As noted below, I had a chance last week to attend a very informative conference in Iceland with representatives from the major hospitals and medical schools of the Nordic countries (Iceland, Sweden, Denmark, Norway, and Finland). The health systems in these countries are owned and financed by the government and are often appropriately cited for the quality of care offered to the public. Indeed, in debates here in the US, they are often called out as examples of what we might strive for in terms of universal coverage and a greater emphasis on primary care than we have.
An advantage of actually meeting with people who run such systems is that you get to hear some of the details that do not make it into the public discussions here. I thought I would share just one aspect with you. In so doing, please recognize that I make no apologies for or denials about the inadequacies of our own approach. I am just trying to relate aspects of theirs that might be overlooked.
So, the simple question I asked was this: When the parliament sets the national budget for health care, how does it decide how to much to allot? Here in the US, the "budget" that we set for health care is partially set by Congress (for Medicare) and by state legislatures (for Medicaid), but well over half of our health care budget is not set centrally, but results from thousands of decisions and transactions by multiple players in the system. I was curious to learn, in contrast, how a welfare state decides on the appropriate amount.
I did not get answers about each country, but a pattern began to emerge. Using Iceland as an example, the answer seems to be that the parliament uses, as a rough guide, a desire to maintain overall health care costs at a certain percentage -- 10 or 11% -- of GNP. The US, at 15% is viewed as too high. Other European countries, at under 10%, are viewed as too low.
I pursued the question further. Is this percentage based on a quantified assessment of the actual health care needs of the public, i.e., is it driven by public demand (e.g., a growing aging population)? No. Does it take into account the government's expectation for certain quantifiable levels of service quality, medical quality, or operational efficiency of hospitals and other parts of the system? No.
In essence, this appropriation by the parliament is a politically derived decision, just as it would be for any appropriation for a program of important national priority, and it therefore competes with other worthy national programs for resources.
I offer this not in criticism, but just as a useful reminder to those of us in the US. The managers of the Nordic hospital systems, once their single annual appropriation is handed down, make important decisions about what services to offer to the public and what services not to offer. They also respond to appropriation levels by determining service quality levels. In the face of inevitable limitations on the ability of the nation hospital system to offer all services demanded by the public, a growing parallel system is emerging, in which private practitioners offer elective therapies and procedures outside of those supported by the national system.
Of course, we make similar managerial choices here when we run hospitals. The difference is that we do so in response to a variety of price signals set forth by a meld of public and private payers. Also, we have the advantage of one factor not really present in Europe, philanthropy from generous donors who help us provide advanced diagnoses and treatments that would not otherwise be available to the public.
As I note above, I am not saying one is better than the other. Just different. I predict, though, that the systems will start to look more and more alike over time. Pressure in the US for a more nationally-determined approach. Pressure in Europe for more of a private market approach. It shouldn't surprise us to see this convergence. After all, the countries are dealing with the same organisms, both biologically and politically.