US Health Care Reform Is Only Getting Started

NEW HAVEN: Clouded by a belief in national exceptionalism, the United States has generally been loath to adopt successful models of health care from other countries. This fact remains despite clear evidence that several peer countries spend less on health care and achieve better health outcomes than are found in the United States. In particular, the social democracies of Scandinavia – Sweden, Denmark and Norway – outperform the United States, employing what is termed the “Scandinavian model.” This model consistently attains the best health outcomes in the world at a reasonable cost. The question is – can we learn from it?

Evidence of the Scandinavian models’ effectiveness is indisputable. Scandinavian countries spend only slightly more than half of what the United States spends per capita on health care. Total health expenditures in Sweden, Denmark, and Norway were 11.8, 10.1, and 8.9 percent of the GDP, respectively, whereas health spending comprised 16.3 percent of the US GDP in 2007, climbed to nearly 17.4 percent of the GDP by 2009, and may reach 20 percent of GDP by the year 2021. Even with their comparatively limited budgets, in all three Scandinavian contexts, the publicly financed health insurance systems in these countries cover 100 percent of citizens, while approximately 15 percent of Americans remained uninsured prior to the implementation of recent reforms. Even in spending less and covering more, Sweden, Denmark and Norway boast more physicians and hospital beds per 10,000 people than are available in the United States.

Based on such an intuitive health system structure, Scandinavian countries have proven capable of achieving superior health outcomes for their citizenries. As of 2007, Sweden’s infant mortality rate was 2.5 per thousand live births compared with 6.8 infant deaths per thousand live births in the United States. Some, but not all, of this discrepancy may be due to more aggressive efforts to save preterm births in the United States; however, Sweden boasts better health outcomes in several other areas as well. Maternal mortality was 1.9 deaths per 100,000 live births, compared with 12.7 in the United States. Self-rated health also differs considerably; 38 percent of Scandinavians compared with only 28 percent of Americans consider themselves to be in very good health. While every model of health care delivery has its faults, the Scandinavian model has long been lauded in the academic literature for its equity and efficiency.

Despite these clear successes, many Americans dismiss the Scandinavian model as being “socialist” and therefore irrelevant. Nevertheless, a nuanced comparison, which we present in our new book The American Health Care Paradox, may reveal timely lessons for the American experience. Using international data from the World Values Survey and a series of in-depth interviews with key policymakers and practitioners, we found a surprising pattern: The United States and Scandinavia share several core values.

According to our data, people in Scandinavia and in the United States share the fundamental value of personal freedom. History would tell us that freedom is the raison d’être for the United States—the root of its founding ideology; however, data from the World Values Survey indicates that Americans’ views of their own freedom, and of their ability to control their own lives, is similar to those expressed in Scandinavia, represented by Sweden and Norway in this survey. The survey asked, “Some people feel they have completely free choice and control over their lives, while other people feel that what they do has no real effect on what happens to them. Please use this scale where 1 means ‘no choice at all’ and 10 means ‘a great deal of choice’ to indicate how much freedom and control you feel you have over the way your life turns out.” On this item, people across countries indicated virtually identical views of their freedom, with scores of 7.7 in the United States and 7.8 in Scandinavia.

The likeness extends to views about competition, where we had anticipated marked differences, given the pervasive endorsement of free-market competition and technological sophistication in the United States. Data from the World Values Survey told another story. People were asked to place their views on the following 1-10 scale, with 1 representing the statement “Competition is good. It stimulates people to work and develop new ideas,” and 10 representing “Competition is harmful. It brings out the worst in people.” Ratings were identical in the United States and in Scandinavia, at 3.4 on the 10-point scale. This finding was particularly relevant to counterarguments that heretofore have deemed Scandinavian countries as collectivist, and thereby extraneous to the United States’ experience. On the contrary, we found Scandinavians to be as open to the potential benefits of competition as Americans. 

The likeness further extends to national views about the value of science and technology. Despite heavy US investment in high-tech health care, citizens reported statistically indecipherable faith in science and technology to improve global conditions. When asked “All things considered, would you say the world is better off or worse off because of science and technology?” the US and Scandinavia ranked as 7.2 and 7.1 comparatively.   

Recognition of these similarities helps to eliminate several of the most commonly cited reasons for the United States being unable to learn from peer nations. Despite what pundits may suggest, it is not the case that a national love of freedom or competition renders a nation incapable of providing high quality health care to the American populace. Nor is it the case that our fervent embrace of scientific innovation is incompatible with a more humanist view of health care. Despite these similarities, the US and Scandinavian nations have pursued different paths. So what then is the sticking point? 

The analysis also revealed considerable difference between the US and Scandinavian value bases.

Most saliently, the scope of the social contract is decidedly different. Americans were significantly less likely than Scandinavians to view taxation of the rich to support the poor as an essential feature of democracy, and expressed concern about the moral consequences of government support on the recipient. This value is consistent with the American fear that the availability of government unemployment payments weakens people’s resolve to work and fosters overdependence on government programs. In contrast, Scandinavians accept taxation as a necessary corollary to their own vulnerability, believing that the taxes they pay are going to fund programs for people who need them, which might one day include their own family, or even themselves. Recipients are not overly stigmatized, and the fears of others becoming dependent or taking advantage of government programs are less ingrained. The implications of such differing views of individualism are palpable in the discourse around US health care.

What we take from this analysis is not concrete steps about what the United States should implement as far as reform, but rather, a new perspective on the scope and nature of the American health care challenge. Health policy debate in the United States continues to be narrowly focused in comparison to Scandinavian peers. American political parties debate the best ways to curtail spending, expand access and improve quality of health care services, as they have for decades. Some progress has been made, but most stakeholders agree that reforms undertaken thus far have been insufficient to enable long-term cost control or achieve universal access.  The United States has invested in health care without seeing significant returns in health. Thus, the United States is only at the start of a reform conversation that may need to broaden considerably – to recognize the social determinants of illness and the interaction between health and social services – in order to achieve reforms that deliver better health outcomes at reasonable cost. The process of investigating the Scandinavian model calls attention to the deeper dilemmas inherent in the current American approach to health care. The ubiquitous impact of these values underlines the enormity of the challenges ahead for the United States in reforming its current approach.