Healthcare in America — The Next Conversation – Before We Go Any Further
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- Healthcare for all
Before We Go Any Further
Before we get too far into how healthcare for all could actually work, let’s look at two examples from opposite ends of the spectrum.
One is a system that, by most measures, worked remarkably well. The other is a system that started with good intentions and a legitimate goal, but failed because we didn’t follow through.
We’ll do the home run first.
It’s almost a fairy tale come true. Or, more likely, Asgard with the Thunder Gods in charge.
In 1969, Norway discovered oil in the North Sea. The Norwegians made a decision that would eventually define much of their future: the wealth generated by that resource belonged to the country, not to a handful of people who happened to own the wells.
They didn’t spend it all at once. They built a system around it, eventually creating one of the world’s largest sovereign wealth funds and using the proceeds as part of a broader social contract with the Norwegian people. Norway still follows that basic philosophy today.
Their healthcare system isn’t quite as simple as saying, “It costs you $300 a year and the government picks up the rest.” But the basic idea is surprisingly close.
Norwegian residents generally pay modest user fees for many healthcare services. Once those approved payments reach the annual ceiling, the government-issued exemption card means they no longer pay those user fees for covered services for the remainder of the year. In 2026, that ceiling is NOK 3,278. Hospital admissions in public hospitals carry no user fee.
Why does it work?
Well, Norway has a few advantages we don’t.
Norway is small. Norway is wealthy. Norway has a relatively homogeneous population and a much smaller healthcare system to manage. And Norway isn’t a global superpower with a massive military, industrial, infrastructure and healthcare complex supporting more than 340 million people.
They have a lot of cod to dry, but they don’t have quite as much country to run.
So I’m not suggesting we simply copy Norway.
That’s not the point.
The important part is the commitment.
Norway made a decision that the country’s natural resources were part of the country’s future, not simply an opportunity for whoever happened to control them. They built institutions around that decision and have continued to maintain them through changes in government and economic conditions.
They have even been trying to reduce their dependence on the very fossil fuels that made them wealthy, with enormous investment in electric vehicles, renewable energy and other technologies.
That doesn’t mean Norway is perfect. Far from it.
Their wind-energy expansion has produced its own political and environmental battles, including concerns about the effect of wind farms on reindeer grazing areas and Indigenous Sámi interests.
Apparently even the Thunder Gods have to deal with zoning disputes.
We wouldn’t want anything happening to Rudolph’s red nose, now would we?
But Norway illustrates something important.
A commitment is only a commitment if you keep it after the applause dies down.
Now let’s look at the other example.
This one happened here at home.
Good Intentions Are Not Enough
In 1963, President John F. Kennedy signed the Community Mental Health Centers Act. The idea was to move mental-health treatment away from large, isolated institutions and toward community-based care.
There were good reasons for doing it.
Many state psychiatric hospitals had become terrible places. Abuse, neglect, overcrowding and dehumanizing conditions were not imaginary problems. New medications offered new possibilities for treating people outside institutions, and the growing civil-rights movement was rightly challenging the idea that people with mental illness could simply be warehoused indefinitely.
The goal wasn’t wrong.
The problem was what happened next.
The federal government encouraged deinstitutionalization and envisioned a network of roughly 1,500 community mental-health centers. But the promised community infrastructure was never fully built, and funding for many services did not keep pace with the people being released from institutional care.
States also faced increasing pressure to reduce the cost of institutional care. Over time, many facilities closed and responsibility shifted toward outpatient care, Medicaid, local governments and other systems.
But there was a problem.
You can’t simply close the hospital and assume the community will magically take its place.
A person with severe schizophrenia doesn’t necessarily become capable of living independently because the state hospital closes its doors.
Someone who needs medication management, supervision, housing, food, transportation and continuing psychiatric care doesn’t stop needing those things because we have decided that institutionalization is no longer acceptable.
The alternative has to exist before the old system disappears.
And too often, it didn’t.
Oregon provides a particularly painful example.
The state closed Dammasch State Hospital in Wilsonville in 1995. Later, Oregon’s Eastern Oregon Psychiatric Center in Pendleton closed in 2014, further reducing the state’s institutional capacity.
And to be fair, the old psychiatric hospitals had serious problems. Some were places no civilized society should have tolerated.
But there is a lesson here that applies far beyond mental health:
When something is broken, we have a tendency to cut it instead of fixing it.
We close the hospital.
We eliminate the program.
We reduce the budget.
We declare victory.
And then we discover that the problem didn’t disappear.
It simply moved somewhere else.
The Dry Statistics
The numbers are difficult to ignore.
HUD reported that 771,480 people experienced homelessness on a single night in January 2024, an 18 percent increase from 2023 and the highest number recorded in that annual count.
Mental illness is not the only cause of homelessness. Housing costs, addiction, poverty, domestic violence, unemployment and other factors all play major roles.
But serious mental illness is unquestionably part of the problem.
And when a person with severe mental illness has nowhere to live, nowhere to receive continuing treatment and no one capable of managing the system around them, the alternatives can become remarkably predictable.
The emergency room.
The psychiatric hospital.
The jail.
The sidewalk.
Then back around again.
That’s not a healthcare system.
That’s a revolving door.
And that brings us back to healthcare for all.
I’m not using Norway as proof that America can simply copy Norway.
We can’t.
Nor am I using the failure of America’s mental-health deinstitutionalization effort to argue that government healthcare can’t work.
That would miss the point entirely.
I’m using these two examples because they illustrate two things we need to understand before we go any further.
The first is what happens when a country makes a long-term commitment to its citizens and continues to honor that commitment.
Norway decided that certain things were simply part of the social contract.
Healthcare is one of them.
The second is what happens when we start down a path with good intentions but fail to build the infrastructure necessary to reach the destination.
The goal doesn’t change simply because the first attempt didn’t work.
You fix the problems.
You don’t abandon the goal.
There will be hiccups. There will be mistakes. There will be unintended consequences. There will be politicians screaming that the whole thing is a disaster.
That’s politics.
The question is whether we have enough commitment to keep working on the problem anyway.
Because if we aren’t willing to make that commitment up front—if we’re only willing to support healthcare for all as long as it is easy, inexpensive and politically convenient—then there isn’t much reason to continue the discussion.
Healthcare for all isn’t just a question of designing a system.
It’s a question of whether we are willing to finish what we start.
| Healthcare For All, The Evolving Series |
