His Hip, Hooray!

I write my column His Hip, Hooray! in TCS Daily on 4 June 2004.

The Swedish prime minister waits in line like everybody else for medical care

Sweden's prime minister, Göran Persson, has never been known as a jovial man and has often been criticized for his grumpy and harsh political manners. But lately Persson has become grumpier and ruder than ever before, both to his political opponents and to his colleagues.

Why? In September last year he was diagnosed to need an urgent operation for his arthrosis in the hip. Persson has obviously been in great pain, walking with a limp, and he has reportedly been using strong painkillers. He has been forced to cancel official travels, such as the recent EU-Latin America meeting, since he is in too much pain to take such a long flight.

Now, after waiting for more than eight months he finally received his operation yesterday (June 3rd).

Göran Persson shares his hip troubles with many others of his age, but in Sweden a hip replacement is a very complicated affair, even if you are the prime minister. Sweden's "egalitarian" health care system features the same serious problem as all other centrally planned systems: shortages, due to a culture of rationing. For an operation like hip replacement, a procedure that typically takes less than two hours, there is a waiting list ranging from a minimum of seven months to more than two years. More than 5,000 Swedes are estimated to be waiting in line for this procedure alone (not counting those that still have to get an examination from a doctor, and a diagnosis).

The problems of the Swedish health care system are well known in the country, and the fabled image of the welfare state, with the government providing for everything from cradle to grave, is gone. Or rather, we still pay the same high amount of taxes but we do not get the same amount of government services for them.

Göran Persson said that he was going to wait in the queue for his operation just like everybody else, enduring months of pain and reducing his ability to work properly in his important capacity. He was scheduled to get the operation in December, but suddenly an opening was made available now. We could praise the prime minister for sticking to his egalitarian principles and for not seeking official favors. But the problem is precisely that those egalitarian principles have, as an unintended consequence, produced a two-tiered health care system. The failing, shortages-ridden, public health care system is for the poor, and a system of private health care (or simply going abroad) is for the rich, who can afford both to pay Sweden's high taxes and private health care. Privately paying patients are usually treated by private providers in a few weeks.

In public health care you pay for a queue line ticket, in private health care you pay for health care. All citizens have to pay taxes for the public health care (about 50-60 percent of your wage), and most cannot afford to pay again to get health care privately. A hip replacement operation would cost about €8,000 -- which is not much thinking of the amount of pain the procedure can relieve, and the amount of money most Swedes pay in taxes. But it is far more than most can afford.

For a long time, the Social Democratic Party has used the argument of "equal access to health care" to attack the centre-right parties for questioning the public healthcare model and even trying to break up the tax funding monopoly. It would be politically impossible for Persson to use his own money to buy the operation on the private health care system. The government, which already has a bad image thanks to the flaws of public healthcare, would lose all its remaining credibility.

Will Persson's political opponents capitalize on this opportunity, particularly in the light of the sudden operation, in which the system's problems are clearly visible in one person's plight? Could this be the turning point for the Swedish all-compassing welfare state?

Probably not. Not because people in general do not see its faults or are particularly convinced of its value, but because there is a serious lack of alternatives. When the centre-right parties discuss reforms of the public health care system they always confine themselves to what appears today as politically possible. Those who concern themselves exclusively with what seems do-able in the existing state of opinion always find that even this becomes politically impossible as the result of changes in a public mood which they have done nothing to guide.

The Social Democratic cradle-to-grave welfare state was not presented to the electorate in piecemeal reforms, but as a bold new political concept. Even though the social democratic ideals suffered from inherent contradictions, and the attempt to put them into practice produced something utterly different from what the ideals expected, it does not alter the fact that their programme for change was the only one which actually influenced the development of social institutions.

The socialist ideology became the only explicit general philosophy of social policy, the only system or theory which raised new problems and opened new horizons. It contrasted the existing state of affairs with an ideal of a possible future society. Most alternatives were mere compromises or half-way houses. There seemed to exist only one direction in which to move. Now, that direction is gone, and the ideology has gone out of the Social Democratic party. But there are no new directions being proposed, so Swedes stick to what little they have left of the old model, and the centre-right parties invariably lose elections.

A truly radical alternative, contrasting to the old industrialist health care system, could inspire people to change. It would have to consider the introduction of new technologies and changes in people's preferences, towards less curative health care and towards more palliative health care. But it would also include dynamism and decentralization, putting the patient in the position to decide on his or her own health.

Until we see such a political alternative offered, we will have to wait in line for health care, just like Göran Persson. Or buy it abroad.