timeline of the Health Care Law," CNN, June 28, 2012, accessed February 24, 2013, http://www.cnn.com/2012/06/17/politics/health-care-timeline/.

http://www.cnn.com/2012/06/17/politics/health-care-timeline/

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Republican Senator Charles Grassley, of the Senate Finance

Committee, was not swayed by the president, as he had consistently claimed

that he would not support any bill if there were not enough Republicans to

mandate a 70-80 vote.2 Meaning, he would vote on the Republican side

unless there was a seventy to eighty percent majority in agreement. Still, the

first reform draft was passed in the senate after a month-long markup,

during which 788 proposed amendments had to be considered. Fifteen days

later, the house also passed the bill by an extremely small margin.

The second draft brought on a new, more intense, struggle between

the two parties. Bill Nelson (a Democrat from Nebraska) was one of three

Senate members who had not been persuaded into voting either way. He

was pressured fiercely by the Democratic Party and President Obama to vote

in favor of healthcare reform. Hence, he became the 60th and final vote

needed to pass the second draft of reform entitled ‘America’s Affordable

Health Choices Act.’3

The second draft was in the works, when Senator Ted Kennedy died

after his battle with cancer. Senator Kennedy had been extremely influential

in supporting the President’s plan, as healthcare reform in America was his

lifelong dream. The death of Senator Ted Kennedy, in August 2009, left

2 John K. Iglehart, "Obama's Vision and the Prospects for Health Care Reform," The New England Journal of Medicine, October 1, 2009, http://www.nejm.org/doi/full/10.1056/NEJMp0908476?view.3 Emily Smith, "Timeline of the Health Care Law," CNN, June 28, 2012, accessed February 24, 2013, http://www.cnn.com/2012/06/17/politics/health-care-timeline/.

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democrats fearful at the prospect that the former majority they had

previously enjoyed was at risk. President Obama quickly stepped up to back

democrat Martha Coakley speaking on her behalf during the Massachusetts

elections to fill Senator Kennedy’s seat. In a close race, Republican Scott

Brown won the election and replaced Massachusetts’ seat in the senate.

Scott Brown’s vow to vote against any health reform bill compelled the

Democrats to take serious action. Knowing that they would no longer have

the higher edge to push the bill passed the senate, they went to desperate

lengths to keep the ball rolling.4

Although President Obama claimed to adhere to a bipartisan policy, his

address to Congress, during the Bipartisan Health Care – Summit 5,

threatened to use “reconciliation” in order to overthrow them entirely if they

did not adhere to the desires of the Democratic. Reconciliation, a process

only historically used when dealing with issues regarding deficit and budget,

was indeed used to defeat the Republican Party and pass the healthcare

reform bill. On March 21, 2010, the Senate used the reconciliation clause to

pass the Patient Protection and Affordable Care Act despite 100% opposition

from Republicans. It was signed into law by President Obama on March 23,

2010.5

4 Emily Smith, "Timeline of the Health Care Law," CNN, June 28, 2012, accessed February 24, 2013, http://www.cnn.com/2012/06/17/politics/health-care-timeline/.5 Ibid

http://www.cnn.com/2012/06/17/politics/health-care-timeline/

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President Obama used several tactics to threaten, demean, and

pressure any opposition to his bill. In addition, his demand to pass healthcare

reform by the end of the year heightened the controversy of the situation

and truly forced a stalemate between the Republicans and Democrats.

Obama refused to fail at his objective and constantly reminded Congress, “I

am not the first president to take up this cause, but I am determined to be

the last.”6 The phrase, “My way or the highway,” comes to mind when

describing the President’s leadership style and influence regarding

healthcare reform in America.

*Health Insurance Reform in Switzerland was also extremely

controversial and tricky. The decentralized Swiss government was forced to

reform healthcare due to rapidly rising costs. In an attempt to understand

how large the issue was, “The Government appointed a commission of

experts, representatives from labor and capital and civil servants to develop

an encompassing overview of the financial problems and possibilities of

social insurance in Switzerland.”7 The government felt that regulating

6 "Remarks by the President to a Joint Session of Congress on Health Care | The White House," Remarks by the President to a Joint Session of Congress on Health Care | The White House, accessed February 24, 2013, http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-to-a-Joint-Session-of-Congress-on-Health-Care.7 Silja Häusermann, "Reform Opportunities in a Bismarckian Latecomer: Restructuring the Swiss Welfare State," Government Department, Harvard University and IPZ, University of Zurich, June 2006, http://www.people.fas.harvard.edu/~ces/conferences/bismarck/docs/pdf/haeusermann.pdf.

*Finding information regarding key politicians in Swiss healthcare reform was extremely difficult, therefore this section was organized differently than the previous section on the United States.

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insurance would be the best way to cut costs. Their main goals were to

contain costs, provide efficiency, control the market competition thereby

increasing solidarity, and promote individual responsibility.

The proposal was presented to Parliament in 1991. However, in a state

with direct democracy the government needed to take the national

referendum into account. In order to define direct democracy and national

referendums we must realize that, “In the Swiss political system, legislative

reforms (and other political decisions) must pass a popular referendum. The

referendum system is the primary cause of a built-in conservative bias in

policy making because radical changes mostly do not find a majority.”8

Depending on how you look at it, direct-democracy can be a blessing or a

curse. In the positive, it gives the common everyday person a voice and

reinforces a sense of beliefs and belonging. Yet on the other hand, direct-

democracy maintains a much slower pace for passing legislation. “Two of the

three reforms (healthcare and pension) have been subjected to a

referendum, which shows a weakness of well-established consensus building

mechanisms within government and parliament.”9 From this perspective it

almost makes the federal government redundant, but someone has to draft

legislation.

8 European Observatory on Health Care Systems, "Health Care Systems in Transition: Switzerland," Who.int, 2000, http://www.euro.who.int/__data/assets/pdf_file/0003/96411/E68670.pdf.

9 Jochen Clasen, "Social Insurance in Europe," Google Books, 1997, accessed February 24, 2013, http://books.google.com/books/about/Social_Insurance_in_Europe.html?id=dogOb37lX5EC.

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Since most health related responsibilities do not fall to the federal

government they also depended on cantonal and municipal entities to

provide them with the task of reform. The cantons in Switzerland are broken

up into 26 separate entities.10 As their governmental system requires, “The

federal government can only legislate on a social policy once the authority to

do so is transferred from the sub-national.”11 Once the federal government

was laden with the responsibility of reform, they also received pressure from

the many interest groups which insisted they had a say as well. In order for

reform to be successful, it was crucial that the federal council took all of the

reactions of the many actors into consideration and formulated a plan based

on compromise.

The complexities faced by the government in mandating national

insurance coverage were, and still are, the reason social reform in

Switzerland takes so long. Readmitting a constitutional amendment for

mandatory health insurance took 106 years, from 1890 till 1996.12 This delay


11 Silja Häusermann, "Reform Opportunities in a Bismarckian Latecomer: Restructuring the Swiss Welfare State," Government Department, Harvard University and IPZ, University of Zurich, June 2006, http://www.people.fas.harvard.edu/~ces/conferences/bismarck/docs/pdf/haeusermann.pdf.


http://www.people.fas.harvard.edu/~ces/conferences/bismarck/docs/pdf/haeusermann.pdf


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in time shows how slow social reform can be in a direct-democracy. The

debate regarding retrenchment was nothing new for Switzerland. Over the

fifteen years prior to the legislation actually getting passed, cost

containment had been a major priority for the Swiss government and people.

This was one aspect of reform that everyone agreed on. However,

proceeding with reform in light of ever growing concerns for economic and

demographic development provided a large divide amongst several actors.

One major issue dealt with the extent to which reform would reach, “There is

far more controversy about the measures that need to be enacted to achieve

the aims of the reform. The federal government feels that the fundamental

mechanisms of the law must be retained and refined, whereas other actors

are demanding more far-reaching reforms.”13

Although the government had to keep in mind all of the groups and

entities that could have opposed the reform, one area that remained stable

was the cooperation of the political parties. There are four parties which

have remained consistent for over 45 years, the Social Democrats, Liberal

Democrats, Swiss People’s Party, and the Christian Democrats. Three out of

four parties claim similar stances when it comes to social reform and thus

contributed greatly to the success of pursuing healthcare reform. These

three parties together had the power to push through even controversial

measures, but the knowledge of the impending public referendum kept them


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in check.14 Still, political parties becoming more influential in Swiss politics

has become a trend since 1980, “Political parties have become more

relevant in policy formulation, compared to the past. Many recent

modernizing reforms were designed by the parties in parliament, rather than

by labor and capital in the pre-parliamentary negotiations. This may be

explained by the inability of the social partners to foster compromises over

retrenchment, by the higher proportion of women in parliament or by the

stronger sensibility of parties to libertarian values and gender equality, as

compared to trade unions and business organizations.”15 Regardless, it was

not party agendas that complicated healthcare reform. In fact, since 1990

the political parties have been very successful in negotiating compromise

between them. And since the majority had a common goal of reducing cost

expenditures in healthcare, they easily agreed on how to define reform,

"Social policy in Switzerland does not mean redistribution, but status

protection.”16 Their aim was not to redistribute wealth, but to encourage








http://books.google.com/books/about/Social_Insurance_in_Europe.html?id=dogOb37lX5EC


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active participation and individual responsibility to finance the mandatory

health insurance.

Ruth Dreifuss, the first female president of Switzerland, made it her

mission to push healthcare reform through this process. Before her

presidency, in the position of the interior minister, she began by dividing and

conquering. Health reform was set in two stages. First, she concentrated on

a global budget and increasing federal subsidies. Then she attempted to

move some of the weight for hospital funding to the cantons. However, the

cantons felt that the added financial burden was too much to bear, thus they

would not approve the motion.17 These types of obstacles did not bother

Dreifuss, despite the recurring opposition from many sides she continued to

negotiate the details of reform. This persistent attitude made her seem like

the Margaret Thatcher of Switzerland. Whenever someone is determined to

accomplish a goal there are always those who will reject the idea. The right-

winged, Swiss People’s Party was that conflicting entity. On the occasion of

Dreifuss’ retirement, the party president Ueli Maurer stated, “I appreciated

Ms. Dreifuss as a very obstinate and without frills politician. But he added:

Her policies were wrong. She leaves us a great deal of unsolved problems in

social security. From this perspective, we welcome her retirement.”18Despite 17 European Observatory on Health Care Systems, "Health Care Systems in Transition: Switzerland," Who.int, 2000, http://www.euro.who.int/__data/assets/pdf_file/0003/96411/E68670.pdf.

18 "Dreifuss Leaves behind a Controversial Political Legacy," Swissinfo.ch, November 25, 2002, accessed February 24, 2013, http://www.swissinfo.ch/eng/Specials/Votes_for_women!/Women_in_politics/Dreifuss_leaves_behind_a_controversial_political_legacy.html?cid=3031464.

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all controversy, parliamentary debates on healthcare reform continued until

March of 1994 when the National Referendum took place, finally passing the

reform legislation into law.19

Now that we have looked at both the U.S. and Swiss reforms, we will

compare some of the similarities and difference between the two states,

such as direct democracy versus representative democracy, party

cooperation, the power of persuasion and leadership by Obama and Dreifuss,

and the outcome of healthcare reform in Switzerland, especially as it

pertains to the future outcome of reform in the United States.

As previously mentioned, direct democracy has both positive and

negative aspects. From a liberal perspective the positive impacts seem to

outweigh the negative effects. Representative democracy puts more

emphasis on government member’s personal opinions when it comes to the

United States and truly defies liberal theory as the U.S. government has

thrown out their responsibility to represent the entirety of the American

population. Instead of the government working for the people, the United

States government has continually caused a clash with the American people

without regard to their thoughts or opinions. It would be interesting to see

what the U.S. would be like if a direct democracy replaced the current

representative democracy. Using Switzerland as an example, we might see

that the U.S. government would actually be held accountable; however, we


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may also see that in a country as large as the United States, the negative

impact of extended time to pass legislation would overthrow the positive

view of giving the American people a voice. This new autonomous

government has taken liberties far beyond what the American founders

intended. This idea can be clearly seen in the ruckus caused by healthcare

reform in the U.S. After President Obama succeeded with his reform, several

states revolted, petitioning the Supreme Court to rule the imposed insurance

reform unconstitutional. Even then, the checks and balances system proved

ineffective to keep the government accountable to the people. This has

deconstructed American solidarity causing vast distrust of the government

and widespread apathy.

Secondly, political parties in Switzerland and the United States have

both maintained consistent legitimacy in their respective countries. The

difference between these two states is the level to which they have been

able to negotiate and compromise. While Switzerland does not have a

balance between parties, this fact is inconsequential when considering the

effect of reason and caution which remains in the minds of those in

government due to acknowledgement of national referendum. Yet in the

United States, the collaboration between Republicans and Democrats is

nonexistent. New trends of stalemate and the death of bipartisan

cooperation have taken over the majority of decision-making in Washington.

Third, leadership from Barack Obama and Ruth Dreifuss have both

been characterized by strong, defiant agendas and unwavering commitment

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to passing healthcare reform. They have both received criticism for their

stubborn platforms when working with their respective governments.

However, when comparing their style and tactics which they used to ensure

their aims were met, it is evident that Dreifuss has accomplished more by

considering all the alternatives which were being presented. Although her

views were not appreciated by a large number, she insisted that the

importance of containing healthcare costs was more important than personal

opinion. She did not waiver on her mission, but looked at alternative

solutions to make reform happen instead of polarizing her government, as is

the case with Obama. Obama showed a lack of tact at times when trying to

coerce the Republican Party to agree with his plan. On more than one

occasion he took the liberty to threaten the Republican Party, essentially

saying they could either get on board or do things the hard way. His

condescending message to Republicans exacerbated the already

controversial issue of reforming healthcare. As a result, the struggle of

expanding health insurance in the United States became yet another reason

for Americans to disapprove of the lack of cooperation within their

government.

Finally, looking at the outcome of Swiss healthcare reform, we can see

that healthcare cost have continued to rise in Switzerland despite attempts

to curtail the issue, albeit they are rising at a slower rate. Switzerland has

indeed incorporated universal health coverage for their citizens and

readjusted the financial burden so that everyone is able to receive medical

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attention regardless their income. This reform would have been impossible

to implement if not for the federal government. However, the cantons have

also played a large part in emphasizing their role to shape reform as well. It

is far too early to know precisely the impact that healthcare reform in the

U.S. will have; but if we apply Switzerland’s example to the United States,

the outcome for the U.S. will not be as desired. A reworking of health

insurance and financial burden is not enough to cut the necessary costs in

healthcare. Healthcare expenses will continue to rise, just as they have in

Switzerland. What both governments failed to do was to enlist those at the

bottom of reform; the doctors, nurses and healthcare administrators. They

failed to rework the way medicine is provided in hospitals and doctors’

offices. Without reforming healthcare management and distribution they

stand little chance to restrict the excessive flow of cash into healthcare.

In conclusion, we can see that multiple factors play into healthcare

reform, both causing and being affected by the controversy of the topic. Both

states had the ultimate goal of keeping healthcare costs to a minimum.

Dreifuss was not well received by the Swiss People’s Party. She faced

adversity when navigating through the many levels of government and

public support she needed to pass healthcare reform, but she did not let

opposition keep her from her task. Obama did the same in a much different

way. He took on the challenge of reforming healthcare, but became so

caught up in the political games that he quit listening to the common people

that had inspired him to pursue healthcare reform in the first place. The

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specific leadership styles of each president are typical of politics in their

respective countries. U.S. politics are quite dramatic while those of

Switzerland maintain composure under pressure. And while healthcare

reform would be controversial in any country, the comparison between

Switzerland and the United States shows that controversy can be handled in

many different ways.

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Bibliography

Clasen, Jochen. "Social Insurance in Europe." Google Books. 1997. Accessed February 24, 2013. http://books.google.com/books/about/Social_Insurance_in_Europe.html?id=dogOb37lX5EC.

"Dreifuss Leaves behind a Controversial Political Legacy." Swissinfo.ch. November 25, 2002. Accessed February 24, 2013. http://www.swissinfo.ch/eng/Specials/Votes_for_women!/Women_in_politics/Dreifuss_leaves_behind_a_controversial_political_legacy.html?cid=3031464.

European Observatory on Health Care Systems. "Health Care Systems in Transition: Switzerland." Who.int. 2000. http://www.euro.who.int/__data/assets/pdf_file/0003/96411/E68670.pdf.

Häusermann, Silja. "Reform Opportunities in a Bismarckian Latecomer: Restructuring the Swiss Welfare State." Government Department, Harvard University and IPZ, University of Zurich. June 2006. http://www.people.fas.harvard.edu/~ces/conferences/bismarck/docs/pdf/haeusermann.pdf.

Iglehart, John K. "Obama's Vision and the Prospects for Health Care Reform." The New England Journal of Medicine. October 1, 2009. http://www.nejm.org/doi/full/10.1056/NEJMp0908476?view.

"Remarks by the President to a Joint Session of Congress on Health Care | The White House." Remarks by the President to a Joint Session of Congress on Health Care | The White House. Accessed February 24, 2013. http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-to-a-Joint-Session-of-Congress-on-Health-Care.

Smith, Emily. "Timeline of the Health Care Law." CNN. June 28, 2012. Accessed February 24, 2013. http://www.cnn.com/2012/06/17/politics/health-care-timeline/.

http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-to-a-Joint-Session-of-Congress-on-Health-Care

http://www.whitehouse.gov/the_press_office/Remarks-by-the-President-to-a-Joint-Session-of-Congress-on-Health-Care

http://www.nejm.org/doi/full/10.1056/NEJMp0908476?view

http://www.nejm.org/doi/full/10.1056/NEJMp0908476?view



http://www.euro.who.int/__data/assets/pdf_file/0003/96411/E68670.pdf

http://www.swissinfo.ch/eng/Specials/Votes_for_women!/Women_in_politics/Dreifuss_leaves_behind_a_controversial_political_legacy.html?cid=3031464

http://www.swissinfo.ch/eng/Specials/Votes_for_women!/Women_in_politics/Dreifuss_leaves_behind_a_controversial_political_legacy.html?cid=3031464



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Passing Healthcare Reform- Key Politicians’ impacts with Regards to Switzerland and the U.S