Health Care and Culture: Lessons from Denmark

by Ben Westermeyer

COPENHAGEN — “I do not have a driver’s license. And I don’t want one.” Torben Jørgensen, a teacher of European history and resident of Copenhagen, bikes everywhere. I met him at a coffee shop to talk about Danish health care, but somehow we ended up talking about cycling instead. Torben’s transportation habits are not unusual in Denmark; 9 in 10 Danes own a bike while only 4 in 10 own cars. Copenhagen, the country’s capital, is recognized as the most bike-friendly city in the world.

“It’s faster, it’s cheaper, and it’s good for my health,” Torben explained to me when I asked him why he chooses to bike.

Torben does not bike out of tradition or environmental consciousness, although he is aware of the added benefit. He does it because of its speed, cost-efficiency, and health benefits. Torben is representative of most Danish bikers in that regard. A Danish Cycling Embassy survey found that the most popular reason that Danes cycle was “It’s faster” followed closely by “It’s easier”. Cycling is not popular in Copenhagen because of something intrinsic to Danish culture; it is popular because of its speed and ease of use. That is good news for other cities that want to increase cycling.

If cities invest in making cycling a faster, easier, and safer option than driving, cycling’s popularity will likely increase.

That is exactly what Copenhagen has done. In 1970, Copenhagen’s traffic counts reported that cars outnumbered bikes 351,133 to 100,071. After several decades of cycling infrastructure investment, there are now more bikes than cars on Copenhagen’s streets. The city hasn’t stopped investing, either. Since 2005, Copenhagen has spent over $17 million on building bike bridges, constructing curbs to separate bike lanes from cars, and expanding bike parking.

Cycling and Health Care

Although cycling may not seem relevant to the Danish health care system, it strongly influences the country’s use of health care. Exercise prevents many medical ailments. According to the Danish Cycling Embassy, Denmark gains approximately 1 euro in health benefits for every kilometer traveled by bike instead of car. A study from the UK found that people who bike to work are four times as likely to meet the recommended 150 minutes of physical activity per week. Such consistent exercise goes a long way in preventing expensive health problems. Although cycling offers health benefits, it is a form of transportation, first and foremost. The exercise that Torben gets from it is just a byproduct of his daily commute. That’s why biking to work is such an effective way to maintain good health; it doesn’t feel like exercise.

Cycling is not nearly as popular in the U.S. Admittedly, the continental U.S. is about 180 times the size of Denmark and American cities tend to be more spread out than Danish ones. Such sprawl inevitably limits American cities’ potential to emulate Danish cycling culture. However, cycling’s lack of popularity in the U.S. cannot be attributed solely to longer travel distances. In Denmark, 31% of trips under 2.5km (1.55 mi) are traveled by bike while only 2% of such trips in the U.S. are. Even for short trips, Americans choose not to bike. A comparison of Copenhagen’s streets to those of even the most bike-friendly cities in the U.S. explains why; with narrow bike lanes, no separation curbs, and inconvenient routes, biking in urban America is not as fast or safe as biking in Copenhagen. But if sustained government investment in cycling infrastructure can convert car commuters into bikers in Copenhagen, then the same can be done in the U.S. Making roads more bike-friendly can stimulate bike culture, improve public health, and lower health care costs.

Is Health Under Our Control?

Denmark is a welfare state. Taxpayers fund free and equal access to health care, education, and unemployment benefits. While Denmark provides universal health care coverage, 10 percent of residents under the age of 65 remain uninsured in the United States. This is a source of envy among Americans; a majority believe the government ought to ensure that everyone is covered. However, insuring more people will in itself increase health care costs, and high costs are Americans’ greatest dissatisfaction with the health care system. So, it seems that the U.S. faces a dilemma: it cannot increase access without increasing costs. But Denmark has done just that. While guaranteeing free access to all its residents, Denmark spent $5,205 per capita on health care in 2016. The U.S. spent $9,892.

If Denmark outperforms the U.S. in terms of access and costs, what is holding back widespread support for an American welfare state health care system?

There are many potential answers to such a complex question, but I will focus on one: the restrictive nature of the welfare state conflicts with Americans’ confidence in our ability to control our lives.

In 2016, the Pew Research Center published a collection of surveys revealing ways that Americans and Europeans are different. While 63 percent of Europeans agree that “success in life is pretty much determined by forces outside our control”, only 43 percent of Americans agreed. Another question found that the vast majority of Europeans valued state guarantees over individual liberties. Americans were quite the opposite: 58 percent chose individual liberties as more important.

Such strong belief in control and liberty impacts our attitudes towards health care. We believe that we control our health, and so we want to choose the health insurance plan that covers us only for problems that we believe to be foreseeable. That way, we can avoid paying for health services we deem superfluous. The U.S.’s decentralized market-based system reflects this desire for personal control. Americans can choose to buy health insurance from a wide range of companies which offer many levels of coverage, or even choose not to buy health insurance at all.

These choices do not exist in Denmark. Danes pay a predetermined amount for health care through their taxes based on their income. Then, they select one of two plans. 98 percent of Danes choose Group 1, in which enrollees pick a general practitioner as their gateway to care, whom they can access for free. The rest enroll in Group 2 and pay a little extra for the luxury of getting to see any general practitioner.

The rigidity of the Danish health care system does not allow Danes much choice in the amount they pay or the coverage they receive, but they are mostly okay with that.

Michael Hedegaard is an expert in investment and finance. He has worked at the Export Credit Agency of Denmark, founded a business consultancy, and currently teaches at Copenhagen Business School. As a businessman, Michael is familiar with evaluating risks, but he believes that in the long run health troubles are too unpredictable for strategically choosing his own coverage to pay off.

“If you have a problem with your health, it is not your fault,” Michael told me.

“It’s a lottery,” Torben agreed.

Michael and Torben’s shared belief that health problems are often uncontrollable is a reason they are okay with accepting compulsory enrollment and less choice in their type of coverage. If health is not controllable, then there is little financial benefit in having control over the amount of coverage. However, if Danes were more like Americans and believed they generally could control their health outcomes, they would be hesitant to surrender so much autonomy. But Danes like Michael and Torben are wary of the randomness of health problems, and not just out of naivety.

Michael’s investment career has taken him to Kenya several times. On one of his trips, he was stung by a stonefish, one of the most venomous in the world. Michael’s general practitioner immediately referred him to the right experts, who provided the necessary antivenin and care to ensure a full recovery. The whole process was, of course, free of charge.

As a survivor of mouth cancer, Torben had an even more serious experience with the Danish health care system. He was diagnosed 11 years ago, underwent treatment for eight months, and has been cancer-free ever since.

“I received my full paycheck for the eight months I didn’t work,” Torben explained. “I used all the resources of the health system without ever reaching into my pocket. 2,600 kroner ($433) per night in a hospital bed.”

A conversation he had with his doctor upon diagnosis gave Torben confidence in his belief that his health is largely out of his control.

“I told my doctor, ‘I’m a heavy smoker, that’s probably it.’ And my doctor responded, ‘We have no way of saying whether it was your lifestyle or something else that caused this.’” The Danes I spoke with are aware of the unpredictability of health troubles. But according to Torben, the same cannot be said about Americans.

“Your health is not entirely controllable,” Torben argued. “This American idea that you are responsible for your own health is crazy.”

Our cultural obsession with personal liberties is a stubborn barrier to the American public supporting the rigid welfare state approach to health care. As long as we believe we can control our health and seek out health plans to match our expectations for our use of care, we will refuse to support compulsory health insurance that only gives us two options.

Although the welfare state model may be too restrictive to gain widespread popularity in the U.S., it is not the only type of single-payer system. Other approaches to single-payer could grant its users more flexibility and gain support. It is possible for the U.S. to move towards a single-payer approach to health care. However, such an approach would need to preserve more choice than the Danish welfare state does.

A System of Collective Trust

On my way to speak with Michael, I saw a sleeping baby in a stroller parked outside of a grocery store. The parents had decided not to inconvenience themselves with bringing their child into the store. A common practice in Denmark, it is one of the greatest culture shocks that Denmark has to offer: trust. Denmark is one of the most trusting countries in the world. Most Danes trust each other, trust their institutions, and would probably even trust you. In fact, one survey found that 78 percent of Danes would trust a complete stranger.

High levels of trust hold the Danish welfare state together.

You must be able to trust that you are not the only one working, paying taxes and contributing to society, but that your fellow citizens also do so if they are able to,” says Gert Tinggaard Svendsen, Professor of Political Science at Aarhus University. “The other precondition is that you must be able to trust that the authorities spend our tax money sensibly and actually pay us back in terms of education, health care, roads and bridges.”

Without that trust in the government and in each other, confidence in the tax system’s ability to provide free health care access would deteriorate. Recently, that has started to happen.

“Yes, there’s a surprising willingness to pay taxes in Denmark,” Michael explained. “It is decreasing though. Have you heard about the recent scandal with the tax authorities?”

I hadn’t. Michael was talking about the Danish tax department losing $15 billion in revenue (5 percent of Danish GDP) due to several cases of mismanagement and fraud. In one case, a group of foreign companies applied for refunds on dividend taxes for holdings that they had fabricated. The ease with which these companies defrauded the system exposed the vulnerability of a system contingent on trust.

“Trust that has been built up through generations can be lost in a single second,” Prime Minister Rasmussen stated in response to the scandal last year. “If that happens, the foundation on which our welfare state rests will crumble.”

If just one child were kidnapped from outside a grocery store, Danes would think twice before leaving their children outside again. Likewise, when just a few companies manage to cheat the Danish tax system, Danes begin to wonder why they should have to pay into a system that does not know how to handle their money.

While Denmark works to maintain its uniquely high levels of trust, the United States cannot build any in the first place.

According to the 2018 Edelman Trust Barometer, Americans’ trust in U.S. institutions dropped 37 percent to a historically low level. Several factors contribute to the lack of trust. Donald Trump is the least popular American president in modern history. America’s diverse society is so severely segregated and fragmented that it’s difficult to develop any sort of collective trust. In contrast to Denmark, a strong sense of hierarchy in the U.S. pits people against each other.

“If the prime minister walked into this coffee shop, you would call him Lars,” Michael predicted. “I would assume he would sit down here, and we would have a talk.”

Such egalitarianism does not exist in the U.S. Even if a senator came into a coffee shop, let alone the president, Americans would surely address that senator by their last name. Although formal address of superiors is a minor cultural norm, it places one person above another. The less we see those around us as equals, the less that we feel connected to them.

Collective trust is difficult to develop anywhere, but it has especially been a challenge in the U.S. Because trust is a such crucial element to a functional welfare state, and because governments cannot inorganically adjust trust levels through policy, increasing government involvement in American healthcare will be a challenge.

Doctors, insurers, and politicians help operate a nation’s health care system, but culture commands it.  Lifestyle choices determine how frequently health care is used, attitudes towards risk drive demand for health insurance, and the degree of trust within a nation dictates the level of government involvement. The question of whether the U.S. health care system can emulate Denmark’s is a question of our capacity to emulate Danish culture.

Ben Westermeyer is a junior at St. Olaf college majoring in Economics. He is studying abroad in Denmark during Spring 2018.

The views expressed in this article are those of the writer. The Contemporary takes no position on matters of policy or opinion.

The cover photo above was taken by Copenhagen by Design. The cycling photo was taken by Kasper Thye and can be found here.

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