High-Priced Pain: What to Expect from a Single-Payer Health CareSystem

The urge to save humanity is almost always only a false front for the urge to rule it.

-H. L. Mencken[1]

There is a renewed interest in "socialized medicine." Policy elites generally agree that the establishment of a universal, nationalized health care system would best be achieved through the creation of a single-payer health care system. This is nothing new. Since the Great Depression, political leaders advocating a government-run system have proposed massive large-scale changes, either through a government takeover of the system as in Britain or Canada or through extensive government control and regulation as embodied in the failed Clin­ton Health Security Act of 1993.[2]

Meanwhile, the pages of American medical and health policy journals are replete with research and discussion of the failures of the current system, including lack of coverage, erosion of benefits, uncontrolled spending, and cost barriers. While the specifics may vary, many Americans, including medi­cal professionals, express serious dissatisfaction with the present U.S. model of health care. Not surpris­ingly, a single-payer national health insurance pro­gram routinely resurfaces as a major proposal for comprehensive change.

Policymakers should ignore imagined outcomes and focus closely on the performance of existing models: the British, Canadian, and other state-run systems. In these systems, health care is subject to bureaucratic and political rationing and driven by political and budgetary pressures. This leads to 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, in British Columbia, Canada, a health worker strike resulted in the cancellation of 5,300 surgeries and numerous MRI examinations, CT scans, and lab tests. Canadians have 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." Over time, government officials will claim a compelling interest in many areas now considered private.

No government policy can solve all health sys­tem problems and cost nothing. Many of these problems could be resolved if policymakers at both the federal and state levels eliminated the existing distortions in the flawed health insurance markets and established a fair and equitable tax credit sys­tem that would enable every American family to afford health insurance.[3] Desirable social objectives can be achieved in ways that are compatible with Americans' values of individual and economic free­dom and result in a new health care system that is more financially sustainable and produces better economic performance.

Rationale for the Single-Payer Proposal
The single-payer proposal enjoys strong support in certain quarters of America's health policy commu­nity. For example, analysts at the Institute of Medi­cine (IOM) have urged the adoption of universal coverage, rejecting incremental expansions of insur­ance coverage as inadequate to address the many problems of the current health care system. Among the acceptable approaches to achieve that goal, aside from requiring individual or employer-based insur­ance, is the establishment of a single-payer system administered by the federal government.[4]

Likewise, the World Health Organization (WHO) has called health care a "human right" requiring the provision of "universal and comprehensive primary health care, irrespective of people's ability to pay."Ac­cording to WHO analysts, equal access "implies equal entitlement to the available services for everyone."[5] Moreover, according to a WHO report, achieving health care "equity" requires national health planning.[6]

Writing in the JAMA (Journal of the American Medical Association), the Physicians' Working Group for Single-Payer National Health Insurance identified four key principles:

1. Access to comprehensive health care is a human right. It is the responsibility of society, through its government, to ensure this right. Coverage should not be tied to employment.
2. The right to choose and change one's physician is fundamental to patient autonomy. Patients should be free to seek care from any licensed health care professional.
3. Pursuit of corporate profit and personal fortune have no place in caregiving. They create enor­mous waste and too often warp clinical decision-making.
4. In a democracy, the public should set health policies and budgets. Personal medical deci­sions must be made by patients with their caregivers, not by corporate or government bureaucrats.[7]

Support for a single-payer system is not perva­sive throughout the medical profession. For exam­ple, the American Medical Association, the largest professional medical association, favors insurance market reform and the provision of generous health care tax credits and subsidies to low-income Amer­icans to expand health insurance coverage.

Nonetheless, there are prominent medical spokesmen for the single-payer approach. For example, the single-payer position is endorsed by the Society for General Internal Medicine,[8] the American Medical Student Association,[9] and two former editors of the New England Journal of Medi­cine.[10] The current JAMA editor in chief has stated, "We are the only developed country in the world that doesn't have a specific health plan for our people. It's a disgrace."[11]

Political support for a single-payer system is con­fined almost exclusively to liberal Democrats. Repre­sentative John Conyers (D-MI) is the sponsor of the United States National Health Insurance Act (H.R. 676), which has 75 cosponsors, including Represen­tative Charles Rangel (D-NY), ranking member of the powerful House Ways and Means Committee.[12] Senator Edward M. Kennedy (D-MA) and Represen­tative John Dingell (D-MI) have also long champi­oned legislation to establish national health insurance. Among Democratic political leaders, former Vice President Al Gore has also come out in favor of a single-payer system as "the best solution" to the nation's health insurance problem.[13] This is a position shared by the Massachusetts Democratic Party[14] and the Green Party platforms.[15] Demo­cratic National Chairman Howard Dean has also called for national health insurance.[16]

Top 10 Expectations from the Single-Payer Experience

In the professional medical literature, the desire to provide health care for all, particularly for the uninsured, is advanced as one of the primary rea­sons for a single-payer program.[17] However, the potentially adverse effects for the American people of adopting a single-payer system remain largely unexamined in the medical literature.

There is a profound disconnect between what is promised and what is likely to occur based on con­crete experience. The anticipated outcome of improved access for individuals, particularly the poor, is the primary outcome imagined. Obviously, the government could provide universal insurance coverage and finance that coverage through taxa­tion. For policymakers in Congress and state legis­latures, the more important issue, as the 19th century French economist Frederick Bastiat warned, is "that which is not seen"-the long-term consequences for individuals and families and for their doctors of adopting such a system.[18]

A growing body of empirical evidence shows that nationalized health care systems have unde­sirable consequences. Based on these national experiences, particularly the experiences of the British National Health Service (NHS)[19] and the Canadian Medicare system, such consequences should be expected.

Expectation #5: Personnel shortages.

In 2002, the British NHS, a model of central planning, was found to be "critically short of doctors and nurses." This was blamed on "failure in the past to plan far enough ahead."[74] According to projections, the NHS will not reach the European average for physician staffing until at least 2024.[75] Not surprisingly, the remaining staff are "ludicrously overburdened."[76]

Similarly, Canada has a shortage of physicians, which has been blamed on an erroneous 1991 government prediction of oversupply. This estimate prompted mandatory reductions in medical school enrollment and postgraduate training sites throughout the provinces. These actions decreased physician supply while Canada's population grew by 300,000 to 350,000 per year. Meanwhile, the average workweek for Canadian physicians increased from 46.9 hours in 1993 to 53.3 hours in 1998.[77]

As a result, some 18 percent of Canadians now have trouble finding a doctor. Shortages in rural primary care, radiation oncology, anesthesiology, radiology, psychiatry, and obstetrics have been reported. Indeed, nearly 60 percent of family physicians refuse to take on new patients or have limited their number.[78] Although the volume of work has increased significantly, the ratio of diagnostic radiologists per 100,000 population has not changed over the past decade. Similarly, the number of ophthalmologists is expected to fall by half over the next 20 years.[79]

Canada has 2.1 physicians (including residents) per 1,000 population compared to the OECD average of 2.8. To reach sufficient physician supplies, Canada would need to train 500 more physicians per year (a 25 percent increase). This shortage is exacerbated by government limits on residency slots and physician immigration and by the exodus of Canadian physicians to practice in other countries. Canada lost approximately 411 physicians annually to the United States from 1992 to 1998 but lost only 209 in 2002 and 80 in 2003. In 2004, for the first time in more than a decade, Canada registered a net gain of 55 physicians, with 262 migrating abroad.[80] From 1996 to 2002, according to the Canadian Institute for Health Information, there was a net migration of 49 neurosurgeons from Canada, a nation that then boasted only 241 neurosurgeons.

"It's not about the money," said Dr. Sriharan, a 38-year-old immigrant from Sri Lanka, "We can't do our job properly with operating room time so extremely limited here." He and his colleague could perform only one or two procedures on some days, so non-emergencies would go months or even years before getting necessary treatment.[81] In 1970, Canada ranked second in surveys measuring physicians per 1,000 people; but as of 2005, it had fewer physicians when compared with other nations, ranking 16th out of 23 countries. To rank as highly as first-ranked Austria, Canada would need to have 25,500 more doctors.[82]

In response to shortages in rural areas, recent proposals have included increasing the number of lesser-trained non-physician clinicians or "simply forcing new graduates to work in under-serviced regions."[83] Since 1993, the number of nurses per 100,000 Canadians has also dropped by more than 10 percent. Moreover, one in three is nurses is older than 50 years, but only one in 10 is under 30.[84]

The Health Council of Canada recently warned that if the government does not address the shortage of doctors and nurses in Canada, "the scarcity of human resources will reach a crisis point."[85] For example, nursing shortages forced a Vancouver hospital to outsource 980 surgeries to private clinics in 2004.[86] In May 2006, a shortage of operating room nurses in a Calgary hospital meant no surgeries for eight operating days. Dr. Glenn Comm, president of the Calgary and Area Physicians Association, estimated that up to 64 hours of surgery time were lost.[87] In a recent needs assessment, Canada was found to have a current and worsening shortage of anesthesia staff, identifying a deficit of at least 656 full-time-equivalent anesthesiologists for the period 2000- 2016.[88] To address physician shortages, the Canadian government spent an additional $27 million in 2005- 2006, and $35 million in 2006-2007, to train up to 200 international medical graduates each year.[89]

For similar reasons, the recruitment and retention of general practitioners and specialists is considered a chronic and widespread problem in Britain as well.[90] Job dissatisfaction has grown due to low pay, overwork, stress, medical litigation, bullying, racism, and underfunding of the health service.[91] As a result, British physician and other staff shortages have forced the NHS to recruit abroad.[92]

In Britain, government directives reducing the hours that "junior doctors" may work and the total length of their training meant that new physicians had less experience, and hospitals had problems covering the work to be done. The NHS "streamlined" junior doctors' training by reducing the breadth and duration of clinical preparation required to become a consultant, dismissing fears that medical education was simply "being dumbed down" to address physician shortages.[93]

British shortfalls are exacerbated by an accelerating trend of early retirement among consultants and nontraditional work patterns among female physicians. (About half of female physicians work part-time, and many take a career break.)[94] Separate European Union (EU) rules limiting doctors' hours threaten to create massive physician shortages and constrain crucial emergency access. As of August 2004, the EU Working Time Directive limits junior doctors to working 58 hours per week. The NHS estimated that the directive will cause a loss of 270,000 working hours per year, the equivalent of 3,700 physicians. Failure to comply can result in fines or employment tribunals.[95]

In the United States, the debate over physician supply has careened from dire predictions of oversupply to more recent predictions of shortages.[96] Where a normal market could easily manage supply and demand through prices, the central planners running a single-payer health care system find that the long lag time between policy interventions and the length of physician training makes even frequent assessments of the physician workforce "a critical, but elusive goal."[97]

Dental care in Britain is also burdened by the great demand that accompanies "free" health care in the NHS. Dentists are paid a fixed amount for each procedure-fees that have declined over time. To make a living, NHS dentists see an average of 30 to 40 patients per day, compared with the 12 per day seen by dentists in the United States. As a result, "ever fewer British dentists are willing to endure the grueling, assembly-line work required to participate in the National Health Service."

Despite an enlarging and aging population, Britain has fewer dental schools than before, and fewer dentists are being trained. Patients are forgoing routine dental exams and cleaning and are "waiting until the last possible minute to get their teeth fixed." Shortages are so severe that in August 2003, 600 people turned up outside a tiny dental surgery office in Wales to secure one of 300 appointments for the NHS dentist. Some had camped in tents overnight; half were turned away. A British patient remarked, "It was like a bread line."[98]

None of this should be surprising. Without the functioning of a real market and real prices, as Nobel Laureate Friedrich Hayek observed, a central planner faces an impossible task in attempting to allocate labor or other resources. It simply cannot be done efficiently.[99] Moreover, reduced and fixed salaries for nurses, mid-level providers, physicians, and pharmacists, among others, affect recruitment and retention across these professions.[100]

Attracting talented young people may prove more difficult with lower wages, especially considering the median medical student debt of $135,000.[101] Since the deregulation of Canadian medical school tuition in 1998, tuition fees have "skyrocketed," causing fears that lower-income students could not afford to become physicians because government fees would be insufficient for their debt load.[102] In Great Britain, there are similar concerns that increasing debt "will cause many students, particularly those from working class backgrounds, to decide against a career in medicine"[103] when 70 percent of medical students already come from upper classes.[104]

Bright students have numerous career alternatives. Indeed, Thomas Sowell, a prominent economist, argues:

[M]edical school may no longer look like such a good investment to many in the younger generation. Britain, which has had government-run medical care for more than half a century, has to import doctors from the Third World, where medical school standards are lower.[105]

Moreover, as many as one in four medical graduates in Great Britain never practice medicine, opting for more lucrative careers in other fields.[106] According to the 2001 census, over 26,000 medical doctors in England and Wales were employed but not working as medical practitioners.[107]

To meet these shortfalls, the NHS has depended for many years on International Medical Graduates (IMGs), particularly in less popular specialties such as geriatrics, genitourinary medicine, and psychiatry.[108] This has increased substantially in recent years, with IMGs representing 15 percent of consultants appointed during 1964-1991 and 24 percent of those appointed since 1991. In addition, to meet NHS pledges for more physicians, the government began a world-wide advertising campaign for doctors in 2001.[109] By 2002, nearly half of the 10,000 new doctors in Britain were from non-EU overseas countries,[110] rising to more than two-thirds of a total of 15,000 in 2003.

While 22.7 percent of Canada's physicians earned their medical degrees outside of Canada, since the 1990s, the number of immigrants taking up practice in Canada has constantly declined.[111] Physician shortages and migration reflect a symptom "of a deeper malaise" in nationalized health systems: "planning failures, the inability (or unwillingness) to pay fairly, and lack of career prospects."[112]

Expectation #7: Waiting times.

Queues indicate a shortage in a centrally planned economy, but they are inevitable when government sets prices at or below the equilibrium level.[132] According to the OECD, among countries that report significant wait times, reduced physician availability largely explains most variations in wait­ing, followed by lower funding and bed capacity.[133]

In Canada, queues are common. A survey of spe­cialist physicians in Canada found that the waiting time for radiotherapy of non-small cell lung cancer rose from 27.3 days in 1982 to 42 days in 1999. In Ontario, the median wait for knee replacement sur­gery doubled from eight weeks in the late 1980s to 16 weeks by 1999. In 1990, median Canadian waiting times for angioplasty and coronary bypass were 11 weeks and 5.5 months, respectively. In comparison, 1999 median waiting times for angio­plasty ranged from just 4.5 weeks in New Brun­swick to 13 weeks in Newfoundland, and waits for elective coronary bypass ranged from 8.5 weeks in Ontario to one year in Newfoundland. Interna­tional comparisons show that waits for elective car­diac bypass or angiography were even longer in Britain and New Zealand (1995 data).[134]

More recently, the average wait between general practitioner referral and specialty consultation in Canada was 17.7 weeks, and the total wait time for treatment was 90 percent longer than in 1993. Delays such as 32.2 weeks for orthopedic surgery and 30 weeks for ophthalmology treatment were described as "beyond clinically reasonable."[135]

With regard to access to technology, Canada per­forms "dismally" when compared to other OECD countries. While ranking number one as a health care spender, Canada ranks 15th out of 24 in access to MRIs, 17th out of 23 in access to CT scanners, eighth out of 22 in access to radiation machines, and is tied for last in access to lithotripters. Lack of access to machines has meant longer waiting times for proper diagnosis.[136]

Studies have found waiting times to be longer in Canada than in the U.S. for a variety of elective sur­geries. In comparing American Medicare patients to Canadian patients, researchers found that the aver­age waiting time was twice as long for both the initial orthopedic consultation (four weeks vs. two weeks) and knee replacement surgery (eight weeks vs. three weeks) in Canada. A recent survey in Canada and four other countries showed that the average waiting time for elective surgery was more than one month, with 27 percent of people surveyed indicating that they had waited more than four months.[137]

In the end, "the corrosive and debilitating debate over money" in socialized medicine accounts for people having to wait for hours in crowded emer­gency rooms or for a year or more for surgery or diagnostic tests.[138] Between 1993 and 2003, aver­age waiting times in Canada rose 70 percent despite a spending increase of 21 percent, from $1,836 to $2,223 per capita.[139] It should be noted, however, that lack of diagnostic equipment and limited oper­ating room time are not merely evidence of poor planning, but often intentional mechanisms "used to control hospital costs, enabling administrators to meet their budgets."[140]

In Britain, the queue problem is legendary. Faced with hospital queues exceeding 1 million, with many patients waiting more than a year for inpa­tient treatment, the NHS increased spending by more than one-third since 1999.[141] The share of public spending in the United Kingdom rose from 80 percent in 1998 to 86 percent in 2004, well above the average of 73 percent for OECD coun­tries.[142] However, only 2.4 percent was spent on new beds or surgeries. The bulk, 29 percent, went toward NHS personnel pensions, and 27 percent went to pay raises for physicians and nurses and to hiring new staff.

In 2006, the waiting list in Britain did fall below 800,000 for the first time, but 24,800 had waited more than six months, and the NHS overall experi­enced "a sharp fall" in productivity, declining to its lowest level since 1990.[143] As of 2006, the maxi­mum wait for surgeries remained at six months.[144] Moreover, the median waiting time between a deci­sion to admit a patient to the hospital and actual admission for treatment actually rose from 43 days in 1999-2000 to 54 days in 2004-2005.[145]

All this effort has come at great cost. The cumu­lative deficit run up by Britain's NHS since 1997 is approaching £750 million. The NHS is now "facing the biggest financial crisis in its history after it emerged that front-line trusts in England ran up deficits of £1.27 billion last year."[146] As a result, "[w]ards are being closed, frontline medical staff cut, operations cancelled-and piles of unpaid bills are mounting up." Over the past seven years, the NHS has doubled the amount spent on health, but "much of it seems to have been dropped into a black hole." According to Chris Grayling, the Con­servative Party health spokesman, "The reality is that much of the NHS is now bankrupt and all round the country hard decisions are being taken about cutting back services."[147]

Moreover, some of the wait lists have been reduced not by performing the desired services, but by simply refusing to make appointments avail­able. Similarly, to ration care and save £25 million a year, local health trusts have been told to cut GP referral rates to match the lowest 10 percent nationally. Consultant-to-consultant referrals are also being limited, thus denying patients a second opinion. Emergency departments must redirect 40 percent-70 percent of patients back to GPs or walk-in clinics, as they will not be paid for any ser­vices rendered.[148]

Other countries reduce wait lists artificially by reducing demand. For example, in Spain, finan­cial incentives induced specialists to contain demand, and in New Zealand, the booking system raised clinical thresholds for adding patients to waiting lists.[149]

According to Britain's Royal College of Radiolo­gists, the lack of machines and greater patient complexity lengthened waiting times for radio­therapy. In 1998, 28 percent of patients waited more than four weeks to start potentially curative radiotherapy. In 2002, 81 percent of patients surveyed waited longer than four weeks.[150] By 2003, the median wait was five weeks. The per­centage of patients waiting longer than national guidelines for radical treatments increased from 32 percent in 1998 to 72 percent in 2003; the per­centage of patients waiting for adjuvant treat­ments during the same period rose from 39 percent to 62 percent.[151] As of 2005, there were lotteries in Britain for anti-cancer drugs, chemo­therapy treatments, and even for a place in line waiting for diagnostic scans.[152]

New EU work regulations set for 2008 will restrict the use of MRI scanners in Britain, affecting as many as 300,000 procedures per year. Increased waiting times, lower quality, and increased risk from radiation exposure are expected results.[153]

Although the NHS promised that 95 percent of patients would start treatment for cancer within 62 days of being referred, June 2006 figures showed that 9 percent spent longer in queues, equating to around 12,000 people a year. The main delays occur in the wait for diagnosis, where lack of staff and equipment prevent completion of diagnostic tests. The biggest waits are for colon cancer, the third most common form of cancer in Britain, affecting 34,000 people a year, where insufficient access to colonoscopy delays diagnosis.[154]

Although patients prefer fewer barriers to spe­cialty care, rationing by queues and rationing by means of gatekeepers are crucial methods by which officials control expenditures, rather than the effects of poor design or underfunding.[155] While the NHS has long used waiting lists and denial of coverage for treatment that health authorities "con­sidered of doubtful benefit," it has preferred "to pretend this was not rationing."

In 1998, Shadow Secretary of State for Health Ann Widdecombe argued that "it was unhelpful to deny the existence of rationing; it always had and always would exist."[156] Only in recent years has the Labour party acknowledged "that a tax-financed service cannot provide everything that the pharmaceutical industry and medical technology can create."[157] However, in nationalized health care systems, politicians and bureaucrats-rather than patients-continue to decide which health care options are available.

[1] For a historical discussion of this debate, see Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982), p. 389. See also Jo Ivey Boufford and Phil Lee, "Health Policy Making: The Role of the Federal Government," in Marion Danis, Carolyn Clancy, and Larry Churchill, eds., Ethical Dimensions of Health Policy (New York: Oxford University Press, 2002), pp. 158 and 199-200.

[2] There are a variety of innovative policy options. For example, see Stuart M. Butler, "Reducing Uninsurance by Reform­ing Health Insurance in the Small-Business Sector," Heritage Foundation Backgrounder No. 1769, June 17, 2004, at http://www.heritage.org/research/healthcare/bg1769.cfm .

[3 ]Institute of Medicine of the National Academies, Board on Health Care Services, Insuring America's Health: Principles and Rec­ommendations (Washington, D.C.: National Academies Press, 2004), at http://www.nap.edu/books/0309091055/html (October 2, 2005).

[4] U.N. Commission on Human Rights, "Statement by the World Health Organization," Agenda Item 10: Economic, Social and Cultural Rights, April 1, 2003, at /static/reportimages/515013611CAE8C19F59F88D53EBA6D7B.pdf (July 14, 2005), and Russell Mokhiber and Robert Weissman, "Health Care Is a Right: A People's Charter for Health," The San Francisco Bay Guardian, December 26, 2000, at http://http://www.sfbg.com/focus/113.html (July 14, 2005).

[5] Margaret Whitehead, "The Concepts and Principles of Equity and Health," World Health Organization, Regional Office for Europe, Copenhagen, 1991, pp. 3-15, at /static/reportimages/A8C8BE1AD11459B8A529842A5048EE7B.pdf (March 15, 2005).

[6 ]Physicians' Working Group for Single-Payer National Health Insurance, "Proposal of the Physicians' Working Group for Sin­gle-Payer National Health Insurance," JAMA,August 13, 2003, pp. 798-805.

[7] Eugene Rich, letter to Bob Doherty, Senior Vice President, Governmental Affairs and Public Policy, ACP-ASIM, 2002, at http://www.sgim.org/ACPAccess.doc (September 27, 2005), and Society of General Internal Medicine, "Support Health Care Reform," Issue Brief, at http://www.sgim.org/HealthSystemsbrief.cfm (September 27, 2005).

[8] American Medical Student Association, "AMSA's Universal Health Care Leadership Institute 2005: Training Tomorrow's Leaders in the Health Care Justice Movement," 2005, at http://www.amsa.org/uhc/uhcli.cfm (September 28, 2005).

[9] Arnold Relman, "The Health of Nations," The New Republic, March 1, 2005, at http://www.tnr.com/ doc.mhtml?i=20050307&s=relman030705 (September 27, 2005; subscription required), and Marcia Angell et al., "Proposal of the Physicians' Working Group for Single-Payer National Health Insurance," Physicians for a National Health Program, at http://www.physiciansproposal.org/proposal_group.htm (September 28, 2005).

[10] Liz Kowalczyk, "Universal Health Plan Is Endorsed," Boston Globe, August 13, 2003, p. A1.

[11] The bill is comprehensive. It would provide universal coverage under a government health insurance program for all "med­ically necessary" care, outlaw private health insurance that duplicates benefits provided by the government, and establish a "global budget" for medical services. The bill would finance the program through existing government revenues for health care, an increase of personal income taxes on the top 5 percent of income earners, new taxes on stocks and bonds, and a "modest" (but unspecified) payroll tax increase.

[12] Mark Halperin, Elizabeth Wilner, and Marc Ambinder, "Gore Supports Single-Payer," ABC News The Note, November 14, 2002, at http://www.abcnews.go.com/sections/politics/DailyNews/
TheNote_Special2.html (September 27, 2005).

[13] Massachusetts Democratic Party, "The Platform of the Massachusetts Democratic Party," at http://www.massdems.org/about/platform.htm (September 27, 2005).

[14] Greens/Green Party USA, "Platform of the Greens/Green Party USA," at http://www.greenparty.org/Platform.php (September 27, 2005).

[15] Charles S. Johnson, "Dean Wows Dems with Speech," The Billings Gazette, July 17, 2005, at http://www.billingsgazette.com/index.php?id=1&display=rednews/2005/07/17/
build/state/58-dean.inc (September 28, 2005).

[16] Physicians' Working Group, "Proposal of the Physicians' Working Group for Single-Payer National Health Insurance."

[17] Frederick Bastiat, "That Which Is Seen, and That Which Is Not Seen," 1850, at http://www.jim.com/seen.htm (September 27, 2005).

[18] Alain C. Enthoven, "The NHS Plan: A View from 30,000 Feet," Adam Smith Institute (London), 2001, pp. 1-7, at /static/reportimages/FFB715269EB94A466A9306E4C2990D00.pdf (October 1, 2005).

[19] Lindsay Thompson, David Goodman, and George Little, "Is More Neonatal Intensive Care Always Better? Insights from a Cross-National Comparison of Reproductive Care," Pediatrics, Vol. 109, No. 6 (June 2002), pp. 1036-1043.

[20] Koravangattu Sankaran, Li-Yin Chien, Robin Walker, Mary Seshia, Arne Ohlsson, Shoo K. Lee, and the Canadian Neonatal Network, "Variations in Mortality Rates Among Canadian Neonatal Intensive Care Units," CMAJ, Vol. 166, Issue 2 (January 22, 2002), pp. 173-178, at /static/reportimages/98A5695FB4133DE751B140801FA29F17.pdf (September 1, 2006).

[21] David Green and Laura Casper, "Delay, Denial and Dilution: The Impact of NHS Rationing," Institute of Economic Affairs (London), Health and Welfare Unit Choice in Welfare No. 55, January 2000, at /static/reportimages/324A1D21D2A72C70E242B75DE3E36EC3.pdf (October 1, 2005).

[22 ]Organisation for Economic Co-operation and Development, Health Data 99, citedinDavid G. Green, "They've Had a Good Innings! Does the NHS Discriminate Against the Elderly?" Civitas Background Briefing No. 1, p. 3, at /static/reportimages/394992C3F51A015ED1E1BB94B2302855.pdf (September 1, 2006).

[23] Green and Casper, "Delay, Denial and Dilution."

[24] United Kingdom Office for National Statistics, "Expenditure on Health in the UK," 2006, at /static/reportimages/00C8DF570BEB1D2528777E8760EA3F3E.pdf (September 1, 2006).

[25] Organisation for Economic Co-operation and Development, "OECD Health Data 2006: How Does the United Kingdom Compare," at /static/reportimages/4BFDFCC8DE4C3C729F0B800046DD46CB.pdf (September 1, 2006).

[26] Nigel Hawkes, "Hospital Salaries Eat Up Half of Health Service's £3.6bn Windfall," The Times, February 3, 2006, at http://www.timesonline.co.uk/newspaper/0,,174-2022820,00.html (August 30, 2006).

[27] BBC News, "Woman Loses Herceptin Court Bid," February 15, 2006, at http://news.bbc.co.uk/1/hi/health/4715430.stm (August 30, 2006), and Karol Sikora, "The Price of Life," The Daily Telegraph, August 22, 2006, at http://www.telegraph.co.uk/health/ main.jhtml?xml=/
health/2006/08/22/hcancer22.xml (August 25, 2006).

[28] Pierre Lemieux, "Canada's 'Free' Health Care Has Hidden Costs," The Wall Street Journal, April 23, 2004, p. A15, at http://www.independent.org/newsroom/article.asp?ID=1292 (October 1, 2005).

[29] Darren Yourk, "Ontario Health System 'Woefully Inadequate,'" The Globe and Mail, April 20, 2004, at http://www.theglobeandmail.com/servlet/story/RTGAM.20040420.
wsars0420/BNStory/Front (October 1, 2005; subscription required).

[30] Mark Stabile and Courtney Ward, "The Effects of De-listing Publicly Funded Health Care Services," draft conference paper for "Health Services Restructuring: New Evidence and New Directions," Kingston, Ontario, November 17-18, 2005, at /static/reportimages/9EB143F307E34F29C15743765743BB0D.pdf (August 27, 2006).

[31] Mark J. Eisenberg, "An American Physician in the Canadian Health Care System," Archives of Internal Medicine, Vol. 166, No. 3 (February 13, 2006), pp. 281-282.

[14] "Competition Only Way of Rescuing Healthcare, Say Kirby and Keon," Canadian Healthcare Technology, October 2004, at http://www.canhealth.com/oct04.html#anchor34729 (August 27, 2006).

[33] Richard Feachem, Neelam Sekhri, and Karen White, "Getting More for Their Dollar: A Comparison of the NHS with Cali­fornia's Kaiser Permanente," BMJ, Vol. 324, Issue 7330 (January 19, 2002), pp. 135-143, at http://bmj.bmjjournals.com/cgi/ reprint/324/7330/135 (October 1, 2005).

[34] Mark Gould, "Lesson from America," The Guardian, November 5, 2003, athttp://society.guardian.co.uk/nhsplan/story/ 0,7991,1077525,00.html (February 24, 2005).

[35] Geoffrey Rivett, "The Next Chapter of From Cradle to Grave: Fifty Years of the NHS," Health Service Journal, at http://www.nhshistory.hsj.co.uk/index.htm (September 28, 2005).

[36] Minnette Marrin, "The Health Service Is Sick from the Neck Up," The Daily Telegraph, January 21, 2000, p. 28, at http://www.minettemarrin.com/minettemarrin/2000/01/the_health_serv.html (October 2, 2005).

[37] Anthony Browne and Matthew Young, "NHS Reform: Towards Consensus," Adam Smith Institute (London), 2002, pp. 8, 10, and 15, at /static/reportimages/799A262248F0D5AF09880B8BA0E23553.pdf (February 24, 2005).

[38] Rivett, "The Next Chapter."

[39] Richard Smith, editorial, "Oh NHS, Thou Art Sick," BMJ, Vol. 324, Issue 7330 (January 19, 2002), pp. 127-128, at http://bmj.bmjjournals.com/cgi/content/full/324/7330/127 (October 1, 2005).

[40] William W. Lewis, The Power of Productivity: Wealth, Poverty and the Threat to Global Stability (Chicago: University of Chicago Press, 2004), pp. 9-14, 75, and 97.

[41] Joanna Coast, Jenny Donovan, Andrea Litva, John Eyles, Kieran Morgan, Michael Shepherd, and Jo Tacchi, "'If There Were a War Tomorrow, We'd Find the Money': Contrasting Perspectives on the Rationing of Health Care," Social Science & Medi­cine, Vol. 54, Issue 12 (June 2002), pp. 1839-1851.

[42] Ibid.

[43 ]Andrew Bindman, "Whose Health Care Is More Efficient?" BMJ, Vol. 327, No. 7418 (August 28, 2002), pp. E96-E98, at http://bmj.bmjjournals.com/cgi/content/full/327/7418/E96 (October 1, 2005).

[44] Editorial, "The Perils of Cutting Medicaid," The New York Times, April 17, 2004, p. A14.

[45] James Frogue, David Gratzer, Timothy Evans, and Richard Teske, "Buyer Beware: The Failure of Single-Payer Health Care," Heritage Foundation Lecture No. 702, May 4, 2001, at http://www.heritage.org/Research/HealthCare/HL702.cfm.

[46] Browne and Young, "NHS Reform," pp. 8-15.

[47] John Goodman, Gerald Musgrave, and Devon Herrick, Lives at Risk: Single-Payer National Health Insurance Around the World, (Lanham, Md.: Rowman & Littlefield Publishers, 2004), pp. 147-150; Angus Deaton and Christina Paxson, "Mortality, Income, and Income Inequality over Time in Britain and the United States," National Bureau of Economic Research Working Paper No. 8534, October 2001, pp. 3-48; Ananova.com, "Health Chiefs Accused of Rationing Alzheimer's Drugs," Novem­ber 1, 2002, at http://www.ananova.com/news/story/sm_706687.html (February 25, 2005; unavailable January 10, 2006), and National Center for Policy Analysis, "British Hospitals Ration Alzheimer's Drugs," Daily Policy Digest, November 25, 2002, at http://www.ncpa.org/iss/hea/2002/pd112502f.html (October 1, 2005).

[48] Sikora, "The Price of Life."

[49] British Dental Association, "Response from the British Dental Association to Modernising NHS Dental Services in Scotland," 2004, pp. 2-20, at /static/reportimages/6DD22D585ECC683C34D1200CB8538EC9.pdf (October 1, 2005).

[50] Malcom Dean, "The NHS-The Problem Is Capacity, Not Funding," The Lancet, March 23, 2002, p. 1043.

[51] Nigel Hawkes and David Charter, "NHS Chief Says Hospitals Must Spend Less on Drugs and Staff," The Times, April 12, 2006, p. 8, at http://www.timesonline.co.uk/article/0,,8122-2130210,00.html (August 29, 2006).

[52] Patrick Wintour, "Blair Faces Inquiry into NHS Crisis," The Guardian, April 19, 2006, p.1, at http://www.guardian.co.uk/uk_news/story/0,,1756374,00.html?gusrc=rss (August 28, 2006), and Chris Ham, "Creative Destruction in the NHS," BMJ, Vol. 332, No. 7548 (April 29, 2006), pp. 984-985.

[53] Louis C. Gapenski, Understanding Health Care Financial Management: Text, Cases, and Models, 2nd ed. (Chicago: AUPHA Press/Health Administration Press, 1996), p. 317.

[54] R. P. Fallon, "Not-for-Profit  No Profit: Profitability Planning in Not-for-Profit Organizations," Health Care Management Review, Vol. 16, No. 3 (July 1991), pp. 47-61.

[55] S. E. D. Shortt, editorial, "Waiting for Medical Care: Is It Who You Know That Counts?" CMAJ, Vol. 161, Issue 7 (October 5, 1999), p. 823, at http://www.cmaj.ca/cgi/content/full/161/7/823 (October 1, 2005).

[56] Walter Block, editorial, "Socialized Medicine Is the Problem," Surgical Neurology, Vol. 60, Issue 5 (November 2003), pp. 467-468; Randall Palmer, "Preelection Row Erupts over Canadian Health Care," Forbes, May 7, 2004, at http://www.forbes.com/business/healthcare/newswire/
2004/05/07/rtr1364269.html (October 1, 2005); and Mary Anastasia O'Grady, "In Canadian Health Care Some Are More Equal Than Others," The Wall Street Journal, May 21, 2004, p. A11, reposted at http://www.charterhealth.ca/news/2004may21.html (October 1, 2005).

[57] Lemieux, "Canada's 'Free' Health Care Has Hidden Costs."

[58] Jagdish Bhagwati, In Defense of Globalization (New York: Oxford University Press, 2004), p. 15.

[59] Anthony Browne, "Scandal of NHS Beds Auction," The Observer, January 6, 2002, at http://observer.guardian.co.uk/nhs/story/0,1480,628437,00.html (October 1, 2005).

[60] Marie Woolf, "MPs Condemn Scheme Allowing Them to Jump NHS Queues," The Independent, December 15, 2003, at http://news.independent.co.uk/uk/health_medical/article82560.ece (October 1, 2005).

[61] Nick Meo, "Tour Operators to Offer Cut-Price Surgery in India," The Times Online, February 13, 2004, at http://www.timeson­line.co.uk/article/0,,3-999258,00.html (October 1, 2005).

[62] Martin O'Malley and Owen Wood, "When Doctors Walk Off the Job," CBC News Online, February 24, 2005, and March 11, 2004.

[63] Robert J. Reid, David Schneider, Morris Barer, Robin Hanvelt, Kimberlyn McGrail, Nino Pagliccia, and Robert G. Evans, "The Doctor Is Out: Physician Participation in the Rationed Access Day Work Stoppage in British Columbia, 1998/99," Long­woods Review, Vol. 1, No. 1 (2002), pp. 3-10; CBC News, "Quebec GP's Walk Off the Job," November 13, 1998, at http://www.cbc.ca/story/news/national/1998/05/29/gp980529e.html (September 28, 2005).

[64] CBC News, "Striking N.B. Hospital Workers Target Premier's Riding," September 27, 2004, at http://www.cbc.ca/story/canada/national/2004/09/27/newstrike040927.html (September 27, 2005).

[65] Deborah Jones, "'Playing God' During Labour Disputes Causes Stress," CMAJ, Vol. 170, Issue 13 (June 22, 2004), p. 1905, at http://www.cmaj.ca/cgi/content/full/170/13/1905-a (September 28, 2005).

[66] Laura Eggertson, "Health Council: Shortages Critical," CMAJ, Vol. 172, Issue 6 (March 15, 2005), p. 734, at /static/reportimages/00451B737DE24E37293F7C7A7FC9D21F.pdf (August 29, 2006).

[67] CBC News, "Operations Cancelled as Doctors Attend 'Study Session,'" February 11, 2005, at http://www.cbc.ca/toronto/story/ tor-anesthesiologists22050211.html (September 7, 2006).

[68] Ontario Medical Association, "Anesthesiologists to McGuinty: The Time for Action Was Yesterday," February 11, 2005, at http://www.oma.org/Media/news/pr050211.asp (September 7, 2006).

[69] Ibid.

[70] Brian Edwards, "The First 50 Years of the NHS," Student BMJ, July 1998, p. 231, at http://www.studentbmj.com/back_issues/0798/ data/0798ed1.htm (September 28, 2005), and Microsoft Encarta,on-line ed. (2004), s.v. "Welfare State," at http://au.encarta.msn.com/encyclopedia_781539608/Welfare_State.html (September 28, 2005).

[71] John Carvel, "Work to Rule on Overtime, BMA Urges Consultants," The Guardian, May 16, 2003, at http://society.guardian.co.uk/NHSstaff/story/0,7991,957063,00.html (September 28, 2005), and "Consultants to Vote on Industrial Action," The Guardian, May 22, 2003, at http://society.guardian.co.uk/NHSstaff/story/0,7991,961203,00.html (September 28, 2005).

[72] Reid et al., "The Doctor Is Out," and Kay Grigar, "Czech Doctors 'Postpone' Services," Radio Praha, January 6, 2004,at http://www.radio.cz/en/article/49112 (September 28, 2005).

[73] Wendy Moore, "Wanless Report Outlines 'Rolls-Royce' Health Service for 2022," BMJ, April 27, 2002, p. 998.

[74] Dennis Sewell, "A Question of Late Delivery," New Statesman, May 19, 2003, p. 27.

[75] Phil Hammond, "The Ex-GP's Tale (NHS in Crisis)," New Statesman, February 4, 2002, p. 31.

[76] Canadian Federation of Medical Students, "Physician Supply and Non-Physician Clinicians in a Changing Canadian Health Care System: Adjusting to the New Reality," Canadian Federation of Medical Students Position Paper, draft, August 13, 2003, at http://www.cfms.org/representation/papers_view.cfm?
id=4&what_section=representation (September 28, 2005).

[77] CBC News, "Crunch Looms for Access to Health Care: Doctors Survey," October 27, 2004, at http://www.cbc.ca/story/canada/national/
2004/10/27/physicians_study041027.html (September 28, 2005).

[78] Wait Time Alliance for Timely Access to Health Care, "It's About Time! Achieving Benchmarks and Best Practices in Wait Time Management," final report, Canadian Medical Association, August 2005, at http://www.cma.ca/multimedia/CMA/
Content_Images/Inside_cma/Media_Release/pdf/2005/wta-final.pdf (September 1, 2006).

[79] Lorne Tyrrell and Dale Dauphinee, "Task Force on Physician Supply in Canada," Canadian Medical Forum Task Force, November 22, 1999, pp. 1-25, at /static/reportimages/B9A583A6DC0C4FBF07BEFC517BFDF2ED.pdf (September 28, 2005); Canadian Institute for Health Information, Supply, Distribution and Migration of Canadian Physicians 2002, August 27, 2003, p. 4, at http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_47_E&cw_topic=47&cw_rel=AR_14_E (September 28, 2005); Jeff Chu, "How to Plug Europe's Brain Drain," Time Europe, January 19, 2004, at http://www.time.com/time/europe/magazine/printout/
0,13155,901040119-574849,00.html (September 28, 2005); Canadian Institute for Health Information, Supply, Distribution and Migration of Canadian Physicians, 2003, August 20, 2004, Table 2.2, Table 14.0, Table 17.0, and Table E2, at http:// secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_310_E&cw_topic=310&cw_rel=AR_14_E (February 24, 2005); and Canadian Institute for Health Information, Supply, Distribution and Migration of Canadian Physicians, 2004, August 23, 2005, at http://secure.cihi.ca/cihiweb/dispPage.jsp?
cw_page=PG_385_E&cw_topic=385&cw_rel=AR_14_E (October 3, 2005).

[80] Clifford Krauss, "Windsor Journal; Doctors Eying the U.S.: Canada Is Sick About It," The New York Times, October 17, 2003, at http://query.nytimes.com/gst/fullpage.html?sec=health&res=980CE0DE143EF934A25753C1A9659C8B63 (August 28, 2006).

[81] Nadeem Esmail and Michael Walker, "Health Minister's Claims Do Not Appear to Be Based in Fact," CANSTATS, April 19, 2005, at http://www.canstats.org/readmore.asp?sNav=pb&id=748 (September 1, 2006).

[82] Canadian Federation of Medical Students, "Mandatory Return of Service," Canadian Federation of Medical Students Position Paper, August 22, 2003, at http://www.cfms.org/representation/papers_view.cfm?
id=9&what_section=representation (September 28, 2005).

[83] Press release, "Will a Nurse Be There for You?" Canadian Federation of Nurses Unions, December 14, 2004, at /static/reportimages/F6EE4E6282D99A39479C7CC180E83A1E.pdf (September 28, 2005).

[84] Allison Dunfield, "Canada Near Crisis over Doctors and Nurses: Report," Globe and Mail Update, January 27, 2005, at http://www.theglobeandmail.com/servlet/story/
RTGAM.20050127.whealth0127/BNStory/National (September 28, 2005).

[85] CBC News, "1,000 Surgeries Outsourced in Vancouver," November 3, 2004, at http://www.cbc.ca/story/canada/national/2004/11/03/van_hospital041103.html (September 28, 2005).

[86] "Nursing Shortage Causing Operating Room Delays," CityTV (Calgary), May 24, 2006, at http://www.citytv.com/calgary/ news_29615.aspx (August 28, 2006).

[87] Douglas Craig, M.D., Robert Byrick, M.D., and Franco Carli, M.D., "A Physician Workforce Planning Model Applied to Canadian Anesthesiology: Planning the Future Supply of Anesthesiologists," Canadian Journal of Anesthesia, Vol. 49, Issue 7 (August/September 2002), pp. 671-677, at /static/reportimages/3F6E98B6DD9FF4D11B9E2ED47A4C52AC.pdf (September 1, 2006).

[88] Dwight Duncan, Ontario Minister of Finance, "2006 Ontario Budget: Budget Speech," 2006, at http://www.ontariobudget.ca/english/statement.html (September 1, 2006).

[89] Adam Geldman, "NHS Staff: The Issue Explained," The Guardian, June 26, 2002, at http://society.guardian.co.uk/NHSstaff/ story/0,7991,460023,00.html (September 28, 2005).

[90] Rivett, "The Next Chapter."

[91] Jo Revill, "Patients Left as Doctors Push Trolleys," The Observer, August 3, 2003, at http://observer.guardian.co.uk/uk_news/story/0,6903,1011542,00.html (September 28, 2005), and Press Association, "Consultant Numbers Fail to Keep Pace with Demand," The Guardian, December 11, 2003, at http://society.guardian.co.uk/NHSstaff/story/0,7991,1104909,00.html (Septem­ber 28, 2005).

[92] BBC News, "'Dumbed Down' Consultants Warning," March 6, 2004, at http://news.bbc.co.uk/1/hi/health/3536243.stm (September 28, 2005).

[93] Rivett, "The Next Chapter."

[94] Marie Woolf, "EU Rules 'Will Cost the NHS Equivalent of 3,700 Doctors,'" The Independent, March 22, 2004, at http://news.independent.co.uk/uk/health_medical/article65459.ece (September 28, 2005); Sarah-Kate Templeton, "New Rules on Doc­tors' Hours Will Shut Half of Glasgow's Hospitals," Sunday Herald (Glasgow), December 7, 2003, at http://www.sundayherald.com/38511 (September 28, 2005); and BBC News, "EU Law 'Threatens NHS Care,'" April 6, 2004, at http://news.bbc.co.uk/1/hi/ health/3605631.stm (September 28, 2005).

[95] R. A. Cooper, "Weighing the Evidence for Expanding Physician Supply," Annals of Internal Medicine, Vol. 141, Issue 9 (November 2, 2004), pp. 705-714.

[96] David Blumenthal, "New Steam from an Old Cauldron-The Physician-Supply Debate," New England Journal of Medicine, Vol. 350, No. 17 (April 22, 2004), pp. 1780-1786.

[97] Lizette Alvarez, "Britain's Dental System Taxed by High Demand," The International Herald Tribune, August 12, 2003.

[98] Friedrich Hayek, The Road to Serfdom (Chicago: University of Chicago Press, 1944 and 1994), pp. 97-111.

[99] Colin Brown, "NHS Beds Lying Empty in Shortage of Nurses," The Independent, January 20, 2000, p. 2, at http://news.independent.co.uk/uk/health_medical/article287501.ece (September 28, 2005).

[100] American Medical Student Association, "Student Debt: What You Should Know," 2004, at http://www.amsa.org/meded/student­debt.cfm (February 17, 2005).

[101] Lisa Clements, "Ontario Medical Student Bursary Fund Announces Inaugural Disbursement," Ontario Medical Review, December 2001, at http://www.oma.org/pcomm/OMR/dec/01disbursement.htm (September 28, 2005).

[102]

[102] Lisa Clements, "Ontario Medical Student Bursary Fund Announces Inaugural Disbursement," Ontario Medical Review, December 2001, at www.oma.org/pcomm/OMR/dec/01disbursement.htm  (September 28, 2005).

[103] Daniel Gibbons, "Top Up Fees and Medicine: Ability to Commit to Unspecified Debt May Take Precedence over Ability," BMJ, Vol. 328, No. 7441 (March 20, 2004), p. 712, at http://bmj.bmjjournals.com/cgi/content/full/328/7441/712-a (September 28, 2005).

[104] Thomas Sowell, "The 'Cost' of Medical Care," Townhall.com, May 4, 2004, at http://www.townhall.com/opinion/column/thomassowell/2004/05/04/11577.html (September 28, 2005).

[105] Susan Mayor, "University Fee Changes May Deter Poor Students from Studying Medicine," BMJ, Vol. 328, No. 7432 (January 17, 2004), p. 128, at http://bmj.bmjjournals.com/cgi/content/full/328/7432/128 (January 10, 2006).

[106]Danny Dorling, letter to the editor, "Top Up Fees and Medicine: Waive Repayments Completely If Working Life Is Spent in the NHS," BMJ, Vol. 328, No. 7441 (March 20, 2004), p. 712, athttp://bmj.bmjjournals.com/cgi/content/full/328/7441/712 (September 28, 2005).

[107] Michael J. Goldacre, Jean M. Davidson, and Trevor W. Lambert, "Country of Training and Ethnic Origin of UK Doctors: Database and Survey Studies," BMJ, Vol. 329, No. 7466 (September 11, 2004), p. 597.

[108] Rivett, "The Next Chapter."

[109] James Buchan and Delanyo Dovlo, "International Recruitment of Health Workers to the UK: A Report for DFID," Health Policy and Development, December 2004, pp. 180-182.

[110]James Buchan, Renu Jobanputra, and Pippa Gough, "London Calling? The International Recruitment of Health Workers to the Capital," King's Fund, July 2004, pp. 1-12, at http://www.kingsfund.org.uk/resources/publications/london_calling.html (Septem­ber 28, 2005).

[111] James Buchan, "International Recruitment of Health Professionals," BMJ, Vol. 330, No. 7485 (January 29, 2005), p. 210.

[112] Daniel Yergin and Joseph Stalislaw, The Commanding Heights: The Battle for the World Economy (New York: Touchstone, 1998 and 2002), pp. 74-133 and 315-335.

[113] Diane Dawson, "The Private Finance Initiative: A Public Finance Illusion?" Health Economics, Vol. 10, No. 6 (September 2001), pp. 479-486. The figures are based on the Canadian dollar-U.S. dollar exchange rate in 2000.

[114] Phil Hammond, "The Ex-GP's Tale (NHS in Crisis)," New Statesman, February 4, 2002, p. 31.

[115] Monty Mythen, Michael Grocott, and Andrew Webb, "The National Confidential Enquiry into Perioperative Deaths 2000: Then and Now," British Journal of Hospital Medicine, Vol. 62, Issue 5 (May 2001), pp. 262-263.

[116] E. Bennett-Guerrero, J. A. Hyam, S. Shaefi, D. R. Prytherch, G. L. Sutton, P. C. Weaver, M. G. Mythen, M. P. Grocott, and M. K. Parides, "Comparison of P-POSSUM Risk-Adjusted Mortality Rates After Surgery Between Patients in the USA and the UK," British Journal of Surgery, Vol. 90, Issue 12 (December 2003), pp. 1593-1598.

[117] Organisation for Economic Co-operation and Development, "OECD Health Data 2006."

[118] Henry J. Aaron, "Health Care Rationing: What It Means," Brookings Institution Policy Brief No. 147, December 2005, at http://www.brookings.edu/comm/policybriefs/pb147.htm (September 1, 2006).

[119] Gerard F. Anderson, Bianca K. Frogner, Roger A. Johns, and Uwe E. Reinhardt, "Health Care Spending and Use of Infor­mation Technology in OECD Countries," Health Affairs, Vol. 25, Issue 3 (May/June 2006), pp. 819-831.

[120] "'Computer Says No' to Mr Blair's Botched £20bn NHS Upgrade," Telegraph (London), June 4, 2006, at http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2006/06/04/nhs04.xml (September 1, 2006).

[121] David Gratzer, ed., Better Medicine: Reforming Canadian Health Care (Toronto: ECW Press, 2002), p. 53.

[122] Heather Sokoloff and Sarah Schmidt, "Romanow's Remedy: A 47-Step Diagnosis," National Post, November 29, 2002.

[123]Dr. John Radomsky, President, Canadian Association of Radiologists, in hearing, Issue 5-Evidence, Standing Senate Committee on Social Affairs, Science and Technology, Senate of Canada, March 29, 2001, at http://www.parl.gc.ca/37/1/parlbus/commbus/senate/com-e/soci-e/05ev-e.htm (September 1, 2006).

[124] Tim Arnold, "X-Ray Labs Dangerously Outdated: Radiologists Sound Alarm," National Post, October 12, 2000, p. A1.

[125] Andy Shaw, "Diagnostic Imaging Across Canada: The Emperors Still Have No Clothes," Canadian Healthcare Technology, January/February 2002, at http://www.canhealth.com/jan02.html#anchor19080 (August 28, 2006).

[126] Ibid.

[127] Standing Committee on Social Affairs, Science and Technology, Senate of Canada, speaking notes for the release of The Health of Canadians-The Federal Role: Recommendations for Reform, Vol. 6, October 25, 2002, at http://www.parl.gc.ca/37/ 2 /parlbus/commbus/senate/com-e/SOCI-E/press-e/notesoct02-e.htm (September 28, 2005).

[128] CBC News, "Budget Cuts at Health Canada Gut Research Libraries," January 9, 2006, at http://www.cbc.ca/ottawa/story/ot-healthcuts20060109.html (August 26, 2006).

[129] Ontario Hospital Association, Hospital Capital Funding Working Group, "Funding & Financing Hospital Infrastructure Renewal," April 2000, at http://www.oha.com/oha/reports.nsf/($Att)/pspr4jtj9b/$FILE/fundingfinancinghospital.pdf?OpenElement (October 1, 2005).

[130] Hugh Mackenzie, "Financing Canada's Hospitals: Public Alternatives to P3s," October 2004, p. 22, at http://www.forumonpublicdomain.ca/files/P3economistreportfinal.pdf (August 25, 2006).

[131] Thomas Sowell, Basic Economics (New York: Basic Books, 2000), pp. 22-47.

[132] Luigi Siciliani and Jeremy Hurst, "Explaining Waiting Time Variations for Elective Surgery Across OECD Countries,"Organisation for Economic Co-operation and Development Health Working Paper No. 7,October 2003, at http://www.oecd.org/ dataoecd/31/10/17256025.pdf (August 28, 2006).

[133] Martin Zelder and Greg Wilson, "Waiting Your Turn: Hospital Waiting Lists in Canada (10th Edition)," Fraser Institute Critical Issues, October 2000, at http://oldfraser.lexi.net/publications/critical_issues/2000/
waitingyourturn/section_06.html (October 1, 2005).

[134] Luma Muhtadie, "Wait Times on the Rise Across Canada, Report Says," The Globe and Mail, October 21, 2003, at http://www.theglobeandmail.com/servlet/story/RTGAM.20031020.wwait1020/
BNStory/National (February 24, 2005).

[135] Esmail and Walker, "Health Minister's Claims Do Not Appear to Be Based in Fact."

[136] Christopher T. Erb and Robert F. Rich, "The Canadian Health Care System," Institute for Government and Public Affairs, University of Illinois at Urbana-Champaign, October 2005, pp. 15-16, at http://www.igpa.uiuc.edu/publications/workingPapers/ wp130.pdf (September 1, 2006).

[137] Brian Laghi, "Set Standards for Wait Times, Pettigrew Urges," The Globe and Mail, April 21, 2004, p. A5.

[138] Nick Bosanquet, "The NHS in 2010," Reform, December 2004, at http://www.reform.co.uk/filestore/pdf/The%20NHS%20in%202010.pdf (September 1, 2006).

[139] Wait Time Alliance for Timely Access to Health Care, "It's About Time!"

[140] "National Health Service: Walking Wounded," The Economist, November 24, 2001, p. 31.

[141] Organisation for Economic Co-operation and Development, "OECD Health Data 2006."

[142] Nigel Hawke, "£5bn Injection Can't Lift NHS Debt," The Times, December 03, 2005, at http://www.timesonline.co.uk/article/0,,2-1901828,00.html (September 5, 2006).

[143] U.K. Department of Health, "NHS Delivering on Care and Costs," June 7, 2006, at http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/
PressReleasesNotices/fs/en? CONTENT_ID=4135905&chk=xZ5var (September 5, 2006).

[144] Reform, "Waiting Times," at http://www.reform.co.uk/website/health/nhsperformance/waitingtimes.aspx (August 25, 2006).

[145] Graeme Wilson and Celia Hall, "Billions Injected But NHS Debt Hits New High," Telegraph, June 8, 2006, at http://www.telegraph.co.uk/ news/main.jhtml?xml=/news/2006/06/08/nhs08.xml (September 5, 2006).

[146] Karyn Miller, "NHS Debts Soar to over £1bn," Telegraph, April 24, 2005, http://www.telegraph.co.uk/news/main.jhtml?xml=/news/ 2005/04/24/nhs24.xml (September 5, 2006).

[147] Nigel Hawkes, "Secret NHS Plans to Ration Patient Care," The Times, April 7, 2006, pp. 1 and 2, at http://www.timesonline.co.uk/ article/0,,8122-2122800,00.html (September 5, 2006).

[148] Siciliani and Hurst, "Explaining Waiting Times Variations for Elective Surgery Across OECD Countries," p. 16.

[149] Board of the Faculty of Clinical Oncology, "Equipment, Workload and Staffing for Radiotherapy in the UK 1997-2002," Royal College of Radiologists, September 2003, at http://www.rcr.ac.uk/index.asp?PageID=149&PublicationID=185 (October 1, 2005).

[150] D. Ash, A. Barrett, A. Hinks, and C. Squire, "Re-audit of Radiotherapy Waiting Times 2003," Clinical Oncology, Vol. 16, Issue 6 (September 2004), pp. 387-394, at http:///static/reportimages/AB485B6D75A16D3D1A6173B33492E8C6.pdf (October 1, 2005).

[151 ]BBC News, "MPs Attack Cancer Care 'Lottery,'" January 25, 2005, at http://news.bbc.co.uk/1/hi/health/4203625.stm (October 1, 2005).

[153] Fiona MacGregor, "Doctors Say Patients' Lives Will Be at Risk If EU Enforces MRI Rules," The Scotsman, September 21, 2005, at http://news.scotsman.com/health.cfm?id=1969902005 (September 28, 2005).

[154] Jo Revill, "Cancer Queue Grows as Treatment Target Is Missed," The Observer, April 30, 2006, at http://observer.guardian.co.uk/ uk_news/story/0,,1764598,00.html (August 29, 2006).

[155] Wolfgang Himmel, Anja Dieterich, and Michael Kochen, "Will German Patients Accept Their Family Physician as a Gate­keeper?" Journal of General Internal Medicine, Vol. 15, Issue 7 (July 2000), pp. 496-502, at http://www.blackwell-synergy.com/doi/ pdf/10.1046/j.1525-1497.2000.10016.x (January 18, 2006), and Mark Liebow, Arlene Bierman, and Oliver Fein, "The World We Live in: Health Policy from a Primary Care Perspective," Journal of General Internal Medicine, Vol. 15, Issue 7 (July 2000), pp. 519-520, at http://www.blackwell-synergy.com/doi/pdf/10.1046/j.1525-1497.2000.05000.x (January 18, 2006).

[156] Rivett, "The Next Chapter."

[157] Ibid.

[158] David A. Alter, C. David Naylor, Peter C. Austin, Benjamin T. B. Chan, and Jack V. Tu, "Geography and Service Supply Do Not Explain Socioeconomic Gradients in Angiography Use After Acute Myocardial Infarction," CMAJ, Vol. 168, Issue 3 (February 4, 2003), pp. 261-264, at http://www.cmaj.ca/cgi/reprint/168/3/261 (January 18, 2006).

[159] L. Pilote, P. Merrett, I. Karp, D. Alter, P. C. Austin, J. Cox, H. Johansen, W. Ghali, and J. V. Tu, "Cardiac Procedures After an Acute Myocardial Infarction Across Nine Canadian Provinces," Canadian Journal of Cardiology, Vol. 20, No. 5 (April 2004), pp. 491-500.

[160] Press release, "Long-Term Care and Home Health Services in BC on Steady Decline," Canada Centre for Policy Alternatives, April 4, 2005, at http://www.policyalternatives.ca/index.cfm?
act=news&call=1067&pa=3bb76202&do=Article (September 5, 2006).

[161] Green and Casper, "Delay, Denial and Dilution," pp. 23-36.

[162] BBC News, "MPs Attack Cancer Care 'Lottery.'"

[163] David Walker, "What's Your Poison?" The Guardian, March 5, 2004, at http://www.guardian.co.uk/analysis/story/0,3604,1162473,00.html (October 1, 2005).

[164] Dave Blackhurst, "Obese Patients to Be Refused Hip Operations," The Sentinel, April 29, 2006, at http://www.thisisthesentinel.co.uk/displayNode.jsp?nodeId=158338&
command=displayContent&sourceNode=158321&contentPK=14405926 (August 28, 2006).

[165] John Carvel, "New Payment Rules 'Threaten NHS Operations,'" The Guardian, July 6, 2006, at http://www.guardian.co.uk/medicine/ story/0,,1813641,00.html (August 28, 2006).

[166] Physicians' Working Group, "Proposal of the Physicians' Working Group for Single-Payer National Health Insurance."

[167] Arthur Okun, Equality and Efficiency: The Big Tradeoff (Washington, D.C.: The Brookings Institution, 1975), pp. 19-63.

[168] Steffie Woolhandler, Terry Campbell, and David Himmelstein, "Costs of Health Care Administration in the United States and Canada," NEJM, Vol. 349, No. 8 (August 21, 2003), pp. 768-775, at http://content.nejm.org/cgi/content/full/349/8/768 (October 1, 2005; subscription required).

[169] Henry J. Aaron, "The Costs of Health Care Administration in the United States and Canada-Questionable Answers to a Questionable Question," NEJM, Vol. 349, No. 8 (August 21, 2003), pp. 801-803, at http://content.nejm.org/cgi/content/full/349/8/801 (October 1, 2005; subscription required).

[170] Rosie Waterhouse, David Cracknell, "Fraud and Waste Cost NHS £7bn a Year," The Sunday Times, December 2, 2001.

[171] Fair Investment Company, "Howard Slams Brown's 'Credit Card' Budget," March 17, 2004, at http://www.fairinvestment.co.uk/ news-Howard-slams-Brown'
s-'credit-card'-budget-2997113.html (October 1,2005), and Minette Marrin, "Everywhere We Turn, Nanny Is There and Ready to Hit Us," The Sunday Times, January 4, 2004, p. 13.

[172] "We Need More Managers Not Fewer, Claims Morgan," Public Finance, April 28, 2006, at http://www.cipfa.org.uk/publicfinance/news_details.cfm?news_id=27443 (September 5, 2006).

[173] Mark Litow, "Rhetoric vs. Reality: Comparing Public and Private Health Care Administrative Costs," Council for Affordable Health Insurance, March 1994, at http:///static/reportimages/05F5B4A166E3452ABB145AC13AAF52F5.pdf (October 1, 2005).

[174] Henry J. Aaron, "A Healthcare Prescription That's Hard to Swallow," Los Angeles Times, January 30, 2006, at http://www.latimes.com/news/opinion/commentary/la-oe-aaron30jan30,0,3097774.story (September 5, 2006).

[175] Christopher J. Conover, "Health Care Regulation: A $169 Billion Hidden Tax," Cato Institute Policy Analysis No. 527, October 4, 2004, at http:///static/reportimages/45261FBC5907D553C3ED2E76758C9F83.pdf (September 5, 2006).

[176] Almut Schoenfeld, "Germany Rethinks Generous Perks for Civil Servants," The Wall Street Journal, April 5, 2004, p. A17.

[177] Bosanquet, "The NHS in 2010."

[178] Reform, Bulletin, February 21, 2002, at http://www.reform.co.uk/website/pressroom/bulletinarchive.aspx?o=12 (August 25, 2006), and "Public Spending," at http://www.reform.co.uk/website/economy/publicspending.aspx (August 25, 2006).

[179] Vancouver Board of Trade, "Reforming the Canadian Healthcare System," May 2006, at http://www.boardoftrade.com/policy/ Healthcare_FINAL15may06.pdf (August 25, 2006), and Canadian Department of Finance, Budget 2006: Focusing on Priori­ties, Chapter 4, at http://www.fin.gc.ca/budget06/fp/fpc4e.htm (August 25, 2006).

[180] Peter L. Berger, The Capitalist Revolution: Fifty Propositions About Prosperity, Equality, and Liberty (New York: Basic Books, 1986), p. 181.

[181] Vancouver Board of Trade, "Reforming the Canadian Healthcare System."

[182] British Columbia Medical Association, "Accountability in Health Care," Policy Backgrounder, December 2000, at http://www.bcma.org/public/news_publications/publications/
policy_backgrounders /AccountabilityInHealthcare.asp (September 5, 2006).

[183] Jacques Chaoulli, M.D., "A Victory for Freedom: The Canadian Supreme Court's Ruling on Private Health Care," Heritage Foundation Lecture No. 892, July 22, 2005, at http://www.heritage.org/Research/HealthCare/hl892.cfm.

[184] Deanna L. Williamson and Miriam J. Stewart, "Low-Income Canadians' Experiences with Health-Related Services: Implications for Health Care Reform," Health Policy, Vol. 76, Issue 1 (March 2006), pp. 106-121.

[185] Hillary Clinton, "Now Can We Talk About Health Care?" New York Times Magazine, April 18, 2004, at http://www.nytimes.com/2004/04/18/magazine/18POLICY.html?ei=5007&
en=04fab51c50c58daf&ex=1397620800&partner=USER­LAND&pagewanted
=all&position= (October 1, 2005).

[186] News release, "Why the UK Needs a National Nutrition Strategy," Institute of Food Research, September 8, 2003, p. 2, at /static/reportimages/D5A6FA5C835FE7A4FE9162DADEEB0265.pdf (October 1, 2005).

[187] BBC News, "Government Unit 'Urges Fat Tax,'" February 19, 2004, at http://news.bbc.co.uk/1/hi/health/3502053.stm (Octo­ber 1, 2005), and Sue Fairweather-Tait, "Healthy Diet, Healthy Body, Healthy Economy," pH7 Magazine, December 11, 2003, at http://www.epolitix.com/EN/Publications/PH7/8_1/BA960509-
1E9C-42ED-8BCD-FC01942031EB.htm (February 28, 2005; unavailable January 20, 2006).

[188] Press statement, "UK Parliamentary Inquiry into Obesity, International Association for the Study of Obesity," International Association for the Study of Obesity, January 29, 2004, at http://www.iotf.org/media/iotfjan29.htm (October 1, 2005).

[189] N. J. Wald and M. R. Law, "A Strategy to Reduce Cardiovascular Disease by More Than 80%," BMJ, Vol. 326, No. 7404 (June 28, 2003), p. 1419, at http://bmj.bmjjournals.com/cgi/content/full/326/7404/1419 (October 1, 2005).

[190] Oscar H. Franco, Luc Bonneux, Chris de Laet, Anna Peeters, Ewout W. Steyerberg, and Johan P. Mackenbach, "The Poly­meal: A More Natural, Safer, and Probably Tastier (Than the Polypill) Strategy to Reduce Cardiovascular Disease by More Than 75%," BMJ, Vol. 329, No. 7480 (December 18, 2004), pp. 1447-1450, at http://bmj.bmjjournals.com/cgi/content/full/ 329/7480/1447 (October 1, 2005).

[191] Press statement,"UK Parliamentary Inquiry into Obesity."

[192] Sarah Womack, "Family Life Faces State 'Invasion,'" The Daily Telegraph, June 26, 2006, at http://www.telegraph.co.uk/news/main.jhtml?xml=/
news/2006/06/26/ndata26.xml (August 25, 2006).

[193] Shahid M. Chandna, Joerg Schulz, Christopher Lawrence, Roger N. Greenwood, and Ken Farrington, "Is There a Rationale for Rationing Chronic Dialysis? A Hospital Based Cohort Study of Factors Affecting Survival and Morbidity," BMJ, Vol. 318, No. 7178 (January 23, 1999), pp. 217-223, at /static/reportimages/E56BE00157A19F11A3A8007A8B427103.pdf (September 7, 2006); Alzheimer's Disease International, "NICE Guidelines: Dementia Drugs to Be Denied to Those in the Mild and Severe Stages of the Disease," January 23, 2006, at http://www.alz.co.uk/media/nr060123.html (September 7, 2006); Reinhold P. Grün, Niculae Constantinovici, Charles Normand, and Donna L. Lamping, "Costs of Dialysis for Elderly People in the UK," Neph­rology Dialysis Transplantation, Vol. 18, No. 10 (October 2003), pp. 2122-2127, at /static/reportimages/0343F62921C58D6F7EDA9351E6621A51.pdf (September 7, 2006); and Murali Krishnan, Charmaine E. Lok, and Sarbjit V. Jassal, "Epidemiology and Demographic Aspects of Treated End-Stage Renal Disease in the Elderly," Seminars in Dialysis, Vol. 15, No. 2 (April 2002), pp. 79-83.

[194] Herbert Hendin, "Suicide, Assisted Suicide and Euthanasia: Lessons from the Dutch Experience," in oversight hearing, Subcommittee on the Constitution, Committee on the Judiciary, U.S. House of Representatives, April 29, 1996.

[195] Herbert Hendin, C. Rutenfrans, and Z. Zylicz, "Physician-Assisted Suicide and Euthanasia in the Netherlands: Lessons from the Dutch," JAMA, Vol. 277, No. 21 (June 4, 1997), pp. 1720-1722; Lonnie R. Bristow, "Physician-Assisted Suicide," state­ment before the Subcommittee on the Constitution, Committee on the Judiciary, U.S. House of Representatives, April 29, 1996, at http://web.acc.qcc.cuny.edu/SocialSciences/ppecorino/MEDICAL_
ETHICS_TEXT/Chapter_11_Termination_
of_Life/Readings-Physician-Assisted-uicide.htm(June 26, 2006); and Agnes van der Heide, Paul van der Maas, Gerrit van der Wal, et al., "Medical End-of-life Decisions Made for Neonates and Infants in the Netherlands," Lancet, July 26, 1997, pp. 251-255.

[196] David S. Landes, The Wealth and Poverty of Nations: Why Some Are So Rich and Some Are So Poor (New York: W. W. Norton & Co., 1998), pp. 495-498.

[197] Michael E. Porter and Elizabeth Olmsted Teisberg, Redefining Health Care: Creating Value-Based Competition on Results (Boston: Harvard Business School Press, 2006), pp. 88-90.

[198] Charles L. Schultze, The Public Use of Private Interest (Washington, D.C.: The Brookings Institution, 1977), pp. 11-108.