Helsana report: income and the use of healthcare services
People on lower incomes make greater use of healthcare services

The Helsana report “Household income and the use of healthcare services” examines how income affects the use of healthcare services. The analysis is based on data from health insurance claims records and official income registers.

The results show that people on lower incomes use healthcare services more frequently – a correlation that remains even when differences in health status are taken into account. At the same time, lower-income households make significantly less use of preventive healthcare services, even though some cantonal programmes are available free of charge. This shows that, in addition to financial factors, health literacy and access to information, in particular, play a key role.
 
The analyses also demonstrate that existing incentives have become less effective. The minimum deductible has remained unchanged at CHF 300.– for around 20 years, while healthcare costs have risen significantly. This has reduced its effectiveness as a steering mechanism.
 
Against this backdrop, there is a clear need for political action. The minimum deductible should be adjusted to restore its effectiveness as a steering mechanism. At the same time, the effectiveness of existing cantonal preventive healthcare programmes appears to be limited. Equal and easy access to preventive health screenings must also be ensured for the entire population, which requires more uniform regulation at national level.
 
Systematically improving health literacy across the population is also essential, as it plays a key role in whether people make use of screening and early detection services. Furthermore, existing measures need to be applied consistently. The new Article 56a of the Federal Health Insurance Act (KVG) allows health insurers to provide policyholders with targeted information about more cost-effective healthcare services, suitable insurance models and preventive healthcare options. This is a prime opportunity to reduce both the misuse and overuse of healthcare services and to ensure that healthcare is being utilised more effectively.

 

What is this about?

 

Whether and how often people use medical services depends on several factors, the most important being a person’s state of health. Other important factors include the type of insurance model, the share of healthcare costs paid by the insured person and the household’s financial situation.

This report examines how household income influences the use of healthcare services. The analysis is based on Helsana claims data linked to income data from compensation offices and family allowance registers and was performed by the University of Basel.

Use of healthcare services

  Was beeinflusst die Inanspruchnahme von Gesundheitsleistungen?
Figure 1: What influences the use of healthcare services?
 

The healthcare system, with its solidarity-based funding model, is one of Switzerland’s major achievements. Per capita premiums and co-payments strengthen personal responsibility, meaning that the system is not put under unnecessary strain. At the same time, no categories of insured persons should be disadvantaged in terms of access to medical services. In its healthcare report, Helsana takes a close look at the topic and reveals in-depth insights.

Marcello Pedruzzi, Head of Tariffs and Quality of Care, Helsana Insurance Company Ltd

People on lower incomes make greater use of healthcare services

 

The first step is to examine whether health status differs across income groups. The results reveal a clear pattern: people on lower incomes are more likely to have chronic health conditions than those on higher incomes (Figure 2). This pattern can be seen across almost all of the disease groups examined.

In some cases, the differences are substantial. For thyroid disease, the proportion of affected individuals is 37% higher in the lowest income group than in the highest. For high cholesterol, the difference is 74%. The difference is particularly pronounced in cases of depression. Here, the proportion of affected individuals in the lowest income group is around three times higher than in the highest income group.
 

PCG as an indicator of health status

Pharmaceutical cost groups (PCGs) classify insured individuals according to the medications they use and serve as an indicator of certain chronic health conditions.

Figure 2 shows how these groups are distributed across different income groups. The figure shows that the two lowest income groups use more PCG-relevant medications than higher-income groups.

PCG heatmap

Figure 2: Distribution of PCGs by income group (most common conditions shown at the top)

Significant differences between income groups can also be seen for chronic pain (Figure 3). People on lower incomes are affected by this condition much more often. In 2023, the proportion of affected individuals in the lowest income group was more than three times higher than in the highest income group. They were also prescribed strong painkillers (opioids) around three times more often.

This clinical picture is particularly relevant from a health economics perspective. On the one hand, treatment often involves long-term therapy, which can be associated with significant side effects and may substantially affect a person’s ability to work or even potentially lead to incapacity for work. On the other hand, there is a risk of patients receiving incorrect or excessive treatment, as well as dependence and misuse.
 

Use of strong opioids among chronic pain patients

Figure 3: Use of strong opioids among chronic pain patients, by income group

The decline in opioid prescribing can be seen across all income groups and is partly linked to international prescribing guidelines. However, differences in opioid use between income groups remain. One possible explanation is differing levels of awareness of the risks associated with long-term opioid use. People on higher incomes appear to be more aware of the risk of dependence and may therefore be more cautious in their use of these medications.
 
However, the reasons behind these differences are likely to be complex. People on higher incomes are more likely to work in less physically demanding occupations, which may reduce their risk of developing chronic pain conditions. They are also more likely to have higher levels of education and therefore greater health literacy. This may help them make more informed decisions about the use of strong painkillers and more selective use of healthcare services. At the same time, the relationship may also work in the opposite direction: chronic pain can limit a person’s ability to work and reduce their income.

 

People on lower incomes use more healthcare services – regardless of their health status

 

As expected, people in poorer health use more healthcare services. It therefore comes as no surprise that people on lower incomes make greater use of healthcare services, as they are more likely to experience health problems. However, even after differences in health status are taken into account statistically, a clear relationship remains. This analysis shows that people on lower incomes continue to use more healthcare services on average (Figure 4). This pattern has remained stable over time and is particularly pronounced for outpatient care and inpatient hospital services.

“A person’s disposable household income has a profound influence on their life and the decisions they make. The same is true when it comes to healthcare. By linking individual-level data, the Helsana report is able to demonstrate this important relationship across the Swiss population in unprecedented detail for the first time.” 

Kurt Schmidheiny, Professor of Economics and Applied Econometrics, University of Basel

Equivalised income and factors included in the analysis

Equivalised income is used to make household incomes comparable across households of different sizes. This is based on the methodology developed by the Swiss Conference for Social Welfare (SKOS). Household income is adjusted using a weighted household size, whereby the first household member is assigned a weight of 1, the second 0.53, the third 0.33 and each additional household member 0.28. For a four-person household, this results in a divisor of 2.14. This approach enables income to be viewed on a per-person basis and ensures that households of different sizes can be compared fairly. Due to the data sources used, only households with individuals under 65 were considered. Minors and households with missing income data were excluded.

To assess the impact of income more accurately, the analysis also takes into account other factors that may influence the use of healthcare services (see Figure 1). These include socio-demographic factors such as age and sex and insurance-related factors such as the insurance model, deductible and premium reduction, as well as regional factors such as the overarching region, premium region and type of residential settlement. Health-related factors such as hospital stays, pregnancies and stays in treatment facilities are also taken into account.

Annual healthcare expenditure by income group

Figure 4: Annual gross healthcare expenditure by income group and type of service (interactive chart)

More detailed analyses show that people on lower incomes not only use more healthcare services, but also spend longer in acute care hospitals on average. This difference remains even after the type and severity of illness have been taken into account.
 

Hospital stays

Regardless of income, people living alone tend to spend longer in hospital. A more detailed analysis of people admitted to an acute care hospital at least once in 2023 also indicates a correlation between income and length of stay. The average length of stay is 4.7 days. The largest difference between income groups is 0.41 days (p < 0.05). Even after adjusting for SwissDRG case groups, people on lower incomes spend longer in acute care hospitals than comparable individuals on higher incomes. A similar pattern can be seen in terms of household size: people living alone stay in hospital for up to 0.27 days longer, on average, than those living in multi-person households. These differences may partly be explained by variations in the resources available to organise follow-up care after discharge. People on higher incomes are more likely to have access to the support and resources needed to arrange a smooth transition from hospital back to everyday life.

The current minimum deductible is becoming less effective as a steering mechanism

 

The purpose of the deductible is to create a financial threshold before healthcare services are used, thereby encouraging more cost-conscious use of healthcare. The minimum deductible has remained unchanged at CHF 300.– for around 20 years. Against a backdrop of sharply rising healthcare costs, its relative significance has declined. As a result, its influence on the usage of healthcare services has weakened: part of the increase in healthcare utilisation may be attributable to this effect. For people receiving an individual premium reduction (IPR), the effective threshold is even lower. Previous analyses suggest that increasing the minimum deductible could further strengthen its steering effect. Model estimates indicate that increasing the minimum deductible from CHF 300.– to 500.– could generate savings of up to CHF 1.16 billion across Switzerland.

“People on lower incomes visit their doctor more often than those on higher incomes, even when their health status is the same. At the same time, they are more likely to choose the minimum deductible. This suggests that raising the minimum deductible could encourage greater cost-sharing, including among people on lower incomes.”

Stefan Felder, Professor of Health Economics, Basel Center for Health Economics (bche), University of Basel

Recent analyses show that the likelihood of choosing a higher deductible decreases as income falls, even after differences in health status have been taken into account (Figure 5). This is the case even though higher deductibles could reduce costs for many households.

Choice of deductible

Figure 5: Choice of deductible by income group and IPR status

Choice of deductible

This behaviour can be explained by several factors. A higher deductible is associated with greater financial risk if healthcare is needed, with lower-income households tending to be less willing or less able to bear this risk.

Health literacy may also play a role. Choosing the most suitable deductible is complex and requires a good understanding of how the system works. Not all insured persons are in a position to engage with these decisions or regularly review their deductible. This is particularly true when part of the premium is covered by an individual premium reduction.

Example: diabetes – quality of treatment does not depend on the patient’s income

 

The fact that people on lower incomes use more healthcare services does not in itself tell us anything about the quality of care they receive. To explore this question, adherence to clinical guidelines for diabetes is used as an example. The analysis shows that the quality of treatment for diabetes is largely independent of income. Recommended check-ups are carried out at similar rates across all income groups, and any differences are more strongly associated with age and sex than with income (Figure 6).

Current guidelines recommend that people with diabetes have at least two detailed blood sugar (HbA1c) tests per year. Completion of at least two HbA1c tests meets adherence level 1. In addition, blood lipid levels (level 2) and kidney function (level 3) should be monitored regularly, and an eye examination should be carried out by an ophthalmologist (level 4).

 

Adherence to diabetes guidelines

Figure 6: Adherence to diabetes treatment guidelines by demographic characteristics and income group
 

Adherence to diabetes guidelines

 

Differences between income groups are small. Whether recommended examinations are carried out depends primarily on healthcare providers and is influenced less by patients themselves. More noticeable differences can be seen between specific population groups. Younger people and those who choose a higher deductible tend to have lower levels of adherence on average. One possible explanation is that younger people may be less aware of, or less concerned about, the long-term consequences of their condition. At the same time, people with higher deductibles may also be more reluctant to undergo additional examinations, particularly when the condition does not lead to immediate organ damage. Overall, the quality of diabetes care appears to be largely independent of socio-economic status. At the same time, there is scope for improvement, particularly among younger people.

Prevention: low-income households need more support

 

Early, targeted preventive care can help prevent illness or improve outcomes, while also reducing pressure on the healthcare system. These kinds of programmes, which may be organised at cantonal level, are supported by the exemption of preventive services from the deductible under compulsory health insurance (OKP): this is supposed to encourage take-up.

Since screening programmes are widely available and largely free of charge in many cantons, one would expect only minimal differences between income groups. However, the analysis paints a different picture. People on higher incomes are much more likely to make use of services such as bowel cancer screening (Figure 7), even in cantons with established screening programmes (Figure 8).

 

Bowel cancer screening

Figure 7: Differences in the likelihood that people who would benefit from bowel cancer screening (colonoscopy or FOBT) actually take part. Reading aid: compared with people in households earning up to CHF 2000.–, those in households earning more than CHF 8000.– are 10.03% more likely to undergo a colonoscopy. All income groups are compared with the reference group of households earning up to CHF 2000.–.

Bowel cancer screening

Several Swiss cantons offer bowel cancer screening programmes for men and women aged 50 and above. Compared with other screening programmes, such as mammograms or PSA testing, bowel cancer screening is considered a particularly cost-effective preventive measure. Regardless of whether a cantonal programme is in place, compulsory health insurance (OKP) covers bowel cancer screening for people aged 50 to 69 in the form of a faecal immunochemical test (FIT) every two years or a colonoscopy every ten years.

Unlike treating an illness, screening takes place when there are no acute symptoms or health concerns. This means that participation depends not only on willingness to take part, but also on health literacy and awareness of the services available..

Bowel cancer screening participation rate


Titel
Text
BE ZH LU UR SZ OW NW GL ZG FR SO BS BL SH AR AI SG GR AG TG TI VD VS NE GE JU
No cantonal programme available
0 % 100 %
Cantonal programme available
0 % 100 %
Figure 8: Proportion of people participating in bowel cancer screening, by canton. Note: the canton of Solothurn did not introduce a screening programme until the end of 2025.

Participation rates vary considerably between cantons, ranging from 25% in Appenzell Innerrhoden to 48% in Valais. Cantons with established screening programmes generally achieve higher participation rates, with some exceptions, such as Uri and Basel-Landschaft. The results show that there is still considerable scope for improvement, even in cantons with organised screening programmes. Exemption from the deductible alone is not enough to significantly increase participation in preventive services. This also suggests that the influence of the minimum deductible has weakened.

“People on lower incomes use more healthcare services, but are less likely to take part in preventive health checks. At the same time, early intervention benefits not only the individual. From a healthcare perspective, prevention is also more effective and sustainable than treating illnesses once they have developed. Targeted measures are needed to address this imbalance.”

Stefan Meyer, Dr rer. pol., Managing Director, Basel Center for Health Economics (bche), University of Basel

Bowel cancer screening is an important tool for detecting serious disease early and can significantly improve treatment outcomes. Against this backdrop, the substantial differences in participation rates between cantons and population groups are particularly important.

Access to preventive health checks is not organised in the same way across all cantons. These differences in access are problematic, since everyone in Switzerland should be able to benefit from easy access to preventive services.

Targeted measures are needed to increase participation in existing programmes. This includes increasing awareness of them as well as strengthening health literacy across the population. At the same time, framework conditions should be put in place that ensure low-threshold, standardised access to preventive health checks across Switzerland.

Art. 56 a KVG

Article 56a of the Federal Health Insurance Act (KVG), which comes into force on 1 July 2026, allows health insurers to provide policyholders with targeted information about more cost-effective healthcare services, suitable insurance models and preventive health programmes.

Data relating to insured persons may be used as a basis for this. This information can be used to provide personalised advice, for example on switching to lower-cost medicines or making use of preventive health checks. The scope of this advice is clearly defined and is intended to be an add-on to the existing role played by service providers. The aim of the legislation is to improve the targeting of healthcare services, reduce both incorrect treatment and excessive treatment, and strengthen prevention.

Conclusion

 

Income has a major impact on the use of healthcare services. People on lower incomes are more likely to experience ill health and use more healthcare services. The key finding is that, even after differences in health status are taken into account, people on lower incomes make greater use of healthcare services. At the same time, these groups often bear only a small share of the costs themselves, for example because they have lower deductibles or receive premium reductions. This suggests that financial incentives in the current system are not strong enough and that some of the additional healthcare utilisation may be due to a lack of steering mechanisms. Against this backdrop, the minimum deductible should be increased to strengthen personal responsibility and restore its effectiveness as a steering mechanism.

A second key finding relates to the role of Article 56a KVG and the impact of existing cantonal programmes. From 1 July 2026, it will enable health insurers to provide insured persons with targeted information. This can help reduce disincentives in the system and improve the targeting of healthcare utilisation.

At the same time, existing cantonal programmes have only demonstrated a limited impact. Despite some services being free, people on lower incomes are much less likely to take part in these examinations. Targeted, low-threshold measures and a more consistent national approach to access are needed to ensure that all population groups can be effectively reached.

 

Basel Center for Health Economics

The Basel Center for Health Economics is an interfaculty research institution of the University of Basel that contributes to solving important societal and political problems in the field of health insurance and healthcare through teaching, research, and policy advice. Last year, bche examined the relationship between income and contract choice for Helsana Insurance; this year, the focus is on healthcare utilization.
 
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bche.unibas.ch

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