Among public health experts Switzerland is known for its quality of care. In international comparison,
the country ranks highly in life expectancy at birth and mortality rates for treatable causes. However,
the cost of healthcare is high and private households pay an important share of expenditure, either
through health insurance premiums or out-of-pocket expenditure. The heavy financial burden placed
on individuals may lead to forgoing care for financial reasons, in particular for low-income households.
Switzerland has a highly complex healthcare system both in terms of system organization and health
insurance. In terms of organization the federal government shares responsibility with the cantons. The
latter have considerable freedom in policy design, which generates important differences within the
country. This variety makes the Swiss healthcare system an interesting laboratory to study healthcare
and health insurance policy. Regarding health insurance individuals have a large set of options to
choose from, however this variety may lead to mistakes and suboptimal choice of insurance.
The first half of this thesis investigates access to community-based ambulatory care and its association
with socioeconomic status in Switzerland. Using routinely collected administrative data, the first
chapter shows that access to community-based ambulatory care is not equitable between
socioeconomically affluent and deprived regions in Switzerland. These disparities are present at a
national level and at a subnational canton, level. The second chapter shows that part of the inequity of
access to community-based ambulatory care observed between cantons can be explained with canton
healthcare policies such as the regressivity of premium subsidy schemes and the cost of health
insurance within cantons. The second half of the thesis focuses on suboptimal health insurance choice
as a potential financial barrier of access to care. The third chapter finds that an important share of the
population is sub optimally insured, which leads to substantial financial loss for individuals. The fourth
chapter finds that the population is divided on its preferences for the introduction of new elements,
such as value-based insurance, into health insurance plans. However, the population is united in its
dislike of high deductibles.
In conclusion, this thesis shows that the variation in healthcare policy between cantons and the
complexity of the Swiss health insurance system may lead to inequity of access to community-based
ambulatory care as a result of financial barriers of access to care. Difficulties which seem to be unfairly
distributed on the less affluent parts of the population. Reforms aimed at making premium subsidy
schemes more progressive and homogeneous across the country are likely to improve equity of access
to community-based ambulatory care. Reforms aimed at a simplification of the health insurance
system, for example by restricting the menu of deductibles, and keeping deductibles low, are likely to
improve individual welfare. Finally, the population’s divided preferences on value-based insurance
design may inform policy design for future health insurance plans.