Is Norway the Greenest System?

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As I was flipping through the pages of the latest “The Week” magazine I was struck by the “Good week for:” mention of Norway as the U.N.’s annual Human Development Index, which rated the Scandinavian country as the world’s best place to live based on life expectancy, education, and income. Interestingly the United States came in eighth.

I was also impressed viewing a piece on T.V. regarding the way Norway is incentivizing the conversion to electric powered automobiles. The program allows the purchaser of an electric car to buy without paying the 25% sales tax as well as registration. The purchaser then is allowed to use the bus/fast lanes, doesn’t pay tolls or ferry fees.

So, here in the States one would declare that this is nice but we are still using a carbon/petroleum or coal based system to produce the electric power. In Norway, however, electricity is produced by hydroelectric power and some natural gas. So they are actually improving the environment. Interestingly the Administration, when asked whether this assistance program is sustainable noted that after a significant proportion of the population purchases or converts to non petroleum based fuel autos and trucks they will go back to the non incentivized system. Interesting!!

So, now let us look at the health care system in this “world’s best place to live.” Do they have the best health care system also to care for their wonderful population?

The National Insurance Scheme insures all Norwegians. This is a universal, tax-funded, single-payer health system, in other words socialized medicine. Compared to France, Italy, Spain and Japan, Norway has the most centralized system.

Percent Insured. 100%. All Norwegian citizens and residents are covered.

Funding. General tax revenues fund the National Insurance Scheme. There is no earmarked tax for health care. The Norwegian tax burden is 45% of GDP. The government sets a global budget limiting overall health expenditures and capital investment. The most important taxes — in terms of revenue — are a VAT or General sales tax of 25%, income tax in the petroleum sector, employers’ social security contributions and tax on “ordinary income” for persons, which is 60.4% and the corporate tax range is between 27-78%. Most direct taxes are collected by the Norwegian Tax Administration (Skatteetaten) and most indirect taxes are collected by the Norwegian Customs and Excise Authorities (Toll- og avgiftsetaten).

Private Insurance. Norwegians can opt out of the government system and pay out-of-pocket. Many pay out-of-pocket and travel to a foreign country for medical care when waiting lists are long.

Physician Compensation. Hospital and nonhospital physicians generally are paid on a salaried basis. Some specialists can receive an annual grant and fee-for-service payments. The government, however, sets reimbursement rates, and, unlike in France, the physician cannot charge higher rates than the centrally set reimbursement rate.

Looking at the patient’s choice regarding their physicians and whether it has become the major problem that we are seeing in the U.S. Patients choose general practitioners (GPs) from a government list. These GPs then act as gatekeepers for specialist services. Patients can only switch GPs twice per year and only if there is no waiting list for the requested GP.

Next let us look at the situation regarding copayment and or deductibles. There are no copayments for hospitals stays or drugs. There are small copayments for outpatient treatment.

Waiting times seem to be an issue not only in Norway but in many of the countries with socialized medicine systems. There are significant waiting times for many procedures. Many Norwegians go abroad for medical treatments. The average weight for a hip replacement is more than 4 months. “Approximately 23 percent of all patients referred for hospital admission have to wait longer than three months for admission.” Also, care can be denied if it is not deemed to be cost-effective.

There are some very generous benefits in this system though. The program also provides sick pay.”  As Michael Moore has noted, the Norwegian system will even pay for ‘spa treatments’ in some cases.”

In Norway, all hospitals are funded by the public as part of the national budget. However, while medical treatment is free of charge for any person younger than the age of sixteen, residents who have reached adulthood must pay a deductible each year before becoming eligible for an exemption card. The card entitles one to free healthcare for the remainder of that year.

The Four Regional Health Authorities (RHA) are overseen by the Ministry of Health and Care Services, which run all public hospitals in Norway. In addition to these public hospitals, there are a small number of privately owned health clinics currently operating.

What about the availability of services and the cost to the patient? Expenditure on healthcare is about US$9715 per head per year, the highest in the world.

While the availability of public healthcare is universal in Norway, there are certain payment stipulations.

Children aged sixteen or younger, and pregnant and/or nursing women are given free healthcare regardless of the coverage they may have had in previous situations. All citizens are otherwise responsible for the annual deductible – which averages around 2040 Norwegian krone (1 Krone equals 0.15 US dollars). Norway’s health system also does not cover specialized care for those above 16 years of age, and anyone needing treatment such as specialized physiotherapy are required to pay an additional deductible. While health appointments themselves are encompassed by the deductible, the patient often covers the extra materials and medical equipment.

In terms of emergency room admission, all immediate healthcare costs are covered. In the case that hospitals in Norway are unable to treat a patient, then treatment abroad is arranged free of charge.

In the U.S. we are very concerned about the huge, often unnecessary high cost of pharmaceuticals, often produced in the U.S. Norway does not produce the bulk of pharmaceuticals consumed domestically, and imports the majority that are used in its health system. This has resulted in most residents having to pay full price for any prescription. The Ministry of Health and Care Services oversee pharmaceutical exporting. Insurance coverage for medicine imported from outside the country is managed through the Norwegian Health Economics Administration (HELFO).

I have previously alluded to the administration of the health care system in Norway.

Norway has four designated Regional Health Authorities. They are: Northern Norway Regional Health Authority, Central Norway Regional Health Authority, Western Norway Regional Health Authority, and Southern and Eastern Norway Regional Health Authority. According to the Patients’ Rights Act, all eligible persons have the right to a choice in hospitals when receiving treatment.

The Norwegian Health Care System was ranked number 11 in overall performance by the World Health Organization in a 2000 report evaluating the health care systems of each of the 191 United Nations member nations.

There is a misconception that healthcare is free in Norway.  Not quite.  The only people who get absolutely free healthcare are those under 16 and those who are pregnant (and that is only for pregnancy related healthcare!).   The rest of us have to pay up to a NOK 2040 cap per individual a year.  Those who require physiotherapy, special forms of dental care and rehabilitation are also required to pay another NOK 2620 cap on top of the regular cap.  That means every individual has to pay for all their doctors appointments and specialist appointments, such as gynecologists, until they have paid all the excess.  You have to pay for the doctors time, the instruments used, even the bandages.  Like any insurance, the Norwegian National Insurance requires people to pay an excess.  The National Healthcare does not include any regular dental care.  This applies to ALL residents in Norway – Norwegians and Internationals.  On top everyone also has to pay higher taxes to cover healthcare costs for the country.  All non-residents have to pay the expensive charges whether pregnant, under 16, or not.  After you have paid your NOK2600 or NOK 4660 excess you can get a ‘exemption card’ that allows you to get the rest of your healthcare for free only for the rest of the year.  For prescriptions, certain people qualify for medication on a so called ‘blue prescription’, which allows them to only pay an excess of NOK520 a year.

What does this mean for the average family?

They don’t pay for any health care appointments for their kids ages 4 and 6 – no doctor appointments, dentist, eye doctors, ear doctors, or the like.  However, when Lil’ Red injures himself (i.e. a glass mirror falls on him in a costume room) and was taken to the emergency ward at the hospital, they have to pay for bandages and equipment.

The international person with a permanent residency status – has to pay for every appointment that they go to– a doctors appointment is around NOK140 during the day and NOK 235 at night, a specialist is NOK315, and my gynecology appointments for just a general PAPs smear are around NOK600 because of all the lab tests involved.  Even if they have to go to the doctor just to get a doctors certificate for sickness to give to my work, they have to pay.  They have to pay the excess user fee, so have had to pay for everything every year.  They also have to pay for all their dental exams and dental work, flat out (it isn’t covered in the health insurance).

Moose, a Norwegian National – he has to pay for everything too – general doctors appointments, specialists, and everything dental.  He is lucky enough to have a doctor at his work and is covered by corporate healthcare.  But then again, that doctor just recommended for him to see his own (pay) doctor for a check up.

Medicine is offered at the four of the five major universities in Oslo, Bergen, Trondheim and Tromsø, who have close cooperation with the university hospitals in the cities. Medical education takes six years and still grants the old cand.med. degree. After school candidates are required 1.5 years of practice before being granted certification. After six additional years of work experience they are awarded specialist certification.

There are no tuition fees for attending public higher education in Norway, as all the costs are covered by the Ministry of Education and Research.

Students are also given the opportunity to apply for financial support (a part loan/part grant) from the Norwegian State Educational Loan Fund. The main requirement for support from Fund is that you are a Norwegian citizen. However, foreign citizens may also be entitled to financial support.[4]

Eligible applicants may be granted financial support (a part loan/part grant) of about NOK 90,000. It is initially given as a full loan, but upon completion of modules in the education around 40 percent of the amount is transferred to a scholarship/grant if the modules are passed. There is no interest paid while taking the education.

While studying, all students belong to a student welfare organization that takes care of such services as housing, on-campus dining, bookstores, kindergartens, advisory services and some health care. Part of this is finances through a student fee, typically at NOK 300–500 per semester. There are a total of 25 such organizations, each covering a geographic area and often consisting of more than one institution. The sole exception is Oslo where there are two.

The malpractice situation in Norway is actually the same as in most European countries. In Norway, as a general rule, compensation for errors in medical treatments is paid through a special scheme known as the Norwegian System of Compensation for Injuries to Patients.

In general, financing of the health care services is the public’s responsibility, and most services are covered by a tax-paid health service scheme (a so-called Beveridge model). However, private service providers are also, to an increasing extent, operating in the Nordic countries: in some situations people would rather pay for treatment at private hospitals than make use of the available public health care schemes. The strong involvement of public financing also affects the no-fault compensation scheme as compensation ultimately comes from the taxpayers. This may have an impact on the level of compensation. The malpractice compensation system is based on no-fault rules, we find that compensation claims indeed can be handled without focus on blame and negligence, and that this ensures both that the patients get equitable compensation and that unnecessary legal procedures are avoided. The system also has had a favorable impact on interaction within the health care sector and upon relationships between health care personnel and patients.

So, is the Norwegian health care system the best along with their environmental mission, etc.?

I guess it is as long as you don’t mind additional fees, high taxes and long waiting lines for service.

Let’s look at the other European countries and see who has the best and worst.

Merry Christmas to everyone, enjoy the holiday season!

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