HEALTH INSURANCE WORKS IN NORWAY
Olson, Keith W.
Health Insurance Works in Norway by KEITH W. OLSON IN the current session of Congress the Kennedy Administration's proposal to provide limited hospitalization and nursing-home care for aged...
...This complete regimentation, enforced by a centralized, nonmedical bureaucracy, is an outstanding example of socialized medicine in practice today—in the U.S...
...The AMA News of January 23, 1961, said "Socialized medicine is compulsory national health insurance . . ." In a New York Times advertisement of April 29, 1961, the AMA referred to the King-Anderson Bill as "The Socialized Medicine for the Aged Legislation . . ." The AMA charges are misleading and untruthful...
...Whether to allocate available resources for expanded medical school enrollments, increased medical research, or some other health project is an ever-present problem in Norway as it is here...
...One of the most treacherous reefs it has to cross is the determined opposition of the American Medical Association...
...More than fifty per cent of persons over sixty-five have incomes of less than $1,000 annually...
...Normally each commune, the equivalent of an American county, has its own office...
...Are the Norwegian people satisfied with the results...
...Subsequent visits for the same illness are, however, fully covered by insurance...
...Medical fees in America are set, for the most part, by individual physicians...
...By 1953, all employes and their families, regardless of income, were incorporated into the national health insurance program...
...Perhaps the Norwegian election last September best illustrates this satisfaction...
...Health insurance 'is not socialized medicine...
...If a Norwegian physician is highly competent and has a pleasing "bedside manner" he will develop a large practice and become a success, professionally and financially...
...The charge that compulsory national health insurance infringes upon the professional freedom of individual doctors is without basis in Norway...
...It is important to examine the effect of this elaborate benefit enterprise upon the everyday medical routine of all those who come in contact with it...
...Under this health insurance program every Norwegian is guaranteed proper medical care for any illness, injury, or deformity, for as long as he needs it...
...All these professional "rights" of the American doctor are shared by the Norwegian doctor...
...The coverage of Norway's health insurance is literally from the cradle to the grave...
...This ratio of inhabitants per physician is even more significant when it is realized that Norway is much more sparsely populated than the United States...
...The five board members must all be commune residents, and at least one must be an employer...
...Health insurance affects Norwegian doctors only in that it makes their services available to the entire population and that it guarantees that almost all fees will be paid, and paid promptly...
...Only a small minority of Americans now have sufficient savings to survive economically a long, serious illness...
...When a Norwegian feels the need of medical treatment, he selects the doctor he desires...
...First, Norway, with her constitutional monarchy, shares a democratic tradition with the United States...
...Are local and individual needs and responsibilities ignored...
...In 1920, only about twenty-two per cent of Norwegians were covered by this health plan...
...The choice is a personal one...
...It is also obvious that the AMA has been impeding the search for a satisfactory fulfillment of this need...
...The three most distinct principles imbedded in Norway's insurance program are decentralization, democratic control and operation, and the recognition of individual differences...
...In this system the element of personal freedom, for KEITH W. OtSON, a doctoral candidate at the University of Wisconsin, has been engaged in a special study of modern Scandinavian history and politics...
...Thus the development of this compulsory national health insurance program was a gradual, harmonious, and democratic evolution...
...Thus, in America, a physician is faced (often daily) with a multitude of different health insurance forms to complete...
...Today, that large segment of American society more than sixty-five years of age is finding it increasingly difficult to finance needed medical care...
...If a patient is unhappy with his choice, he is free to change doctors as often as he wishes...
...Norway is an excellent subject for such a study...
...The present Norwegian inhabitant-doctor ratio is limited by the capacities of Norwegian medical schools, a problem shared by the United States...
...Most people would agree that fifty-three years is an adequate period of time to test a medical program...
...Does the Norwegian medical profession oppose government health insurance...
...The most fundamental aspect of national health is making medical care available to citizens...
...First, the entire system must be self-sustaining...
...In making the decision to attend medical school, the Norwegian youth has more freedom than his American counterpart...
...In short, the Norwegian doctor-patient relationship, with its related freedoms, is identical to the American doctor-patient relationship...
...Has the professional freedom of individual Norwegian doctors been curtailed or eliminated...
...The problem of making medical care available to all Americans does not stop, however, with older citizens...
...And third, all parlies interested in maintaining a healthy Norway contribute premiums: members forty-nine per cent of the total cost, employers twenty-nine per cent, local communes twelve per cent, and the national government ten per cent...
...Norwegians dislike and do not use the adjective, "socialized," in connection with their health insurance in particular and their other health services in general...
...There are no opposition groups, only supporting groups...
...Thus, through the years, group after group was added to the program as the stipulated amount of income, below which all had to join, was raised...
...For example, the AMA News of August 7, 1961, stated, "At a moment when American medicine is preeminent throughout the world, it is proposed [referring to the King-Anderson Bill, designed to place medical care for the aged under Social Security] that we adopt the very systems under which one European nation after another has lost its former leadership [in medicine] . . ." There is little doubt what the term socialized medicine means to the AMA...
...The alternative of private health insurance is also inadequate...
...His Norwegian colleague has but one...
...However, individuals suffering from specified dangerous and long-lasting diseases receive refunds up to the full cost of prescribed drugs...
...The matter of premiums under this program is governed by three principles...
...and for any Norwegian who happens to be living in another country (covering diplomats, tourists, exchange students, and businessmen...
...Over the years the AMA has opposed compulsory smallpox vaccination, public immunization against diphtheria, Federal aid to reduce infant and maternal deaths, the Social Security Act, public venereal disease clinics, voluntary health insurance, school health services, Blue Cross, government medical care for dependents of men in the armed forces, workmen's compensation, and the Red Cross blood banks...
...Socialized medicine, asserts the AMA, will destroy what has helped to make possible the great— and to the AMA, the unique— achievements of American medicine: a voluntary, personal, doctor-patient relationship...
...The program, however, was popular, and year after year representatives who favored its extension were elected to the Storthing...
...During the campaign, not one Norwegian political party opposed the system of compulsory national health insurance...
...Free enterprise American medicine . . ." has not given Americans ". . . the best health care on earth . . ." although the AMA repeatedly makes this claim...
...Such unanimity has long existed...
...In this respect Norway ranks fourth in the world and the United States ninth...
...Not only have the Norwegians achieved medical care and standards envied the world over, but they have done so at low costs, with the enthusiastic approval and cooperation of the medical profession, and still have maintained democratic control of the entire public health system...
...Like an American, he may prefer to become a public health doctor...
...Insurance covers from two-thirds to three-quarters of the cost of the first and second visits to a doctor's office...
...In 1953, the last year for which figures are available for both countries, Norway had one physician for every 900 inhabitants, while the United States had one physician for every 760 inhabitants...
...National health insurance does not pay, however, the full cost of all medical services...
...All dependents are automatically covered at no additional cost...
...AMA attempts to label national health insurance "socialized medicine" are designed by cunning propagandists to discredit what should be applauded and perhaps copied...
...Each local office is administered by a five-man board selected every four years by the elected governing body of the commune...
...Accommodations and treatment in Norwegian hospitals are determined strictly upon medical need, not upon what a patient can or is willing to pay...
...It should be noted that Norwegian doctors, as a group, earn considerably more than other professional groups in Norway...
...financial incentive...
...If an individual physician feels that he has an "abnormal" case, he may charge accordingly...
...There are no gross inadequacies, but rather singular achievements...
...Second, the beginnings of national health insurance in Norway date back to 1909...
...These are United Nations 1957 statistics...
...military establishment...
...When a smaller, poorer nation such as Norway surpasses the United States in a field so vital to our existence as national health, it becomes time for a vigorous reexamination of our entire system of health services...
...To attain this objective the AMA's campaign of half truths must be met by a campaign of truth...
...Acceptance of such an appointment is considered a duty of citizenship...
...The national government payments are made to the National Insurance Institution, which uses these funds to subsidize needy local offices...
...Half of these have assets of less than $1,000...
...Under this program no freedoms are lost...
...Perhaps the skeptical reader will think that these impressive results are achieved because Norwegian medical schools are free, thus providing Norway with proportionately more doctors...
...If they so choose, small communes may share an office, or a large commune may-have more than one office...
...The comparison with our country shows this: 71 years for Norwegian men compared to 66 years for men in the United States...
...Throughout Norway there are approximately 736 local, self-governing insurance offices...
...An American doctor must pry into the personal financial affairs of each patient if he is to determine his fees in accordance with the ability of the patient to pay...
...One of the major objectives facing the second session of the Eighty-seventh Congress, now in session, should be the sorely-needed and much-promised legislation providing medical assistance for the aged...
...The fundamental worth of any system which provides a given society with medical care must be judged by its achievements...
...Perhaps he may decide to become a member of a hospital staff...
...One of the sacred rights of the American doctor is that he alone decides if the patient is to be hospitalized...
...Some individual financial responsibility is maintained to prevent abuse of the program and help finance its total cost...
...Local offices collect premiums, pay expenses and benefits, and listen to appeals...
...Many factors influence the physician's decision, including his professional attainments, the type and length of treatment given, the level of fees charged by other medical personnel in the area, the general economic level of the community, and the ability of the patient to pay...
...When a Norwegian doctor completes his training, he is as free professionally to do as he pleases as is any American doctor...
...Member premiums are collected from anyone whose income exceeds 1,000 crowns ($140, 1961 exchange rate) per year...
...Has the personal doctor-patient relationship been destroyed...
...Hospital bills, as Americans know them, are non-existent in Norway...
...Non-wage earners with small incomes were given the opportunity ol joining this plan voluntarily...
...Since July, 1956, membership has been compulsory for all: not only for Norwegians, but for anyone who has established residence in Norway...
...Since the primary objectives of medicine are to improve and prolong life, it is only natural that two of the most universally accepted measurements of the merits of a given medical system or profession are the infant mortality rate and the life expectancy at birth...
...American Medical Association spokesmen frequently accompany denunciations of socialized medicine with praise for free enterprise medicine...
...He may become a general practitioner or a specialist wherever he desires...
...According to the Health Insurance Institute, there were, in 1959, approximately 1,200 voluntary insurance organizations providing Americans with health insurance...
...The AMA assertion that a national health insurance system involves an endless amount of red tape is ironic...
...The need for a more adequate system of providing medical care to Americans is obvious...
...To help keep families from suffering economic disaster when illness strikes, the Norwegian plan provides a cash sickness allowance for wage earners not able to work...
...The principal reason the AMA gives for its opposition in each instance is that these proposals are "socialistic" in nature and would inevitably lead to completely socialized medicine...
...Only the chairman of the board may receive a salary...
...Just what has compulsory health insurance done to the doctor-patient relationship in Norway...
...Considering his professional freedom and satisfactions, his broad opportunities, and his income under the health insurance program, there is little wonder that the Norwegian doctor so firmly supports the plan...
...The military doctor performs his services for a fixed salary determined by non-medical bureaucrats...
...Not only would socialized medicine . . lower the quality of health care . . . ," in the AMA's judgment, but it would place the supervision and control of medical care in the hands of bureaucracy ". . . far removed from the essential understanding of local and individual needs...
...In 1909 the Norwegian Storthing (Parliament) passed legislation establishing compulsory health insurance for employes with an annual income of less than 1,200 frowns ($381) in rural districts and 1,400 crowns ($435) in urban districts...
...No patients are assigned to doctors in a given area or vice versa...
...Thus the Norwegian medical schools are faced with the pleasant task of selecting their students from all those who wish to become doctors, not, as in America, from only those who both want to become doctors and have the necessary funds...
...In Norway, "normal rates" for all the services which a doctor can perform are established by the Norwegian Medical Association after negotiations with government authorities...
...Also included in the program's benefits are every kind of prescribed rehabilitation treatment and any transportation expense incurred in connection with medical care...
...A more detailed look at a system of compulsory national health insurance, in contrast to socialized medicine, is clearly needed to demonstrate the sharp distinction between the two systems...
...Norwegian doctors are bound to these "normal rates" only by professional ethics, much the same as an Erie County, New York, doctor is bound to his "usual charges...
...A medical system like the one that serves our armed forces may justly be classified as socialistic...
...A quotation from a letter of September 8, 1961, from Odd Bjercke, Secretary-General of the Norwegian Medical Association, to me clearly states the contemporary view of Norwegian doctors following a half-century of experience: "When the present Health Insurance scheme was introduced in 1956 and made compulsory to the whole population of Norway, it was met by wholehearted support from the Norwegian Medical Association and the medical profession in this country...
...doctor and patient, is virtually nonexistent...
...How do the achievements of Norwegian medicine compare with the achievements of American medicine...
...When this plan of government health insurance was made compulsory tor these low income groups, it was done with little political controversy and with no resistance from the medical profession...
...It is also the attending phys-cian who determines how long this hospitalization will last and what medication, laboratory tests, diet, and nursing care the patient will receive...
...When a Norwegian dies, the insurance program pays a funeral grant of 300 crowns ($42...
...All contributors pay their premiums directly to the local office with the exception of the national government...
...In the measurement of life expectancy, Norwegians enjoy the longest life span of any national group in the world...
...The N.I.I, is administered by a five-man board selected, by the Storthing, for a four-year term...
...An average male industrial worker pays roughly the equivalent of slightly more than one hour's wage per week...
...Opposition of the AMA to medical programs is scarcely a new development...
...No tuition is charged at Norwegian medical schools, and long-term, low-interest loans from the government are available to all students...
...Director-General of Health Services, Karl Evang, in his book, Health Services in Norway, summarizes public support with these words: "The average Norwegian is in favor of national health insurance because it gives him so much medical service lor so little money...
...The choice of patients, the doctor-patient relationship, the hours worked, the location of practice, and even the dress of the doctor are equally removed from the jurisdiction of the medical profession...
...Millions more—the majority of Americans—have only partial coverage...
...Approximately fifty million Americans have no health insurance...
...The Norwegian medical profession did not at the beginning, and does not today oppose the health insurance program...
...Second, individual premiums vary, but are based upon income and nothing else...
...The quality of medical care has not been lowered, it has been raised...
...And it is precisely in these areas that American medicine suffers in comparison with Norwegian medicine...
...These payments start on the fourth day of illness, are tax-exempt, vary according to normal income and number of dependents, and are meant to be well below usual take-home pay...
...The infant mortality rate (deaths per 1,000 live births during the first year) in the United States is approximately twenty-two per cent higher than Norway's—26.4 per thousand for the United Stales as against 20.5 per thousand for Norway...
...Furthermore, if an American patient refuses or feels that he cannot pay his surgeon's bill the surgeon must resort to the courts...
...Some answers to the questions raised by the AMA's charges should have become apparent over the last half century...
...In this manner premiums throughout Norway are maintained approximately at the same level...
...Medicines lor ordinary illnesses are not covered except during hospitalization...
...74.7 years for Norwegian women compared to 72.5 years for American women...
...Maternity benefits under the insurance program are equally complete, including a cash allowance to help with a new layette...
...Individual contact with national health insurance, therefore, is on a strictly local basis...
...and the professional freedom of the individual doctor to make all medical decisions pertaining to his patients...
...This headquarters office sends out auditors and inspectors, appoints the business manager for each local office from among locally nominated eandidates, settles appeals made from the communes, gives financial aid if extraordinary expenses beset a local office, and establishes minimum and maximum premium limits beyond which the local offices may not charge...
...Many of these operate in the same geographic area...
...Independent and important though it is, the local office must follow national laws enacted by the Storthing and rules established by the National Insuranee Institution...
...for anyone who works for a Norwegian employer outside of Norway (covering merchant mariners on Norwegian ships...
...Health Insurance Works in Norway by KEITH W. OLSON IN the current session of Congress the Kennedy Administration's proposal to provide limited hospitalization and nursing-home care for aged Social Security recipients will have a rough time...
...Norwegian compulsory health insurance is not socialized medicine...
...But just the opposite is true...
...The health insurance program relieves the Norwegian doctor of a considerable amount of paper work and unpleasantness regarding fees...
...If he lacks these attributes his practice and income diminish...
...Most of the existing private insurance associations were incorporated in the new government program...
...With a few exceptions, hospitals in Norway are publicly owned, and all care is covered by a patient's insurance...
...In some cases the medical profession in a given area has established "usual charges" for a defined geographical area, like Erie County, New York...
Vol. 26 • March 1962 • No. 3
