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The 'dark side' of Finland's famous free health care

(CNN) In his search for examples of a more equitable society, Bernie Sanders has long looked north ... to Northern Europe, that is.

The "Nordic model" consists of strong welfare states funded by relatively high levels of taxation, which enable governments to provide high-quality education and health care for all. Sanders, an independent US senator from Vermont who's a candidate for the 2020 Democratic presidential nomination, says the United States could learn from this.

"I want to thank the Finnish people not just for what they are doing but for giving us a vision, and a model that we in this country can attain to as well," he told a crowd in Vermont back in 2008.

In 2017, Sanders, who describes himself as a democratic socialist, praised neighboring Denmark's health care system, saying, "They are able to run a high-quality health care system -- probably better than ours -- at half the cost. Because it's a public health care system."

Democratic presidential hopeful and U.S. Sen. Bernie Sanders (I-VT) speaks on healthcare in Washington, DC.

A publicly run and funded health care system -- known as "Medicare for All" -- is now one of the senator's big ideas as a candidate for the 2020 Democratic nomination, and he still appears to be drawing inspiration from the Nordic model, recently referencing the low cost of delivering a baby in Finland on Twitter.

Of course, drawing comparisons between a country like Finland (which has the population of Minnesota) and the entire United States is difficult. No health care system -- rooted as each country's is in both its history and geography -- could ever provide a perfect model for the other.

But Finland's 130-year-old health care system does have a lot going for it. Not only is the vast majority of the population -- 88% -- happy with the system, its virtually free care for all means that no Finn has ever been in the red because of medical costs alone (though that doesn't mean there aren't complaints).

As Finnish journalist Anu Partenen points out, you can't plan for sickness like you can for college fees or a new car. No one ever knows when they will need care that is often exorbitantly expensive. "Health care is not like buying jeans," she adds. "The consumer cannot say this cancer treatment is too expensive, I choose not to buy it -- the typical laws of markets don't apply to health care."

In Finland, health care is considered a right rather than a privilege, she says, and therefore more appropriately managed by the government than the private sector.

It isn't just a question of equity, but of efficiency, suggests Partenen. "The (Finnish) government will negotiate the prices of medicines with the companies developing those treatments -- in the US, the problem is that Medicare is forbidden from negotiating such things, which doesn't make any sense," she says, making the whole system cheaper to run.

Then there is the quality of the system, in terms of patient care outcomes. Finland is one of the five countries with the lowest maternal mortality rates, and Finns have longer life expectancy than Americans. Finland also comes out among the top countries in the world for access to health care.

A man and his son go ice-fishing in Vaasa area, on the frozen Bothnia sea (Baltic Sea), on March 20, 2018, in Vaasa.

Of course, it's not all rosy. In March, the Finnish government resigned because it failed to get its health care reform through Parliament -- becoming the second government in a row to fail to do so.

Finnish's decentralized health care system is often managed by local municipalities with populations ranging from hundreds of thousands of people to fewer than 100. And that decentralized nature is not only very expensive to maintain but also can produce vast disparities in the quality of care.

Municipalities receive funding for health care services based on the size of the taxable population, which can make it more difficult to provide services in remote and larger areas -- where those services are also more expensive to begin with.

In March, just after Juha Sipila's government resigned, the governor of the bank of Finland, Ollie Rehn, warned that reform remained urgent "from the point of view of fiscal sustainability."

As the country's population ages and birth rates fall, the number of taxpayers paying into the system is diminishing—while the overall population is living longer and putting greater strain on resources. In 2018, the average single Finn faced a net average tax rate of 30%, compared to 23.8% in the United States.

"Finns are having less and less children. People are getting older. So we need more people here because we need taxpayers," says Juha Tuominen, the CEO of the largest hospital in Finland, which provides one in four Finns with specialized care.

"So if you think of sustainability, either we get more people to Finland or we have to cut the cost," he adds.

To make Finland's health care system financially sustainable, one of the aims of the last government's reform proposal was to cut costs by centralizing services and introducing more private options. But centralization is proving tricky in a country that is sparsely populated in some areas, and where the health care system was designed to serve even the most remote parts of a country that stretches all the way up to the Arctic Circle.

The Turku University Hospital is pictured in Turku, Finland on August 19, 2017.

Way back in 2013, the international Organization for Economic Cooperation and Development was already warning that Finland was lagging behind many other OECD countries in having high rates of unmet needs. At the time, more than 4% of Finnish people reported unmet medical needs due to cost, travel distance or waiting lists -- a proportion significantly higher than in Denmark, Norway, Sweden and the Netherlands.

As funding shrinks for future generations, even more Finns could find their needs unmet, warns Heikki Hiilamo, a social policy analyst who has advised successive governments on how they might reform the system.

Unless it is reformed, he says, the Finnish system could become more unequal, with poor people and those who live in remote areas increasingly excluded from the very system that was designed to serve them -- perhaps something for Sanders to keep in mind, as he mulls the Nordic model's applications in America.

"People outside of Finland tend to see only the good sides of the system," says Hiilamo.

"Normally, we show people the sunny side of the street, but there is a dark side of the street. And health care is on the dark side, and for many years we have had a problem."