EVEN as the Clinton administration prepares to announce a national health-care plan, Sweden - a country whose name is synonymous with universally available, publicly provided, and virtually free medicine - is busy reforming the excesses and shortcomings of its system.
After decades of state-run medicine, when Swedes were told the kind of care they would receive and from whom, people here are demanding more say. Accommodating this demand is opening a door to reforms that are making Swedish health care more efficient and cost-conscious.
"People are now able to choose the doctor and clinic they want," says Goran Rado, undersecretary of state at the Ministry of Health and Social Affairs. "Providing that choice has meant increasing competition [among care providers], and that has led to a more efficient and responsive system."
Not everyone is convinced that making this transition from a top-down system to one that places the patient at the center of decisionmaking can be done without lowering the general quality of care. Some doctors worry that competition for patients will lead to a mix of questionable, people-pleasing approaches with health-threatening shortcuts. Medical researchers are concerned that their role will be reduced in the drive for efficiency.
What no one questions is the basic principle of Swedish health care: to provide quality care under equal conditions for the entire population. Yet even as Swedes remain supportive of this pillar of their welfare state, they are implementing ways to make the system serve the public - and not the other way around - while reducing waste and cutting costs. Old assumptions challenged
For decades health-care coverage was consistently expanded, with more and better being the constant goals. But with Sweden facing the same recession and budgetary constraints as other European countries, old assumptions about universal care are being challenged.
One area facing close scrutiny is the cost and availability of prescription drugs, especially high-cost brand-name products. The wisdom and cost-efficiency of certain operations for a rapidly aging population is another.
"We are used to being able to afford everything, but we can't any longer," says Kaj Mollefors, a surgeon and chief executive of the Northwestern Health Board, a Stockholm County district health-care administration and one of the largest in Sweden's county-based system. "Our goal is to reduce costs, but in a way that increases the patient's choice in the health area."
Sweden - again like other European countries with socialized medicine - already spends less on health care than the United States. Health services account for about 8 percent of Sweden's GNP, compared with 14 percent in the US.
And unlike the US, almost all of Swedish health care is publicly provided: Until now, doctors, nurses, and other health providers have been public employees earning salaries set by the state. Doctors earn less than in the US - but they do not face the threat of large malpractice settlements, since Sweden's no-fault insurance system takes care of predetermined compensations in the event of error. `Managed competition'
Partly because of the country's aging population - 18 percent of Swedes are over 65, with two-thirds of medical outlays here going for people over 80 - health-care costs have been rising. Sweden also has experienced a shift in thinking about the balance between state and individual responsibilities that has swept the health-care field.
Largely in response to these two factors, authorities are now implementing a Swedish version of "managed competition" - the Clinton administration's phrase for its plan to enlist the private medical sector in providing the newly insured with reasonably priced care. The difference is that here the "competition" for patients will remain largely among public health-care providers.
"Freedom of choice in health care and long waiting lists because of low productivity in the medical profession were two recurring themes of the 1991 election campaign," says Mr. Rado, the ministry official.
Those were the same elections that spelled defeat for the Social Democrats, who had been in power for most of the previous 60 years, and under whose reign the health-care system was developed.
Last year Stockholm County was the first to change regulations so that hospitals and clinics receive funds based on services provided, not simply according to a predetermined budget. Productivity has skyrocketed, and waiting lists have plummeted.
Nationally, new regulations allow residents facing more than a three-month wait for an operation to go to another county - and the home county is billed for the service.
"In the first three months our orthopedic clinic experienced a 40 percent rise in productivity," Mr. Mollefors says. "Now we have no lines, and you could say we now have a lack of patients."
The new system has revealed an excess of medical facilities and specialists, Mollefors says. "After just one year we've realized we [in Stockholm County] have about a 30 percent overcapacity in surgery, the same in maternity. We're going to close one or two clinics." The same magnitude of overcapacity is generally true nationwide, he adds.
General practitioners are in short supply, however. "We are very concerned about medical overtreatment," Mollefors says. "We want to place more emphasis on preventive care."
One goal being discussed is to more than double the number of general practitioners, to 1 for every 2,000 people. While Sweden has had trouble attracting doctors to general practice in the past, the proposal under discussion would allow doctors to "work on their own," Rado says, rather than as salaried county employees.
Independence rather than pay levels is the key to attracting doctors to the plan, Rado adds. "We expect the new system to offer greater freedom to doctors, an idea many of them support." Doctors leery
"The assumption seems to be that mercantile tendencies are always good, but in society that is not always so," says Ingvar Krakau, director of the Sollentuna Hospital and Primary Care Center in Stockholm's northwest district. "The new system is based on competition between individual doctors. And when we're trying to encourage primary care that depends a lot on doctors working together, it doesn't seem to be the right idea."
Others say they are not so sure the emphasis on general practitioners in the long run will prove to be as cost-efficient as expected.
"I don't think increasing the availability of GPs is really so useful," says Ter Gellstrom, director of surgery at Stockholm's famed Karolinska Hospital, where the Nobel prize in medicine is awarded. "If the GP can't handle something, then the patient comes here anyway, so you end up with two layers."
Despite some grumblings about the reforms, satisfaction remains high in Sweden's basic system. One thing cost-conscious administrators and reform-fearing doctors seem to agree on is that they do not want to go toward a US health-care system, which they see as focusing on those who can pay.
"[The US] has excellent capacity and providers, but those have to be used in a more equal way," Mollefors says. "I know that sounds socialistic, which is the opposite of my political beliefs, but the advantage of our system is still that it doesn't matter who you are or what you own, you get the same service."