Response to interpellation 2024/25:128 on the Choice System Act
Translated from Swedish by AI; the translation may contain errors. The Swedish text is the original.
Summary AI, written in advance
The debate concerns the Act on Choice Systems (LOV). KD argues that LOV is favorable legislation where municipalities and regions themselves choose whether they want to offer choice 1. KD believes that LOV enables a diversity of actors and creates predictability 2 3, and that welfare crime depends on the criminals' creativity rather than the construction of the law 2. KD argues that the problem is how the compensation system is rigged to distribute care capacity evenly 4. S argues that LOV opens the door to extensive welfare crime and slave-like working conditions 5 6 7. S believes that the system creates a false freedom where market forces are prioritized over the need for care in rural areas 8 9. S wants to review the legislation to remove areas where cheating is greatest 7.
Written by AI in advance and may contain errors. The numbers lead to the speech a statement builds on; check against the text below.
Statsrådet Erik Slottner (KD)
Madam Speaker! Eva Lindh has asked me in what way I will act to eliminate fraud and abuse of our welfare and if I am prepared to abolish the law on choice systems within those areas where the risks for fraud and abuse are greatest.
As Minister for Civil Affairs, I am responsible for the Act on Freedom of Choice, or LOV. The question of how welfare should be resolved simultaneously spans a number of different policy areas.
Initially, it should be emphasized that LOV is a procedural law. The law describes how municipalities and regions should proceed if they want citizens to be able to choose which actor shall perform services for them.
Giving the individual the opportunity to choose the provider is something positive. At the same time, this entails that municipalities and regions need to perform a well-thought-out task, from planning and designing the request documents to thorough follow-up. Abolishing LOV does not make this important basic work any easier.
The most effective measure against welfare crime is to never give companies operating with the support of criminals access to the market. One of the government's primary priorities is to combat crime.
The Government is taking several measures aimed at improving the control and monitoring of the welfare systems. The Government has, among other things, tasked Statskontoret with proposing measures to improve municipalities' and regions' control and monitoring of private providers in order to counter welfare crime, unscrupulous actors, and corruption.
Furthermore, in the budget bill for 2025, the government proposes that the Supplier Control Inquiry's proposal be implemented, whereby Bolagsverket shall be responsible for providing an IT system for coordinated register control of suppliers in public procurements and freedom of choice systems. The inquiry's proposal means that procuring organizations shall be able to turn to Bolagsverket to check information from registers at Bolagsverket, Polismyndigheten, Skatteverket, Kronofogdemyndigheten, and the county administrative boards in a quick and simple manner. Suppliers that have committed crimes or other irregularities shall be able to be easily excluded.
It may be worth mentioning that this proposal has been welcomed broadly during the referral process - virtually all referral bodies support it. Among other things, it is argued that the proposal promotes healthy competition and counters crime in the workplace. The commission's proposal is now being prepared within the Government Offices.
Within the Government Offices, the inquiry's proposal to harmonize the grounds for exclusion in LOV with those that apply for public procurement is also being prepared. The inquiry's proposal implies, among other things, that an applicant can be excluded on grounds that the municipality or the region has written into the underlying material. This would be a major change in relation to how it has been previously.
It is the municipalities and regions themselves that choose how the services shall be provided to the citizens. It is also they who have the best conditions to conduct market and risk analyses to be able to determine what is best in different cases. The choice is in the vast majority of cases free between procurement, choice systems and own management. In addition, there is the possibility to cooperate in different ways with civil society and the non-profit sector.
Eva Lindh (S)
Mr. Speaker! Billions of the taxpayers' kronor end up in criminals' pockets – that is the welfare crime we see right now. It is about employees who feel forced to participate in the cheating, employees who have unreasonable working conditions and clients or patients who actually do not exist, or who in any case do not receive any support despite receiving it on paper, because it benefits those who want to squeeze out a few extra kronor from the system. This is the welfare crime in Sweden today.
Why am I starting with this? Well, because the law on choice systems, which we are discussing today, has proven to be legislation that opens the door to extensive welfare crime. I am not saying that all companies existing within the law on choice systems are fraudsters, but I am saying that the law opens the door to extensive welfare crime. We have seen it in municipality after municipality. Every time a municipality or region begins to review this, one company after another, following the rather extensive review that is required, can be excluded.
When I was a municipal council member in Linköping Municipality, we decided as soon as the Social Democrats took over the government to audit all companies within the home care services, where we had the law on choice systems. We excluded 16 companies. Now we no longer have the law on choice systems because it is not reasonable to have a system that is not for the patients, clients, or users - or whatever one chooses to call them - who need the support they are to receive. This is not supposed to be about getting money or using the operations for criminal purposes.
That is why I have asked the question whether the Minister is willing to seriously tackle welfare crime. The Social Democrats are by no means opposed to having controls and great transparency - of course, one should have that. But regardless of how much effort is put in - if we have a system that allows for abuse, it will be abused.
Is the Minister willing to seriously tackle welfare crime? Perhaps he can start where the fraud has proven to be greatest or at least start by not forcing the regions to have the law on choice systems. The Minister says in his response that in most cases the municipalities and regions can choose. But the regions actually cannot choose whether they want the law on choice systems or not.
I am passionate about this for several reasons. Welfare crime makes me terribly upset because it takes money from the important welfare, which we want to strengthen, not weaken. This also affects so many people, including those who work within these operations.
Markus Kallifatides (S)
Mr. Speaker! I thank the Minister for the answer to the interpellator Eva Lindh's pressing questions. Thanks also for the opportunity to participate in the debate!
In his reply to Eva Lindh, the Minister states that it should initially be emphasized that LOV is a procedural legislation. I mean that it is not the only law regarding choice systems. It is a piece of legislation that gives regions and municipalities the opportunity to establish so-called choice systems, but at present, it is also a piece of legislation that forces regions to introduce choice systems in the very large and for all of us central area of primary care. The state is therefore intervening very powerfully through the law on choice systems in the activities of municipalities and, not least, regions, and quite generally, this is well in line with the Minister's party's position that the entire healthcare system should be nationalized. We Social Democrats are more cautious in this matter, but we are not unfamiliar with cautious reforms that handle pressing social problems.
Eva Lindh has asked two concrete questions to the Minister. I mean that the Minister has given a somewhat clear answer to the first question by stating a number of measures the government has taken and announced to combat fraud and abuse of the welfare systems.
Regarding the second question, I do, however, request a clarification. Have I understood correctly that the SD-led government and the Council of State are not prepared to remove individual areas of activity from the scope of the law on choice systems? Is one not prepared to go through the list of activities within Swedish welfare and, on one basis or another, after a substantive analysis, conclude that this and this should not be possible for municipalities and regions to organize through the law on choice systems? It could be hospital medical care, in vitro fertilization, blood analysis, home dialysis, homeopathic services, ambulance services, services of blood banks, sperm banks and organ banks, social work, social care without accommodation, childcare within preschool, family planning, etc. Is the Council of State and the government really not prepared to review whether we can remove some of these activities from the scope of the law on choice systems?
Kristoffer Lindberg (S)
Mr. Speaker! I thank Eva Lindh for the interpellation which makes it possible for us today to discuss an extremely important issue: LOV and the right of free establishment for companies within the welfare sector.
Let me start in my home region. Two years ago, in October 2022, Region Gävleborg received an application from the company Premicare to terminate the agreement for the health center in Ljusne outside Söderhamn. It was simply not profitable enough for the private company. While Ljusne today stands without a health center, there are four health centers inside Söderhamn, three of which are private.
Now, the phenomenon that has been clear in the country's major cities has also arrived in Hälsingland - and also in other parts of the country. Healthcare providers establish themselves in areas where many people live with mostly mild ailments, that is, in plain terms, city centers and areas with good socioeconomic conditions. At the same time, they opt out of rural areas, smaller towns, and suburbs with poorer socioeconomic conditions. The ideal for the companies' shareholders is as many patients as possible making many short visits for ailments that do not require extensive care.
The reason one can do this is the extreme Swedish market experiment in welfare. The right of free establishment means that care is not where the needs are, but where it is profitable for the private healthcare provider to be. It means that the regions cannot allocate resources where we actually know the greatest needs are. It is clear that Region Gävleborg would be able to run a health center in Ljusne if it did not, as it does now, need to finance an over-establishment in Söderhamn. But this is a consequence of the right of free establishment and the pursuit of profit. This extreme market logic in Swedish welfare means, therefore, that the region does not have the resources to open a health center in Ljusne even though the need exists. The region is also not allowed to direct new private establishments to Ljusne or reject further new establishments in socioeconomically strong areas. Let this sink in.
This means nothing less than that social planning is not governed by the people's representatives and the citizens' needs, but by the market, as if primary care were just any hot dog stand. It is tax money we are talking about. Are we to have Swedish tax-funded primary care for sale on an unregulated market? Or does the government see this problem, and is there the will to actually do something about this?
Does the Minister intend to take any measures to address the inequality regarding access to care that the free establishment right and the Choice Act have brought about? Is the Minister prepared to implement restrictions on the free establishment right and make it possible for the regions to plan their healthcare organization based on the citizens' needs rather than the companies' profit interests?
Statsrådet Erik Slottner (KD)
Mr. Speaker! Some of the questions asked are not those for which I, as Civil Minister, am responsible. Many of the questions concern rather the Minister for Health and Social Affairs' area of responsibility, for example, whether LOV should be mandatory within primary care and regarding the right of free establishment. I am not responsible for that, and I will therefore not be able to answer those questions. I refer the interpellator to the minister who is responsible for precisely those questions.
No tax crown shall go towards financing criminal activity. That is the basis. That is why the government, in a number of different areas, is making efforts to curb the criminal economy - that is, crime overall, but above all, serious crime. The criminal economy must be strangled, and the goal is that no public funds shall go to criminal actors.
Welfare crime is a major problem. We see that it occurs. That is also why we are making many different interventions to address it. But is it LOV's fault that criminal actors establish themselves? No, actually not. Some criminal actors obviously use LOV to enter a public market, but it is not because of LOV or its construction that criminal actors exist.
There are criminal actors who to a large extent also exploit LOU. They succeed in obtaining public contracts through LOU procedures in Sweden. We see many different examples of this. Here, it is probably rather the creativity of the criminal actors that is the problem, not the legislation itself.
It is up to each municipality to choose whether to use LOV and offer freedom of choice within, for example, home care and on the elderly care side. If one does so, LOV sets the framework. It is a way to offer freedom of choice, but it also places demands on the municipalities to be able to handle this, follow up and monitor the operations. If the assessment is made that one does not have the ability and capacity to follow up on private operators' operations or perform sufficient background checks of operators who deliver services to the municipalities, perhaps one should question whether to have LOV and instead use another system. It is up to the municipalities to decide.
As Minister for Civil Affairs, I am responsible for the legislation LOV itself, but as I have said, I cannot answer questions regarding the right of free establishment. I do not need to repeat that.
Eva Lindh says that she is passionate about this issue, but so am I. Just like Lindh, I have a background as a municipal politician in a municipality where the use of LOV was very widespread. I got to come into contact with very many companies, not least within home care, which provided service and care to old and sick people in a way that was full of soul and heart. These were companies that probably would not have been procured in an LOU system, because they were too small, but which were much appreciated by the elderly in a specific district – in my case in Stockholm.
The diversity of actors we could see within the home care service and also on the residential side probably would not have existed if this had not been offered via LOV. But it obviously places great demands on the municipality to follow up on the operations and ensure that the services the companies have been tasked with are performed according to the requirements that have been agreed upon.
What is also the advantage with LOV is that one does not compete on price. It is not the case that the lowest price wins the procurement, but everyone who meets the criteria receives the same compensation. I think that is a big advantage with LOV compared to other systems.
Eva Lindh (S)
Mr. Speaker! I will begin with some comments on the Minister's answer here in the rostrum. The Minister said that if one cannot have control, perhaps one should not have the law on choice systems. It is precisely for that reason that we think it is unreasonable that it is a requirement for regions to have the law on choice systems. The Minister has said that he will not answer that, but the government has a collective responsibility for all issues, even though the current Minister naturally has a specific responsibility. I therefore still want to convey to the Minister that this is unreasonable and that something should actually be done about it.
There are more things that are even more unreasonable about this. I met a woman who had worked with the supervision and control of companies hired under the law on choice systems. She said that when they looked, they found errors. She knew that not all municipalities and regions have the same resources and opportunities to check, but she said that if one starts doing it, one will find errors. Either one has to turn a blind eye and move on to other tasks, or continue—and when one continues, one finds the errors. It could, for example, involve slave-like working conditions.
In Sundbyberg, eight companies have been kicked out after they started checking. I have already raised the situation at home in Linköping. In Norrköping, they have now had to shut down another company within LOV. What they say there is that there is a risk of unserious actors and low quality of care – we know that, because that is how it looks everywhere. They have found serious deficiencies that endanger the health and safety of the care recipients. And so it continues. For example, a large number of hours or occasions have been invoiced for people who either do not exist or have not been granted any interventions. They have invoiced 40 hours instead of 20, or whatever it may be.
The most upsetting thing, of course, is the slave-like working conditions. It is absolutely appalling that we can have it this way in Sweden, a country that many believe has a good welfare state with good working conditions. But that is no longer the case. That is exactly what we are talking about. We have legislation that enables welfare crime and labor-related crime.
It is about resources that all of us taxpayers have paid in with the hope and belief that they go towards a welfare that we want to be part of financing for the elderly and for people who are in need of support and help. But when the resources do not go there, it is upsetting. I therefore want to repeat the question of whether the Minister is prepared to review the law on choice systems and remove the legislation in those areas where we have seen that the cheating is greatest.
Markus Kallifatides (S)
Mr. Speaker! Thank you, Minister, for the previous answer! The answer I suspect is the correct one has become somewhat clearer. It unfortunately appears that the SD-led government and the Minister are not prepared to review which activities shall be possible under the laws on choice systems. I still request a clearer answer, however, if the Minister considers themselves prepared to give such an answer or if it is another Minister who shall give it.
Mr. Speaker! During the summer of 2022, the then Social Democratic government and Minister Ida Karkiainen initiated an inquiry. It came after the unfortunate fact that we Social Democrats were not as successful in the general elections as we had hoped and that Sweden received the SD-led government that we have now. This inquiry on the costs for municipalities and regions for choice systems was completed and handed over to Minister Erik Slottner.
I SOU 2022:69 provides a knowledge overview of the pressing issue of the costs of choice systems in a broad sense. I add a small bonus question here, Mr. Speaker: Does the Minister intend to take the insights from the government's knowledge overview further, not least regarding the costly ultimate responsibility, which all choice systems entail for both municipalities and regions?
Kristoffer Lindberg (S)
Mr. Speaker! Thank you, Minister, for the debate! I want to be clear: My contribution in this debate concerns the law on choice systems and the free right of establishment for private actors, which the state forces the regions to have. It is not about the possibility for citizens to choose healthcare providers, which is a completely different issue.
I believe we all share the view that there is fundamentally something positive in that people can choose which health center or primary care center they want to be registered with, but that does not mean there are no problems with LOV and the right of free establishment within, for example, primary care, which I clearly explained.
In today's reality, we are therefore getting four health centers in one place where there might be a need for two, while at the same time we are left completely without a health center in an area where there is actually a need for at least one. This means that the freedom of choice, which might look good on paper, is in practice a false freedom. It is a freedom for market forces, for the shareholders in the companies, and for the healthy in the big city, but it is far from always a freedom for those who are in the greatest need of care or for those who, for some reason, have not chosen to settle in a big city or a larger community.
Today's system means that taxpayers' money is not actually being used in the best and most efficient way and that primary care cannot be available where it would need to be. My concluding question is therefore: Does the minister intend to implement changes that allow the regions to decide on LOV themselves?
Statsrådet Erik Slottner (KD)
Mr. Speaker! To answer the latest question from Kristoffer Lindberg: No, I do not intend to because I do not have that authority. It is not I who will propose it. It is not the Minister for Civil Affairs who can submit such a bill, but it is another minister who submits a bill that removes the right of free establishment. Therefore, the answer to the question is no. The question may be addressed to the responsible minister.
I want to say again that I do not believe the problem here is the right of free establishment. The problem or the challenge is to structure the compensation system in a way that makes it more attractive to distribute the resources of healthcare capacity evenly across the region.
Through a good reimbursement system, one can actually influence, among other things, the placement of health centers, community clinics, or whatever it is, so that it becomes more even, to take an example. But then one must be a bit smart and clever in how one rigs the reimbursement systems.
It is the same thing on the municipal side. Of course, one can raise the requirements in the tender documents and in that way reduce the number of contractors, if one thinks there are too many. If one thinks it is a problem, one can raise the requirements, because then some will probably not meet them.
One can work in that way, but freedom of choice also places greater demands on politicians to be smart, a bit resourceful, and strategic when they present request documents and set up reimbursement systems. I believe that this fundamentally rewards and sharpens the quality. That is my conviction.
Then I can think that all regions have such a size that they should be able to have the capacity to control and have a follow-up control of the contractors they have. I must say that nonetheless. On the municipal side it can sometimes be more difficult because we have some municipalities that are very small, but there is no region that is so small. All regions have a population whose number is somewhat critical.
I also want to mention the Supplier Control Investigation, which is included in my interpellation answer. I would like to emphasize that we are aligning the grounds for exclusion in LOV and LOU. This was not something the previous government came back with, but now it will become easier.
In line with the updates to LOU and the legislation regarding grounds for exclusion, LOV follows suit. This is very good, as it will make it easier to exclude actors who are not serious. This is something that has been requested, and the government has responded with concrete policy.
We are now providing funds in the budget to the Competition Authority to increase supervision of, for example, contracting entities, and we will proceed with tightening internal control in the Local Government Act, which is another important issue to address this.
We facilitate information sharing between authorities and between municipality and state, which will surely also be able to result in some errors and deficiencies being detected more easily. I know that Minister for Health and Social Affairs Acko Ankarberg Johansson also has several measures underway to ensure that it functions better, for example with a national healthcare register.
So, a great deal is being done to organize this, which however does not attack the freedom of choice itself or the individual citizen's right to choose a healthcare provider, home care provider, or elderly housing. For me, it is very important that we preserve freedom of choice as much as possible, and in that regard, LOV is legislation that is intended to simplify this, so that it does not become the Wild West among municipalities that want to introduce freedom of choice. LOV is a procedural law – legislation on how to proceed if one wants to offer freedom of choice systems to its citizens.
Then Markus Kallifatides asked a number of questions to a government that I am not part of. I am not sitting in an SD-led government, and Markus Kallifatides knows that.
Eva Lindh (S)
Mr. Speaker! There are some things that distinguish us Social Democrats and the SD-led government. It concerns, for example, the view on freedom of choice. We think that freedom of choice is important. It can also be about choosing providers, if the municipality wants that – absolutely.
For us, however, true freedom of choice is being able to influence the content of the support provided. This is important, but just as Kristoffer Lindberg touched upon, it is sometimes limited by legislation when the focus is instead placed on not being able to provide the citizens and residents in the county or region with the care they are seen to need, or when resources are limited so that one cannot provide that support, that care and nursing that people are thought to need.
That is where we differ. For me and for us Social Democrats, it is this that is in focus. Somewhere, it is a choice. Is it most important to retain the law on choice systems, or is it most important not to embrace a system that obviously enables welfare crime? We do not think it is the latter.
We are prepared to review all systems because we want to provide the best welfare so that we save resources, the organization, and everything we have to do the best for the individual and because we want to stand up for a strong welfare in Sweden.
Statsrådet Erik Slottner (KD)
Mr. Speaker! The Social Democrats are always quick to attack freedom of choice or to say that it is freedom of choice that is the cause of many problems, errors, and deficiencies. For me, freedom of choice in itself can never be the problem, but it is how we use freedom of choice and different freedom of choice systems. There we are obviously more or less successful.
As soon as there are problems or irregularities in a private enterprise, it is always the operator who is the problem, but when problems or irregularities arise in a municipal or publicly managed enterprise, it is never the ownership that is the problem. Then it is often a lack of resources that people complain about. I have always been very fascinated by that.
Of course, all operators must sharpen up, regardless of whether they are municipal, public or private. Otherwise, they should not be on the market at all. For me, ownership does not matter. But I am completely convinced that a diversity of providers of public services is fundamentally good for quality.
We have the law on freedom of choice to create predictability and order within the freedom of choice. It is a freedom of choice system that municipalities and regions can make use of.
We can always list problems, but we must also see the good examples that exist in private companies. They exist, for example within elderly care, precisely because LOV exists. Not least, many women run those companies, because they have a will to make everyday life and life better for elderly and frail people.
The problems that are listed can just as easily arise if we carry out a procurement according to LOU as if we do it according to LOV. But the municipalities must become better at follow-up and at having control systems. Therefore, we also tighten the Local Government Act in this respect.
Source: The Swedish Parliament. The speeches come from the open data of the Riksdag, translated into English by AI, which may contain errors.