The urge to save humanity is almost always only a false front for the urge to rule it.
—H. L. Mencken
There is renewed interest in “socialized medicine.” Some prominent Americans want the United States to adopt national health insurance as a means to cover the uninsured, to establish equality of care, and to control health care costs. Their preferred method is a single-payer health care system in which the government, through taxation, finances and regulates the delivery of health care services.
In fact, the single-payer solution to the problem of the uninsured is a “nirvana approach” to health care. Proponents often highlight the imperfections of the current public–private system of health care financing and delivery and contrast these with an ideological vision of a future egalitarian condition in which these imperfections will disappear and everyone will have access to “free” health care. Although the egalitarian vision holds perennial appeal for some Americans, it would impose a socialist-style command economy and require government control of the production and distribution of goods and services. The striking feature of the command economy, as Professor Alain Enthoven of Stanford University, has observed, is “the contradiction between system and pretensions on the one hand, performance on the other.” Policymakers have a duty to examine not only the promises of the single-payer proposal, but also its performance.
Ideology over Experience. Socialism does not work, or at least not very well, based on an ample historical record. Yet supporters of nationalized health care still believe that socialism, through single-payer financing, is uniquely capable of succeeding in the discrete area of health care financing and delivery. Just as nations have learned that political management and control is not the best way to run the coal, steel, farming, banking, airline, or electric power industries, policymakers should conclude that the political process is a poor way to manage health care. Preventing human suffering should, in principle, include rejecting systems that decrease available health resources by depressing general living standards. Any health care intervention, especially any that affects large populations, should scrupulously follow the medical maxim of “first, do no harm.”
Adverse Effects. Health care in a single-payer system will be rationed by means other than price. This will have inevitable adverse effects, including:
Long waits and reduced quality. In Britain, over 800,000 patients are waiting for hospital care. In Canada, the average wait between a general practitioner referral and a specialty consultation has been over 17 weeks. Beyond queuing for care or services, single-payer systems are often characterized by strict drug formularies, limited treatment options, and discrimination by age in the provision of care. Price controls, a routine feature of such systems, also result in reduced drug, technology, and medical device research.
Funding crises. Because individuals remain insulated from the direct costs of health care, as in many third-party payment systems, health care appears to be “free.” As a result, demand expands while government officials devise ways to control costs. The shortest route is by providing fewer products and services through explicit and implicit rationing.
New inequalities. Beyond favoritism in the provision of care for the politically well-connected, single-payer health care systems often restrain costs by limiting surgeries for the elderly, restricting dialysis, withholding care from very premature infants, reducing the number of intensive care beds, limiting MRI availability, and restricting access to specialists.
Labor strikes and personnel shortages. In 2004, a health worker strike in British Columbia, Canada, resulted in the cancellation of 5,300 surgeries and numerous MRI examinations, CT scans, and lab tests. Canada also has a shortage of physicians, and the recruitment and retention of doctors in Britain has become a chronic problem.
Outdated facilities and medical equipment. Advances in medical technology are often seen in terms of their costs rather than their benefits, and investment is slower. For example, an estimated 60 percent of radiological equipment in Canada is technically outdated.
Politicization and lost liberty. Patient autonomy is curtailed in favor of the judgment of an elite few, who dictate what health care needs and desires ought to be while imposing social controls over activities deemed undesirable or at odds with an expanding definition of “public health.” Government officials would claim a compelling interest in many areas now considered personal.
Conclusion. The very real problems of America’s health care system, including the problem of uninsurance, can be addressed through innovative market-based solutions. While critics of the market approach are free to claim that a future health care system based on free and voluntary exchange would have pernicious rather than positive effects, the evidence-based approach to health policy finds little to support the promised superiority of national health insurance. In the end, the socialist vision of medicine will achieve Orwellian results: The promise of health care coverage becomes health rationing, access to universal coverage means delays in access to care, official fairness yields to favoritism by officials, freedom of choice becomes coerced conformity, and democratic deliberation is replaced by bureaucratic decision-making.
—Kevin C. Fleming, M.D., is an internist and geriatrician in the Division of General Internal Medicine at the Mayo Clinic in Rochester, Minnesota.
