By William Watson
When you’re a market-oriented think-tank searching for smart ideas on health-care reform, Sweden is the last place you should look, right? If the French are “cheese-eating surrender-monkeys,” to use the Bush administration’s pet term for them, the Swedes are “dyed-in-the-meatballs government-lovers.” Bismarck may have invented the welfare state, but the Swedes took it to ridiculous proportions, regularly topping the OECD list of most-taxed nations.
So it’s more than a little surprising that for the past few years two of Canada’s most market-oriented think-tanks, Vancouver’s Fraser Institute and Halifax’s Atlantic Institute for Market Studies, have been publishing regular updates on the Swedish health-care system.
The Swedes, it seems, have discovered pragmatism. Or, rather, pragmatism has been forced upon them by demographic circumstance. Their health -care law may require “good health care for all and all treated equally,” but that noble aspiration has run slam into the hard fact of population aging. That 60-year-old Swede who used to put 30-year-old Canadians to shame by outrunning them, outsauna-ing them and probably outsexing them as well, is in his eighties now and is spending a lot of time in the doctor’s office, eating up health-care resources. Ragnar Lofgren, author of the Fraser Institute’s latest report on Sweden, argues that, on the demographic curve, the Land of Midnight Fun is about 15 years ahead of us. In terms of population over the age of 65, they’re now where we will be in 2015. So they’ve already been through a lot of things we’re about to experience.
Waiting lists for health care, for instance. The Swedish crisis with waiting lists began in the 1980s. The immediate reaction was more money for the system, plus legislated care guarantees: If people hadn’t got treatment in 90 days at their local hospital or clinic, they could seek treatment wherever it could be found. That’s not exactly heartening. In some medical situations, 90 days can be an awfully long time, and it doesn’t necessarily follow that once you’ve switched providers you get immediate treatment. But, to begin with at least, this kind of policy did reduce waiting lists, even in the face of suspicion that hospitals and clinics may not mind long waiting lists since it helps them make a case for more funding.
A more recent innovation is the development of Internet tracking of waiting lists across the country. If you’ve got a hernia, say, and are willing to travel, there’s a Web site that will tell you the wait at every hernia-repair shop in the country. There’s even a hospital, Mr. Lofgren reports, that posts estimated waiting times in its emergency ward. The electronic posting might let you know, for instance, that six patients are ahead of you and that you may have to wait eight minutes to see a nurse and 43 minutes to see a doctor.
Compare this to waiting in a typical Canadian emergency room, where the only information you get about what’s happening behind the swinging doors is by huddling with fellow patients and — like suspects awaiting interrogation — comparing whispered conjectures. Mind you, the Swedes are not unfamiliar with user-unfriendly health care. One doctor quoted by Mr. Lofgren notes how in the bad old days emergency rooms had been kept hard and uncomfortable on purpose — on the grounds that the “ER is supposed to be an unpleasant place to be in. One should go there only when absolutely necessary.”
What has forced such antediluvian thinking underground is, not surprisingly, competition. The Swedes have grasped the crucial point that still escapes so many Canadian health-care decision-makers, namely, that the state can purchase health care for all without providing health care for anyone.
In fact, the Swedish state still does do a lot of providing. Roughly 90% of health care is still produced in public institutions. Only 1% is truly private, in the sense that people buy their own health insurance, with care being provided by private suppliers (who sometimes buy services from public institutions). The remaining 9% is purchased by the public sector but provided by private institutions, including hospitals. To simplify, if you are a health-care company that can meet the state’s quality standards for various procedures and do it for what the state is offering to pay, then “Come on down!”
Needless to say, letting private suppliers bid on public contracts has done wonders to increase the efficiency of public suppliers. And — probably the most shocking thing in Mr. Lofgren’s report — unionized workers like working for private companies. As one former union activist put it, “‘I can, if necessary, walk up to the boss and pull his tie and tell him what is wrong. With the country council it was different. How could we affect decisions made in a political way?'”
That 60-year-old Swede of Participaction fame may have had a better body than the average 30-year-old Canadian, but no one ever claimed he had a higher IQ. If Swedes can figure out the purchaser-provider distinction, we can too.