A tale of two systems
Doctors from the US and Norway discuss the issues in their respective medical systems
John Erik Stacy
The Norwegian American
Once again, Americans are forced to endure health care talking points ricocheting through the media. As promised during the election, Congress has presented a plan to replace “Obamacare” (that is, the Affordable Care Act or ACA). The replacement plan on the table is a bill titled The American Health Care Act (“Trumpcare,” if you will).
An opinion voiced by some pundits is that “market forces” will work to simultaneously improve health care and bring down cost through competition. But Americans pay about twice the amount Norwegians do for their health care, and by objective measures such as outcomes for various diseases, the U.S. doesn’t do any better than Norway. So market forces don’t seem to be working in favor of the consumer here in America. This was true both before and after the ACA became the law of the land. And the ACA, though it brought coverage to millions of previously uninsured Americans, did not bring down costs. In fact, the cost of insurance has risen appreciably, and many Americans—notably healthy, young “invincibles”—remain outside the insurance pool.
With this in the background, The Norwegian American was privileged to interview two doctors, David S. Johnson from the U.S. and Ivar Halvorsen from Norway. Dr. Johnson is a family physician with Allina Health in Plymouth, Minn. Dr. Halvorsen, from Stavanger, Norway, is a Public Health Officer and “Overlege” (consultant) at Køhler Legesenter. Here is some of what they had to say when asked about the systems of health care in the U.S. and Norway:
David S. Johnson: Research and some of the care in America is excellent, but some things in our system are really messed up.
For example, the pricing of medication can be extreme. There is now a low-dose version of Viagra available for pulmonary hypertension that costs $1,100 for a 10-day course. Generic Viagra [Sildenafil] costs $10, so if patients or providers are unaware, they may buy something that is over 100 times more expensive than necessary. I’ve also heard that 40% of health-care premiums are spent on biologics like Humira and Enbrel, now used for things like psoriasis and not just crippling arthritis. How much of this is driven by profit motive? The drug companies making these products are making a lot of money and have recouped their costs and more.
Also, we live with patchwork system of insurance plans and providers of health care. A patient may check to be sure that a hospital and surgeon is covered under the plan, but perhaps the anesthesiologist is not so then the patient gets a bill for the entire anesthesiology, even though the patient did the best they knew how to make sure that they were covered. These issues add to the uncertainty that many patients in America face when getting care. And I also understand that the most common reason to declare bankruptcy in America is because of health care bills.
Ivar Halvorsen: In Norway, the state bargains with pharmaceutical companies to lower prices. But this causes a delay for the newest medications. And that is a bit difficult because some persons will always need a medication that is there but not offered in our health-care system. Usually it takes one-half or one year. On the second day of every month, we have a small group of important directors decide what we are going to offer in Norway. This forum of directors, together with the health minister, does the negotiation. So we get the drugs we need, but not always in the time we need it. Regarding treatment delays in Norway, I can now mark a referral, and hospitals can then rearrange schedules to take the important things first. There is a patient coordinator, a nurse, usually calling up the patient after one or two days, telling the patient what is going to happen and when. The patient has the phone number of the coordinator so they can make contact whenever they want. This has improved service very much. Time-sensitive conditions like cancer have always been prioritized and treated immediately.
DSJ: A relative in Sandnessjøen wrote about her hip replacement at a Norwegian hospital. She had a femur fracture, and she shared a lot about the experience, and at the end she wrote “All this was done at no cost to me, and I am happy to pay my taxes so they can do this.”
IH: When the government in Norway shifted parties 10 or 15 years ago, there was a focus on tax issues, but now people are more concerned with service for their tax money. For a time, Norway was reported to be the most expensive health care in Europe, but that also counts nursing home care. Norway is, in fact, somewhere in the middle of the Western countries when it comes to cost. Everyone in the system can expect health care. Some people do fall out of the system. There are a small number of people that get pro-bono help from doctors—such as refugees that are not granted asylum—because they have no rights. Every EU citizen will get help when they stay in Norway, but not elective surgery.
DSJ: Ivar, you told me that when Norwegians move, they are assigned a new doctor in the new town. Can you expand on that?
IH: You will always be offered your own GP [fastlege]. If you go abroad for some years and come back, you will be asked to choose a GP. You pick your own “fastlege” and you can choose in the hospital system. You have the freedom of choice to decide which hospital you would like to use. Both the current (right-leaning) government and the government of the left a few years ago agree on this. Former Prime Minister Gro Harlem Brundtland moved to France. She wanted a hip replacement and wanted it done in Oslo. But the rules did not allow this. In fact, she got operated [on], but that was outside the system. She was not aware of that limitation. But if you have a fracture as a Frenchman in Norway, you would get treatment.
There is also some coverage for cosmetic surgery and dental cost in the system. There is a cut-off line for what the public will pay and what is a private matter for things like breast augmentation. Regarding dental coverage, youth—up to 19 or 20 years old—are covered. And psychiatric long-time patients also have dental care covered. But all others have to pay.
It is important to have a system that people trust. When Norwegians go to the voting booth, health issues will always be very important, and health care issues are often in the news.
DSJ: Hospitals are in the news in America too. Consumer Reports and others review hospitals and report re-admission rates, infection, etc. There are government sources too. And if it comes out that a surgeon took off the wrong foot, it will definitely hit the news. In fact, with the amount of attention given to healthcare, it is difficult for me to understand why we can’t move to a system that is more like Norway.
Perhaps it is because many Americans imagine themselves as rugged individualists, even if they are all doing the same thing. They want to make their own decisions, so the mandatory aspect of Obamacare sits poorly with a lot of people. This means that a lot of people choose not to get insurance but use the emergency room for treatment, and that is covered through subsidies [tax money]. So we are paying for it in a very expensive way.
IH: In Norway, the use of the emergency room has been falling since 1989. We got “socialized medicine” in 1984. The municipalities got the responsibility to set up GP offices. Before that it was free to set up your own office as a businessman. The “fastlege ordning” (the system of personal doctors) started in 2001.
DSJ: In America, “Obamacare” has helped some 20 million more people get health insurance. It is too bad more healthy people haven’t signed on and made it more sustainable. As a doctor, I know many patients and I have seen some patients’ insurance premiums go up dramatically. Here in Minnesota both the Democratic Governor Mark Dayton and the Republican legislature have made it a priority to get the Affordable Care Act to truly be affordable.
This article originally appeared in the March 24, 2017, issue of The Norwegian American. To subscribe, visit SUBSCRIBE or call us at (206) 784-4617.