Many patients have difficulty paying their health insurance premiums. Some cantons have therefore drawn up black lists. The listed patients will then only receive medical services that are classified as emergency measures. For the doctors this is an ethical dilemma, for an HIV patient in Graubünden it ended fatally – he died at the Chur Cantonal Hospital end of 2017. The therapy initiated after a long back and forth came too late, he could no longer be saved.

The incident in the canton of Graubünden has made some headlines on television, radio and in the daily press in recent weeks. What did actually happen?

A 50-year old man died at the Chur Cantonal Hospital of an HIV-related disease. The ÖKK health insurance company repeatedly refused to pay the patient’s HIV therapy. He was blacklisted by the canton of Graubünden for outstanding premium payments. In such cases, health insurance companies only have to pay for emergency interventions. What is considered an emergency, however, is not always clear. A Swiss television broadcast from the Cantonal Hospital Baden describes the dilemma strikingly.1

Lisa Janisch of the local AIDS organisation is appalled. She is convinced that the black list is responsible for the patient’s death. The man had asked twice to get his therapy paid. First when he was diagnosised as HIV-positive and a second time when the disease had already broken out. The ÖKK health insurance company refused to pay on both occasions.

The incident was made public in an article by the “Sonntagszeitung”.2 The health insurance company did not want to comment and states reasons of data protection. However, a spokesman of the ÖKK confirms that HIV-positive patients on the black list are not elligible to get their medication reimbursed. He emphasized that this was not a „pure decision by the ÖKK insurance company“, but this is actually stipulated by law. „We are not allowed by law to reimburse any non-emergency intervention if someone is on a canton’s black list,“ says the spokesman. This reasoning is not only bizarre, but deadly for the patient concerned.

Pregnant women, patients with cancer, diabetes, hepatitis, HIV: Many are affected
A total of 8 cantons have black lists, and around 33,000 patients are on these lists. The “Aargauer Zeitung” reported on 23 February3 that 30 cancer patients were refused treatment. There were also three cases of pregnant women who were not reimbursed for giving birth. The Cantonal Hospital Baden treats three HIV patients who are actually refused treatment. Four other patients are at acute risk of being blacklisted.4 The Aargauer Zeitung also reports of diabetics who are denied insulin.

The Swiss hepatitis strategy recognised the problem a few months ago. It is feared that people with hepatitis C are on black lists and that their cure could be refused. To prevent this, an emergency fund has been considered. However, it is unclear how this could be financed.

The St. Gallen Insurance Court ruled in a case of refusal of reimbursing cost in the event of childbirth that this was necessary and unavoidable at the time of entry into hospital. The insurance court states that too narrow an interpretation of the term „emergency“ would undermine the objective of compulsory health insurance and thus the guarantee of comprehensive basic care for all.5

Black lists are useless
The use of blacklists is controversial. A study commissioned by the Canton of Zurich concluded that premium arrears had increased in cantons with black lists as well as in cantons without black lists. This means that the black lists are of no use, which is why the Canton of Zurich did not introduce such a list.

The first cantons with black lists come to the same conclusion. The cantonal government of Solothurn writes that the black list endangers the basic medical care of an economically and socially weak population group, while at the same time payment morale does not improve. „Benefits are evident only for health insurers.“ The Solothurn cantonal government therefore wants to drop its black list. The same intention is pursued in Schaffhausen. Similar efforts are being made in Aargau, Lucerne and Zug. Thurgau operates „active case management for defaulting premium payers“. According to the local authorities, this is successful, therefore the canton sticks to its black list. Abolition is currently not an issue in the Canton of St. Gallen. By the way: The Graubünden government has already decided to immediately abolish the black list.

Federal Councillor Berset speaks plainly
Swiss television quotes the Federal Councillor: „Even my predecessor warned and said that that was impossible. You can see pretty brutally now that these lists don’t work.“ A discussion is needed, Berset emphasises. However, the decision is in the remit of the cantons.

A motion will probably be submitted in parliament during the summer session. Positive Council Switzerland has considered a lawsuit against the health insurance company. Unfortunately, this is not possible because the deceased patient had hidden his illness from his family and his identity cannot be disclosed. However, we are considering further steps, in particular an intervention to the Conference of Cantonal Health Directors and the health insurance associations.

Horror abroad, too
The system failure in Graubünden is also causing waves abroad. One can hardly imagine how such a thing can happen in rich Switzerland. Let us hope that cantons and health insurance companies will come to their senses. This must not happen again.


David Haerry / May 2018