Main findings of my work

For different reasons, the two studies I have led have not yet been published. One study examined how individuals with chronic obstructive pulmonary diseases responded to a shift from traditional insurance to high-deductible health plans with higher out-of-pocket costs. The analysis suggested lower use of healthcare services following the transition, particularly emergency department visits and hospital admissions. Importantly, there were no clear indications of worsened short-term outcomes, such as patients presenting to the emergency department or hospital with more severe acute illness. This may suggest a shift in how individuals with chronic obstructive pulmonary disease manage their condition—potentially adopting alternative care strategies in response to increased financial exposure, thereby avoiding the need for emergency or inpatient care. These observations contrast with findings in other chronic disease populations, where similar insurance design changes have raised concerns about delayed or foregone care (5). My work highlights how cost-sharing arrangements can influence healthcare utilization in condition-specific and context-dependent ways, shaped by both the nature of the illness and the structure of the surrounding healthcare system.

The second study focused on how healthcare organizations in Rhode Island and New Jersey implemented models for identifying and responding to patients’ unmet social needs within clinical settings. My findings point to a range of implementation challenges, particularly in hospital environments, where workflows are typically centered on acute medical care. Interviews with healthcare leaders, managers and providers involved in these efforts revealed a broader tension between individualized approaches implemented by healthcare organizations to address social needs and the more structural, population-level interventions needed to address root causes such as housing conditions or food access. These reflections raised deeper questions about the role of the healthcare system in responding to social needs, and where responsibility should lie—especially given that community-based and social service organizations often hold deeper expertise and longer-standing engagement with these issues.

In interviews with healthcare leaders, managers and providers about their perceptions of healthcare’s role in addressing social determinants of health, it was striking to note that many viewed social determinants as services that individuals need to access and benefit from. I made similar observations while attending the ethics meetings of the Ethics Advisory group of Harvard Pilgrim Health Care (a provider of health benefit plans, programs and services), which debated ethical aspects of key issues faced by the payer. At the time, these meetings were chaired by Dr. Jim Sabin, who together with Norman Daniels, developed the Accountability for Reasonableness Framework for securing a due process when making difficult prioritization decisions in healthcare systems (6). It struck me that during one of these meetings, several participants did not view «social determinants»—such as heat or transportation—as universal entitlements and argued that those who had paid for their healthcare should not be expected to subsidize these services for others with fewer means. These observations contrast with the approach to social determinants in Norway and other European countries, where the focus is on how population-level policies—such as those related to education, social welfare, and environmental protection—contribute universally to better health outcomes.

Further contributions inspired by my U.S. experience

In addition to my own research, I contributed to a piece co-authored with the other Harkness Fellows, published in Health Affairs: (7). In this piece, we argued that while the U.S. excels in innovation and investment, its healthcare system is fragmented, marked by significant regional disparities and inconsistencies that set it apart from the more unified, government-supported models in other high-income countries. We pointed out that politicized debates over initiatives like the Affordable Care Act—and the varying approaches to its implementation across states—have created a landscape marked by political polarization around healthcare issues. We further argued that framing healthcare as a privilege rather than a right underlies many systemic issues. This approach not only fuels high costs through mechanisms like inflated drug prices and high-deductible plans but also blurs accountability, resulting in a focus on financial outcomes over patient care. In contrast, countries with universal coverage, centralized pricing, and clearer governance demonstrate how a more coordinated system can better address the needs of their populations.

Conversations with public health experts in the United States also motivated me to reflect on other public health challenges faced there and in Norway. One example is the growing promotion of vaping by multinational tobacco companies, which are increasingly targeting the youth market with these products. One such conversation motivated me to write a response to representatives of Philip Morris International, who in the Norwegian medical daily Dagens Medisin had argued that they, through their efforts on harm reduction, should be seen as a «team player» in the efforts for a smokefree world (8). In response, I argued that tobacco companies’ push for harm reduction products primarily to maintain their profits and brand strength, rather than stemming from a genuine commitment to public health. Despite promoting harm reduction, the industry actively resists effective tobacco control policies, particularly in low- and middle-income countries, undermining global public health efforts. Moreover, the tobacco industry’s ongoing marketing to youth and attempts to bypass regulations contradict their claims of supporting a smoke-free future. Given their role in creating the tobacco-related health crisis and their opposition to key tobacco control measures, tobacco companies have no rightful place in the efforts for tobacco prevention and control and should not be seen as trustworthy partners in the push for a smoke-free world.

Reflections on national and international impact

For the Norwegian setting, I think my project on how healthcare organizations are addressing social needs holds greater relevance. This is because the high-deductible health plans are relatively unique to the U.S. context and the out-of-pocket expenses experienced by patients in these plans are many times greater than in the Norwegian context, where the deductible level in primary care is relatively low (currently around 300 USD) and patients do not pay for emergency department visits and hospitalizations. However, I believe the United States has made more progress in exploiting variations in out-of-pocket costs among patient groups to assess their impact on health care utilization and outcomes, whereas, in Norway, the evidence base on the impacts of out-of-pocket payments remains relatively sparse.

I believe my work on addressing social needs raised critical questions about the role of healthcare systems in relation to other sectors’ responsibilities for population health. This links directly to a major challenge faced by healthcare systems worldwide: bridging the gap between health needs and available resources. Priority-setting will be crucial to ensure effective and equitable resource allocation, requiring open dialogue among policymakers, providers, and the public. It may also be necessary to examine how other sectors contribute to population health goals and impact healthcare utilization. As Norway and other countries shape their healthcare systems, it may be beneficial to consider how unmet social needs contribute to poor health and increased utilization, and how these needs can be efficiently and equitably addressed. The approach in the United States, which centers around identifying and addressing social needs in the clinical setting, may not be the way forward. Instead, regional health authorities could work with other social welfare institutions to assess whether patient groups, particularly those with chronic conditions or mental illness, are underserved in terms of social needs like food, income support, or housing. These institutions could advocate for more cross-sector involvement, potentially improving medical outcomes and population health. Such responsibility, guided by the concept of «anchor institutions,» is also being advocated in the U.K.’s National Health Service—a system that, for Norway, tends to offer a better comparison (9).

Career impact and further research

After my Harkness fellowship, I returned to the Norwegian Institute of Public Health in a scientist position. I was quickly pulled into the public health response to the Covid-19 pandemic, working on advising municipalities on managing outbreaks, reviewing emerging evidence to inform national guidance and strengthening the institute’s capacity for research to generate timely analysis. Partly inspired by my Harkness fellowship research on healthcare’s role in addressing social needs, and motivated by the glaring inequities exposed by the Covid-19 pandemic, I explored how this applies globally in a British Medical Journal paper, focusing on the World Health Organization’s role in addressing the social determinants of health (10). During my time in the United States, I experienced maturation and increasing skills to engage with experts, which has benefited me when leading international projects after my return. I have worked with several of my fellow Harkness fellows on EU proposals, led a major World Bank project on financing of healthcare systems, and currently I lead several research projects involving international partners. In my current role, I continue to work on building international partnerships, focused on strengthening the evidence base for public health and social measures for managing pandemics.

The United States: A Changed Landscape from Then to Now

In closing, it is difficult not to briefly reflect on the current political situation in the United States. and its impact on science-based institutions. At the time of writing, the U.S. public administration responsible for healthcare is facing its most challenging moment. I have observed that many key institutions I had the privilege of visiting and learning from, such as the Agency for Healthcare Research and Quality, have experienced significant staff cuts and will likely struggle to fulfill their missions. This serves as a reminder that the trust between politicians and public administration—something we enjoy largely in Norway, and which was crucial to the success of the public health response to Covid-19—should never be taken for granted. Moreover, as the federal government in the United States takes steps to significantly scale back its engagement in global health collaborations, institutions like the Commonwealth Fund and its Harkness Fellowship can play a critical role in sustaining global partnerships and promoting core values such as equity, diversity, and inclusion.