BERN. The governing coalition has split openly over the future of the franchise, the annual deductible that every insured adult pays before basic coverage begins. What began as a technical proposal to adjust cost sharing has become the defining health dispute of the parliamentary term, exposing a fault line between fiscal hawks and social liberals inside the same government.
The current system sets a minimum franchise of CHF 300 per year, with optional deductibles rising to CHF 2,500 in exchange for premium discounts of up to 40 per cent. Above the franchise, patients pay 10 per cent of costs up to an annual cap of CHF 700. The structure has remained essentially unchanged for two decades, even as average costs per insured person have nearly doubled. Children are exempt from the franchise, a feature no party proposes to change.
The proposal now dividing the coalition would raise the minimum franchise to CHF 500 over two steps, paired with a lower co-payment cap for the chronically ill. Its authors argue that higher initial cost sharing would restrain consumption and could cut premiums by 3 to 5 per cent. The health ministry's own modelling suggests savings of around CHF 1.2 billion a year. The proposal originated in the finance ministry rather than the health ministry, a detail that has not gone unnoticed.
Opposition inside the coalition centres on behaviour, not arithmetic. Studies commissioned by the Federal Office of Public Health show that higher franchises deter necessary care as reliably as unnecessary care, particularly among low income patients who skip check-ups and delay prescriptions. A fifth of insured adults already carry medical debt, according to debt counselling services. One widely cited study found that a CHF 100 increase in the franchise reduces doctor visits by around 3 per cent.
Insurers favour the reform, arguing that cost sharing is the only proven brake on demand in a system where patients face no gatekeeping. Doctors are split: hospital physicians see little effect on their volumes, while family doctors report patients who postpone visits until minor problems become expensive ones.
A spokesperson for the insurers' association put the case for change in household terms. “Every franc of avoided overuse is a franc that never enters the premium,” the spokesperson said.
Patient and consumer organisations reject that logic entirely. They argue the franchise functions as a regressive tax on illness, falling hardest on the chronically ill, who hit their maximum every January, and on working families just above the subsidy threshold. Their counterproposal would abolish the franchise for preventive services and generic medicines. They estimate the exemption would cost CHF 600 million a year, roughly a third of the projected savings.
The numbers behind the dispute are stark. Cost sharing through franchises and co-payments now totals roughly CHF 4.5 billion annually, about 12 per cent of all basic insurance expenditure. Households feel this directly: it is the one part of the health bill that arrives as an invoice rather than a premium.
The political path is unusually treacherous. The reform must pass both chambers, where the coalition holds fragile majorities, and would certainly face a referendum, which recent polling suggests it would lose. The health minister has signalled willingness to split the package, passing the chronic illness provisions first and parking the franchise increase.
For households, the immediate question is what changes in January. Under the current draft, nothing before 2028 at the earliest, and then only if the referendum fails to materialise. Choosing a higher optional franchise at renewal remains the one lever households control themselves, worthwhile for the healthy, risky for anyone with regular prescriptions.
The franchise debate endures because it encodes a genuinely unresolved question: whether Swiss health care should discipline demand through wallets or through planning. The coalition's divide suggests the country remains of two minds, and likely will stay so past the next election.
The history of the franchise explains the caution. It was introduced in its modern form with the federal insurance law in 1996 and has been raised only once since, in 2005, after a fight that consumed a parliamentary session. Every health minister since has discovered the same truth: the deductible is the one health policy instrument every voter understands personally.