In 2022, the Biden Administration proposed a new rule to overhaul the enrollment processes for Medicaid, the Children’s Health Insurance Program, and Basic Health Programs in a historic effort to improve access to health care for millions of Americans. The Department of Health and Human Services has simplified application processes to reduce barriers to health insurance plan enrollment. In October 2022, the Biden administration reported that half of states have increased access to 12 months of Medicaid and CHIP coverage after pregnancy.
As of November 3, 2022, the Biden administration had announced $1 billion to fund the expansion of mental health services, attempting to deliver on his promise to double the amount of mental health practitioners in public schools. These efforts were all part of the that administration’s efforts to improve health equity and reduce disparity for Americans in the healthcare system. In 2023, 26 million Americans, or 8% of the US population, were without health insurance at any point in the year. This result placed the United States 34th in the world for health insurance coverage, with nearly all the countries placing higher having universal health insurance. Nearly all of these countries placing higher than the US have universal health insurance. For these reasons the US might benefit from looking to the Swedish universal health care system as a guide to direct federal investments. The Swedish national government works in tandem with locally-elected regional councils to deliver equitable health outcomes to all Swedish citizens, regardless of socioeconomic status. In the same sense, the United States could replace its current value-based healthcare system with an approach to similarly ensure that healthcare is equitably allocated across its population.
The 10.23 million citizens of Sweden have access to a decentralized healthcare system. The Swedish Ministry of Health and Social Affairs determines broad health policy, but the 21 regional councils fund health care through taxation and 70 regionally-controlled public hospitals. An additional 290 municipalities care for the disabled and old. Swedish legislation prohibits hospitalization expenses over $11 USD per day in most districts, and prescription medications are capped at $255 USD per year. Finally, the maximum out-of-pocket expense for all medical consultations in one year is capped at $125. This level of health coverage is not free; Sweden taxes income at 52.9% as of 2022. This cost, however, results in the Swedish healthcare system being ranked as the best healthcare systems in the world by the U.S. News & World Report, while also maintaining the highest ranking of quality of life. In the same sense, although a potential tax hike in America would be met with significant resistance, the potential positive results on quality of life and healthcare might inspire Americans to keep such a policy.
The survival of the Swedish healthcare system is due to a long history of public financing and ownership, and the crucial role of local government. The Serafimer Hospital, Sweden’s first public hospital, was founded in Stockholm in 1752. This institution was commissioned by the federal government and featured eight beds to meet the requirements of both Sweden and Finland—which belonged to Sweden at the time. Because of the scarcity of medical services outside of the capital, local administrations were given the authority to spend funds on hospital development in 1765. One hundred years later, Sweden now has around 50 hospitals and 3,000 beds. Most hospitals started off small, with just 10 to 30 beds and one doctor. Sweden’s efforts to build a solid healthcare system in the mid-18th and early 19th centuries paid off, as it had more hospitals per capita than any other Western nation-state at the time.
In 1813, an administrative body composed of a physician’s association in Stockholm took over responsibility for most healthcare services, which is still in operation today as the National Board of Health and Welfare. This authority produced the current nationalized healthcare legislation that was implemented in the 1970s. While Sweden was building a strong centralized healthcare system, however, it was simultaneously attempting to decentralize and localize health-care management.
For example, county councils were founded in 1862. Through these councils, existing national government-owned hospitals were transferred to county councils, but the national government retained control of mental health services and the national system of provincial general doctors outside of cities. Several additional hospitals were established by county governments in the following decades, a trend aided by industrialization and a burgeoning economy. Following this path, local US administrations like city governments could similarly commission the development of hospitals to ensure that private healthcare systems do not get overwhelmed during pandemics or other public health emergencies.
The size and number of hospitals in Sweden expanded until the 1960s to accompany a growth in the country’s medical field. In this decade, however, the purview of county councils expanded to include not only inpatient services, but also outpatient and mental health resources. Over a few years, government expenses rose to 15% from 8% of the national budget. The Swedish government then emphasized cost-efficiency and performance metrics to improve the quality and quantity of healthcare services offered. This emphasis has improved distributive justice throughout Sweden. America could similarly transition to such a system while maintaining an emphasis on performance and cost-efficiency.
The Swedish socialized system works well precisely because the government allows for private health insurance too. In fact, one in 10 citizens have private health insurance, which costs approximately $435 annually per person. Following trends already in American medicine to decrease compensation for procedural medicine, the US House of Representatives could legislate into practice an equalization of salaries across specialties. This development, inspired by the 1970 Swedish Seven-Crowns Reform, could potentially lead to more physicians pursuing originally less lucrative specialties like family medicine and pediatrics. This correction to our value-based medical system could help increase physician supply in these fields facing shortages across America.
In the 1970s and 1980s, the Swedish healthcare system emerged as a decentralized healthcare system that was a build up of the many events of history. In 2009, the government began to re-regulate the Swedish pharmaceutical industry to promote greater ownership over pharmacies. This change came after nearly half the pharmacies owned by the state were run by National Corporation of Swedish Pharmacies. Policy decisions during this time were reminiscent of the 1970s, with the socialization of the pharmacies. Recently, both county councils and the national government have demonstrated a growing interest in a knowledge-based control over health care services. Sweden has thus been able to navigate external pressures on the healthcare system because of the national government’s commitment to bolster the entire system, combined with county councils’ swift implementation of carefully considered measures.
Efforts to improve access to health care for millions of Americans by overhauling the enrollment processes for Medicaid, CHIP and BHPs have been successful so far. They have simplified application processes, increased access to 12 months of Medicaid and CHIP coverage after pregnancy, and announced $1 billion to fund the expansion of mental health services. However, the US still lags behind other countries in terms of health insurance coverage, with 8.3% of the population being uninsured. A possible solution to this issue could be to adopt a new approach to healthcare, similar to the Swedish system, which is ranked as the best in the world.The Swedish system is based on a long history of public financing and ownership, and the crucial role of local government. While a potential tax in America would be met with resistance, the potential positive results on quality of life and healthcare might inspire Americans to consider such a policy.
Cameron Sabet is a University of Pennsylvania graduate and Georgetown medical student. He has researched at The Lancet, Nature, and BMJ, and has written on health policy for The New York Times, The Washington Post, Smithsonian Magazine, and The Hill.
Alessandro Hammond is a Harvard graduate, Schwarzman Scholar, and incoming MD-PhD at Yale University. He has written for Nature, The Washington Post, and Nature Medicine. He has been featured in Forbes and Good Morning America.
Arnav Ajay Jadav is a Washington University senior researching health care delivery and the epidemiology of noncommunicable disease systems. His work has been published in Hypertension, Circulation, and presented at the American Heart Association.