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Friday, May 15, 2020

The Grim Truth about Swedish Health Care

No, Sweden is not a libertarian role model. Unless, of course, you are the kind of libertarian who likes socialized health care. Bad socialized health care. As if there were any other kind.

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If you ever wondered what it is like to live under single-payer health care, and books like this one aren't quite enough, then here is another account of that life. 

I have lived under Swedish single-payer health care. I spent three years in Denmark, under their single-payer system. Regardless of which system you would import here, I guarantee you that the American people would start another revolution. Given how people are increasingly defiant over the coronavirus lockdowns, imagine if they would have to put up with the health care system described below.

What follows is in large part a translation of an article from the Swedish news site Samhällsnytt, essentially a Swedish version of Breitbart. I wrote a weekly column for them last year on economic policy; time constraints precluded me from continuing. It is a good, no-nonsense website with reporters who do what mainstream media don't. Their editor in chief, Kent Ekeroth, is a former member of the Swedish parliament.

Here is the article by Samhällsnytt; I have added clarifications in [] for translation purposes. Other than that, the translation is as verbatim as possible.
Eskilstuna-Kuriren [A Swedish daily newspaper] has published remarkable news about how the health care system secretly uses so-called treatment limitations - meaning that a patient will be denied certain types of health care. According to the paper, these limitations are introduced [into the patient's medical files] without any consultation with patients; [they are introduced] for patients as young as in their 50s. 
The guidelines from Socialstyrelsen [the National Board of Health and Social Services] for the limitation of health care for certain groups of patients, have had far-reaching consequences in Sörmland [a health-care district or county]. Physicians there explain how so-called treatment limitations for some time now have been applied to comparatively young and healthy patients.
Limitations are introduced in a low-key fashion into the treatment plans of individual patients as "0 - HLR, 0 - in-patient", which means that a patient is not going to get treatment for a heart attack [HLR]. The "0 - in-patient" denies the patient admittance to a hospital; treatment is instead limited to hospice care at home.
I should add here that Swedish health care is strictly rationed. They have the lowest number of hospital beds per capita and one of the lowest ratios of medical professionals. The reason is in good part severe cuts in health care services in the 1990s when hospitals were closed and health care districts fired one fifth of their staff. The Swedish health care system has never recovered from that austerity episode.
According to Björn, a physician interviewed by the Eskilstuna-Kuriren, the treatment limitations are introduced not only for elderly patients, but also for those born in the 1950s and '60s, patients who are relatively healthy and at most need help with a shower at home but otherwise live a fully functional life. 
The treatment limitations are de facto a death sentence for a patient who is denied in-patient care in case of illness. The limitations apply to all kinds of [in-patient] care, not just covid-19. They are often introduced in violation of current rules and regulations, without the patient and his or her family being consulted. This is sometimes done even by nurses instead of a doctor: 
"For example, according to current rules you cannot decide to move a patient to hospice care without consulting the patient. This is something you do together, with the patient present. But I know it [now] happens without anyone being consulted, patient or relatives, and [that it is being done] by a nurse" explains Björn.
This is a report from one health district only, but the treatment guidelines are national, which means that every health care district has to apply them.
He is very critical of how the [treatment limitation] guidelines, initially applicable only to intensive care, are now being expanded to apply to all forms of medical treatment, not only hospice. He notes that it is indefensible to deny preventative treatment, despite access to resources: 
"In my opinion, many doctors have lost their minds. So long as we have resources available, which we do since there are beds still available in intensive care, we must always give people good care. It does not even have to be intensive care, but here we are making decisions that these patients are not even supposed to get in-patient care. Under normal circumstances we would have admitted these patients if they get an infection or something [similar]. Now we are not even going to do that. 
The article concludes with instructions on how everyone can check their national, on-line medical records for notes on whether or not they are included in the "zero treatment" category. 

The news article underlying the Samhällsnytt article is from the daily newspaper Eskilstuna-Kuriren. It is available here. They also report anonymous quotes from two other doctors who express frustration over the treatment limitations. 

In another article, Samhällsnytt explains the details of the treatment limitation guidelines. It is not a surprising read if you are familiar with how a single-payer system works; for more on this, see the chapter on fiscal eugenics in my book The Rise of Big Government. In their article, Samhällsnytt reports that "purpose behind the [treatment limitation] guidelines is said to be to reduce 'ethical' stress among the medical staff." 

The guidelines clearly dictate the conditions under which a patient is to be denied health care: health care providers cannot deny treatment based on chronological age, but can do it based on "biological age". The definition is simple: the more serious your condition is, regardless of age, the less likely you are to get any form of curative treatment. Here is, again, a translation as verbatim as possible:
In the context of a non-routine resource situation, biological age, and its influence on patient utility in terms of continued survival, will be critical [for decision making]. Evaluation of biological age requires an amalgamation of several factors, and can be done based on well-established methods. 
These methods are known as Quality Adjusted Life Years, QALY, and have three essential components:

1. Treatment is allotted among patients based on the likelihood of the treatment being successful (so far, so good);
2. Since health care is rationed (the very premise for using QALY in the first place) the choice of patients to treat must be made on some kind of utility as a return on the treatment;
3. The return on treatment must be based on criteria defined by the payer.

This last point is critical. Here is how it works: government pays for your care, therefore government decides what outcomes it wants from you being treated. Your survival is not the essential part: government wants some return on your treatment that it, not you, can benefit from. Under QALY, that return is "utility" but not as the patient would define it. An individual patient will always value his own survival and recuperation at a maximum value of utility, but that does not help government. If both Jack and Joe rank their utility from a certain medical procedure as "1" on a scale from zero to 1, then how does government decide who gets the rationed resources for treatment?

No, government needs a method that is independent of what the patients believe. The only independent method relevant to government is tax revenue. Which, as it happens, is what QALY is designed for. 

Bluntly: if both Jack and Joe will survive for 20 years but Jack can be expected to pay more in taxes over those years, then he will get the treatment. If tax revenue is uncertain, then whoever can be expected to be gainfully employed for long enough, will get the treatment.

Yes, this is how QALY works, and it is how the Swedish health care system works. It is also what Medicaid for All would look like if it ever became a reality here in America.

We are going to face that debate, in this election cycle. It is coming. Be prepared.

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