Denmark is often used as a comparative example in discussions about universal health care systems versus for-profit and privatized health care such as what exists in the United States. This comparison is for good reason; they do better on average across healthcare metrics and spend less on health care than the U.S. So how does their system work, and what can we do to improve the system in the United States in similar ways?
Healthcare in Denmark is part of the Danish welfare model, which is grounded in the principle of solidarity amongst citizens via their right to free healthcare and education1. The state, or national level of government, controls all regulatory and supervisory power for healthcare. Health services then are provided by the 5 regions and 98 municipalities of Denmark.
About 84% of healthcare expenditure in Denmark is publicly financed, while the other 16% comes primarily from patient co-payments from un-referred healthcare services, as specialists visited without a referral carry personal costs to the patient1. Taxes are collected at the national and municipal levels, then re-allocated to hospitals and general practitioners within the regional level as well as local health centers at the municipal level. All Danish residents are guaranteed the same amount of publicly funded care, including primary, hospital, specialist, and long-term care2. One of their priorities, included in the recent re-structuring of the national health system, is preventive care3. This new initiative was achieved through multiple restructuring efforts in recent years that could be applicable to other similar high-income countries like the U.S.
In 2007, Denmark re-structured their health care delivery system with a focus on helping the increasingly older and chronic disease-burdened population3. Their biggest disease burdens were related to behavioral health, including problems with alcohol and smoking. Many chronic diseases associated with these behavioral health issues were not being dealt with until patients had reached the regional hospital level, which was unnecessarily expensive and contributing to the high national healthcare expenditure4. The new focus in the 2007 restructuring was prevention, which sought to deal with chronic illness before it reached the hospital level. This meant increased emphasis on primary care, as well as new responsibilities for the municipality: disease prevention and health promotion3. In order to incentivize municipalities to provide the best possible preventive care, the new structure put tariffs in place that required each municipality to pay their regional level of government based on their use of the regional hospital. The assumption was that better health promotion and prevention would mean less use of regional hospitals and in turn reduced tariffs5.
Did it work? It’s hard to tell. Health metrics, such as life expectancy, have improved since 2007, but it’s hard to say whether that was the direct result of prevention or a result of a combination of other changes implemented in the restructuring. There are also mixed results on health behavior data. While smoking reduction efforts have seemed successful, decreasing the proportion of daily smokers from 44% in 1990 to 17% in 2015, obesity rates continue to climb6. While it’s not entirely clear how effective the new prevention initiatives are, Denmark has continued to update and improve their prevention and promotion tools. This includes the creation of 11 “health promotion packages” in 2012 and 2013, which are intended to help local health providers and decision-makers plan and organize their health promotion efforts6. The themes of these packages span a wide array of focus areas, including alcohol, obesity, drug abuse, and sexual health.
Adoption Within the United States
The Danish healthcare system has long been used as a role model for possible improvements within other systems, including that of the United States. Both countries face similar problems in terms of healthcare expenditures- an aging population with increasing comorbid chronic diseases. However, it is not as simple as implementing the same programs under entirely different circumstances and expecting the same results. There are a few noticeable differences between the U.S. and Denmark which makes this infeasible.
Population size is a large factor in distinguishing between these countries and their healthcare systems. Denmark has about the same population as the state of Wisconsin, which only represents about 1.75% of the entire U.S. population7. Not only would a restructuring of the U.S. healthcare system require a much larger overhaul, but the size difference also contributes to variance in the countries’ ability to provide personalized care on an individual or community basis. Danish municipalities are able to track at-risk groups within their local community, allowing them to provide preventive care on an as-needed basis. The United States does not currently have the local systems available for such tracking, as evidenced by our differing ability to handle contact tracing during the Covid-19 pandemic8.
As mentioned previously, the two countries also have distinctly different methods of funding their healthcare systems. While Denmark utilizes their welfare system to finance an entirely public universal healthcare scheme, the U.S. system is a mix of both private and public payers and providers. The U.S. has an entire insurance industry devoted to covering healthcare costs of individuals in exchange for premiums, which introduces a large group of private payers into the stakeholder arena that aim to make a profit. The United States has moved to make preventive treatment a priority through the Affordable Care Act by mandating that private health plans cover certain preventive services, including behavioral assessments and health promotion programs, without a copayment or deductible9. The public knowledge of these no-cost services, however, continues to be very low10. There is no government or provider entity, as in Denmark, that is incentivized to make citizens aware of available programs. Also, although American patients are incentivized to use these preventive services and screenings, the identification of chronic illness is often still followed by costly out-of-pocket treatment.
Despite the differences that exist between our countries and systems, we still have much to learn from each other, including in the realm of preventive and precise care. Common problems and goals overlap within the healthcare systems of all countries, as health continues to be global and without borders. While keeping in mind the infeasibility of translocating effective programs and initiatives without adaptation, it is important to reflect on the triumphs and failures of others in our global world. While the United States consistently shows impressive innovation in healthcare and biomedicine, they also spend twice the average healthcare expenditure amongst developed countries yearly11. Despite the U.S. government not universally funding their healthcare expenditure, effective and preventive measures in countries such as Denmark still provide insight into how the U.S. can make care delivery as successful and cost-effective as possible.
2Denmark | Commonwealth Fund. (n.d.). Retrieved July 15, 2020, from https://www.commonwealthfund.org/international-health-policy-center/countries/denmark
3Christiansen T. Ten years of structural reforms in Danish healthcare. Health Policy. 2012;106(2):114-119. doi:10.1016/j.healthpol.2012.03.019
4Chronic diseases · Healthcare DENMARK. (n.d.). Retrieved August 3, 2020, from https://www.healthcaredenmark.dk/the-case-of-denmark/population-health-and-prevention/chronic-diseases/
5Schmidt, M., Schmidt, S. A. J., Adelborg, K., Sundbøll, J., Laugesen, K., Ehrenstein, V., & Sørensen, H. T. (2019). The Danish health care system and epidemiological research: From health care contacts to database records. Clinical Epidemiology, 11, 563–591. https://doi.org/10.2147/CLEP.S179083
6Healthcare in Denmark: An overview. (2016). Ministry of Health.
7Denmark Population (2020)—Worldometer. (n.d.). Retrieved July 31, 2020, from https://www.worldometers.info/world-population/denmark-population/
8Second virus wave “very unlikely” in Denmark, says expert. (2020, May 12). Reuters. https://www.reuters.com/article/us-health-coronavirus-denmark-idUSKBN22O15L
9Aug 04, P., & 2015. (2015, August 4). Preventive Services Covered by Private Health Plans under the Affordable Care Act. KFF. https://www.kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/
10Vbidcenter. (2013, November 1). V-BID in Action: Preventive Care Coverage in the Patient Protection and Affordable Care Act (ACA). University of Michigan V-BID Center. https://vbidcenter.org/v-bid-in-action-preventive-care-coverage-in-the-patient-protection-and-affordable-care-act-aca/
11American Health Care: Health Spending and the Federal Budget. (2018, May 16). Committee for a Responsible Federal Budget. https://www.crfb.org/papers/american-health-care-health-spending-and-federal-budget