The estimates varies, but tens of thousands of Norwegian patients are waiting for medical treatment. The official estimates from the Department of Social Affairs tell us that approximately 40 000 Norwegians are waiting for treatment. Other sources are claiming the numbers to be as high as 100 000 patients. According to the Law of Primary Health Care the patients have a right to medical care, but this right is a mirage for the miserable Norwegians waiting for treatment.
Eystein Tilley, 59 years old, suffered an acute backache, he was incapacitated from a protruded vertebral disc. He was in serious pain and was unable to work. Mr Tilley contacted his doctor and was referred to the nearest governmental hospital. He was informed that he would be admitted for operation in 8 months. In despair he contacted Dr Jens Moe and asked for his assistance. Dr Moe managed to get Mr Tilley admitted to another government hospital where he was helped.
Dr Moe claims that patients risk waiting 4-5 years for orthopedic surgery, 2 years for by pass operations and 5-10 years for plastic surgery of in vitro fertilization. This is the grim reality of "the third way" - the Scandinavian Welfare State.
Dr Jens Moe is an rebellious man putting his loyalty to the patient at the top. When he was a medical student at the University of Oslo in the 1960ies he organized the first doctor.manned ambulance service in Norway. Some years later he launched a private Air Ambulance. His aim was "to bring the doctor to the patient". The red helicopters of the Norwegian Air Ambulance are manned with a pilot, a helper (who is a knowledged mountain climber and scuba diver who can reach the patient even if the terrain does not allow the helicopter to land) and a anesthesiologist. Dr Moe met with fierce opposition; the Director of Norwegian Health Care claimed that this kind of luxury medicine was unwanted in Norway. Today the Norwegian Air Ambulance covers the whole country. It is a non-profit foundation supproted by members and donations and offer emergency services to everybody; members and non-members alike. It is still being a private foundation, but partly subsidized by the government.
In the early 1980ies Jens Moe started the first private health care center in Norway, The Ring Center in Oslo. Against intense opposition he managed to create this first little flower of private health care. The Ring Center now has over 100 employees and between 80 and 100 000 consultations are made annually. Dr Jens Moe realized that an advanced health care center was not enough and planned a hospital to furnish his patients with the hospital treatment they required. The non-socialist government grudgingly gave their go-ahead, but before the hospital could be built it was replaced by a socialist government led by Gro Harlem Brundtland, MD. The socialist government reversed the ruling. Dr Jens Moe has sued the government to obtain his permission to open his private hospital. Eystein Tilley was a witness at the trial in Oslo last November. Dr Moe argues that the laws covering both hospitals and doctors requires that doctors has a moral and legal duty to take care of their patients. When the governmental hospitals are unable to take care of his patients, Dr Moe claims that he has a right and a duty to establish his own private hospital. The government argued that a private hospital would attract scarce doctors and nurses for the state hospitals, that payment for private health care was socially unjust and that for-profit hospitals had no place in Norway. Dr Moe offered to change his company into a non-profit foundation and that he would train his own personnel or employ foreigners, but the government still refused to give him permission to open his hospital. Revealingly there is no law in Norway prohibiting hospitals because they are private. The law only demands a certain level of quality, but this law has been interpreted by the government in such a way that no private hospital can meet the quality requirements. Unfortunately he lost the trial, but Dr Moe has repealed the ruling and - interestingly enough - the Norwegian Medical Association has guaranteed to cover all the legal fees in connection with the appeal. The case is not yet closed. Dr Jens Moe is certainly a brave man. Almost one handedly he has taken on the whole governmental health establishment and true to the Hippocratic ethic, he is fighting for his patients.
How has this miserable situation come about? A short history of the establishment of socialized medicine in Norway is in place. Prior to the second world war a socialist medical student, Karl Evang, argued for a completely socialized health care system. After the war Dr Karl Evang became the Director of Health Care and with the help of the socialist government in power form 1945 to 1965 his plan was carried through. In 1967 a compulsory and comprehensive national health care and pension system was constructed. Both employers and employees were forced to pay for this system.
All Norwegian hospitals were socialized with the passing of the Hospital Act of 1969 (by a non-socialist government). Unnecessary waiting for hospital admission was unknown before 1969. The hospitals were paid on a fee-for-service-system. Later this system was replaced by a system of annual payments regulated by the number of patients geographically assigned to the hospitals. This system allocated most patients to specific and local and central hospitals in each state. Only acute treatment could be given to out-of-county or out-of-state patient. Over a millennium after Norway was united into one kingdom, the country was divided into 20 "health-states". Inefficiency, waste, waiting lists and pain ensued.
In 1982 the time had come to give primary health care the same
treatment. The aim was to contain cost. The former
fee-for-treatment-system was replaced. All Federal District Doctors -
mainly in rural areas - were transferred to the counties. All private
practitioners were "offered" an annual fee of approximately 40% of
their budget to become regulated by the counties. They also retained
a fee-for-service-system, but the fees were reduced to compensate for
the 40% annual fee. I addition the patients have to pay a use fee of
approximately $ 10 for each visit to a general practitioner. Also
almost all new doctors are forced to become salaried employees of the
counties; very few annual fees have been awarded since 1982. This
reform has caused waiting lists and deterioration of services. In
Bergen the waiting time for an appointment with your general
practitioner is several weeks.
Today the payment for the health care and pension system amounts to a 6-10 % tax on incomes and a 12-17 % tax on employers. The system today faces grave economic difficulties and cuts are made.
Is the picture completely hopeless? I am more of an optimist. I work as a general practitioner at Bergen Medical Center, a privately owned health care center. We charge the National Health Care system on a fee-for-service basis, but are denied the annual 40 % fee because we are private. Even if the patients are forced to pay for the governmental system and can obtain consultations with the county or 40%-fee-doctors for $ 10, we have more than enough patients seeking consultations at our center for $ 50 and upwards. Without the fee-for-service-payment from the National Health Care system we would have to double our prices and would certainly be out of business.
The patients thus have a choice of doctors, but not of hospitals. A general practitioner - both governmental and private - does have a genuine choice of treatment concerning primary health care. There is no peer review and the Health Care System never tries to influence the doctor in his choice of primary care treatment - unlike the American Medicare, Medicaid and different HMO-schemes. Litigation is a minor problem. My mal-practice insurance amounts to $ 40 annually.
If the patient is admitted to a hospital, the care of the patient is transferred to the hospital doctors after a longer or shorter waiting period. Patients who wants treatment not given by the state hospitals (mainly plastic surgery and IVF) have to seek treatment out of the country. Patients who do not want to wait the prescribed period have to seek treatment abroad, be redefined as an acute case by their doctor to be admitted at once or use friendship and connections inside the governmental system. The last mentioned route to treatment is of course impossible to document because of the nature of the method, but it is a good example of what Gordon Tullock has called The Welfare State for the Well to Do.
The Norwegian Health Care System is failing. Quality is decreasing, waiting lists are long and many doctors are discontent. Because of the low user fees the demand is artificially high and increasing. The economy of both Health- and Pension-systems are deteriorating and cuts in the budgets are made. Plans for making the system more efficient are implemented continuously - DRGs are presently introduced at some governmental hospitals and a patient list system assigning patients to one doctor for a compulsory one year period is proposed.
The crisis in the system is a cause for hope. The costly technological advances in medicine will force more and more stringent priorities to be set. Even the oil rich Norway can not afford to give everybody "Rolls-Royce" medicine and the politicians will sooner or later be forced to dictate priorities through the system of bureaucratic medicine or allow each individual patient to set his own priorities. The present socialist government is also approaching the Common Market and when Norway enters the Common Market, an enormous expansion in the size and scope of the health care market will ensue. Perhaps there is hope for Hippocratic medicine after all. What is most depressing to me is not the dismal accomplishment of the Norwegian Health Care system, but the sinister trends in the USA. The quality, advancement and dynamism of the American Health Care Market has for a long time been an inspiration to us. The trends towards socialized health care in the USA are depressing. Why are so many Americans so eager to repeat the errors we have made in the last 50 years and just recently started to remedy?