The urge to save humanity is almost always only a false
front for the urge to rule it.
-H. L. Mencken
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.
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,
- 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
- 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.
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
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.
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 WHO analysts, equal access "implies equal entitlement to the
available services for everyone." Moreover, according to a WHO
report, achieving health care "equity" requires national health
Writing in the JAMA (Journal of the American
Medical Association), the Physicians' Working Group for
Single-Payer National Health Insurance identified four key
- 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.
- 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.
- Pursuit of corporate profit and personal fortune have no place
in caregiving. They create enormous waste and too often warp
- 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
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, the
American Medical Student Association, and two former editors of the
New England Journal of Medicine. 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."
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. 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.
This is a position shared by the Massachusetts Democratic Party
and the Green Party platforms. Democratic National
Chairman Howard Dean has also called for national health
Top 10 Expectations from the Single-Payer
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.
However, the potentially adverse effects for the American people of
adopting a single-payer system remain largely unexamined in the
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.
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) and the Canadian Medicare
system, such consequences should be expected.
Expectation #2: Periodic funding crises.
The rationing of health care, whether by price or by some other
means, is inevitable. Under the British NHS, the extensive implicit
rationing is "severe and intentionally conceals life and death
decisions from patients." This is accomplished by design, through
fewer resources and lower spending than one finds in OECD nations.
Doctors carry this out via queues, by withholding specialist
referrals and by telling patients that nothing can be done for
them, rather than disclosing that treatments do exist but are not
Although surveys frequently demonstrate public satisfaction with
single-payer systems such as the NHS, there are chronic complaints
over insufficient funding. Similar concerns are raised in America,
where government programs such as Medicaid are blamed for being
Scrooge-like because of attempts at cost cutting. However, the
problem of insufficient funds is intractable, as there is always
more desire for services than money. In Canada, this has translated
into a system where "everything is free, but nothing is readily
available." That is, when governments restrict public
spending in order to reduce costs, patient demand far outstrips
health care supply.
Indeed, the "NHS has long-run excessive rationing built into
it," say British analysts at the Adam Smith Institute of London,
because there are constant pressures to contain spending and only
indirect and infrequent pressures to increase it. For example, to
contain costs, access to health care in the NHS is rationed by age.
Indeed, British elderly are frequently denied access to beneficial
technologies such as renal dialysis and medicines for Alzheimer's
disease. A recent decision by the National
Institute for Clinical Excellence (NICE) not to pay for two
expensive colon cancer drugs for NHS patients is an example of
explicit rationing. According to Professor Karol Sikora, former
chief of the World Health Organization Cancer Unit, "if you look at
those it has sanctioned and read between the lines, it seems that
you and I are worth only about £30,000 a year to the NHS."
Similarly, access to dentistry in the NHS is rationed by prices
that are set well below the European market. As a result of
insufficient fees, many dentists are unable to recoup practice
investments and decide to "escape the treadmill and piece-work of
the NHS" by opting for private practice or moving overseas.
The cumulative NHS underinvestment in health care during the past
30 years, compared to the European average, has reached a reported
$399 billion. To address historically long wait lists,
the NHS has increased its staff by 45,000 a year since 1999, to a
peak of 1.33 million. However, this has created a deficit of
£700 million- £750 million, resulting in more recent
plans to reduce outlays for drugs, hospitals, and services and to
cut staff levels by 100,000.
Remarking on the current financial crisis afflicting the NHS,
Conservative Party leader David Cameron said:
There is a huge mystery at the heart of British
politics, which is how can they have spent quite so much money on
the health service and yet today we have got thousands of people
facing the sack and we have got hospitals facing closure and vast
Like their market counterparts, not-for-profit hospitals and
single-payer systems must achieve a sufficient positive margin
(i.e., a profit) to ensure financial viability and quality of care
and to keep equipment, buildings, and technology current and
operational. Financing modernization, growth, inflation, and debt
service requires even more revenue. If an organization plans
only to break even financially, over time it will invest
insufficient capital to continue providing services.
This basic economic principle cannot be nullified merely by
rejecting a market economy, as evidenced by the collapse of the
Soviet and East European economies and the demise of Britain's
former state-owned industries.
Expectation #3: Politically driven
While advocates of a single-payer system say that it will bring
about equality in care, the reality is invariably different. For
example, a significant proportion of Canadian doctors have allowed
prominent people, wealthier residents, and personal contacts faster
access to services. Similar queue jumping by famous sports
figures and politicians has also elicited complaints.
There is, in effect, a three-tiered system in Canada. The
wealthy jump queues by going to private clinics or the U.S. for
rapid treatment, and a second tier of "the well-informed and
aggressive can push their way to the front of the line"; those left
in the third-tier queue are often the elderly, poor, and
disenfranchised. With bureaucratically determined
rationing of goods and services in Canada, this has "worsened
rather than improved unequal access because socialism meant queues
that the well-connected could jump."
A 2002 investigation found that more than 10,000 private-pay
patients were given preference over NHS patients in Britain's most
respected national hospitals. Around half of the private patients
came from overseas and were treated before NHS patients, who were
left on waiting lists. For example, Britain's Royal Marsden
hospital received almost a quarter of its income from private
patients in 2001. During the year, this premier NHS cancer facility
treated 2,277 private patients, including over 300 foreigners. In
2003, Members of Parliament (MPs) were given exclusive access to an
NHS primary care practice from which members of the public were
barred. Unlike other NHS patients, MPs did not have to wait in a
In addition, British patients who can afford travel expenses are
traveling to India for cut-rate surgeries. For example, heart
surgery costs an average of £30,000 in Britain, but only
£6,000 in Bombay.
Expectation #4: Labor strikes.
Labor strikes are a common occurrence in state-operated
enterprises. Canada's national public health insurance is publicly
financed but privately run, and care is free at the point of use.
In the past, strikes were considered "unthinkable" for Canadian
doctors. "Now," according to the CBC News, "we've come to
expect it as part of the negotiating process between doctors and
governments." To protest fee cuts triggered by budget
caps, thousands of physicians undertook work stoppages in 1998 and
1999 for elective services in a series of 20 "Rationed Access
Days," while others refused to work on weekends, holidays, or after
In 2004, in a wage dispute with the government, 800 New
Brunswick hospital workers-including laundry, kitchen staff,
licensed practical nurses, and cardiology technologists-walked off
the job, forcing the cancellation of hundreds of surgeries and
routine tests at area hospitals. In April 2004, an
eight-day strike by 40,000 members of the Health Employees Union in
British Columbia forced hospitals to cancel 5,300 surgeries, 700
MRIs, 2,500 CT scans, and tens of thousands of lab tests. That same
month, a strike by 20,000 civil servants in Newfoundland and
Labrador lasted a grueling 27 days.
Patients suffered as a result. While urgent cases were "easy to
decide," for doctors, "the nightmares lay in between, when they had
to decide whether to cancel the bowel surgery of a cancer patient."
Patients were said to be "a hardy bunch and are used to delays."
In February 2005, upset about low pay and the lack of a new
contract, some 250 Ontario anesthesiologists held a one-day
"meeting" in lieu of working to publicize a shortage of about 90
anesthesiologists in the province. The job action closed about 179
operating rooms at 27 hospitals to all but essential surgeries on
that day; hundreds of elective surgeries were cancelled.
The protest was designed "to draw attention to the health-care
system's lack of funding and resources" and to expose critical
issues "putting the health of patients at risk." As of 2005, 43
percent of Ontario's 929 anesthesiologists were over the age of 50,
and in addition to a regular 50-hour workweek, 40 percent of
anesthesiologists worked every fourth night in hospital providing
Although labor costs in Canada had risen from 60 percent of the
health budget in 1948 to 70 percent in 1975, pay was widely deemed
to be poor for junior hospital doctors, nurses, and ancillary
staff. This led to repeated strikes by health care personnel from
1972 to the early 1980s. Staff doctors joined the strikes when the
government moved to limit pay increases and ban private practice in
hospitals. More recently, doctors in the Canadian
system have threatened to use strikes and a work-to-rule strategy
to limit the use of compulsory unpaid overtime to meet government
waiting list targets.
While the experiences of neighboring Canada are particularly
instructive for Americans, they should know that physician strikes,
work stoppages, and slowdowns have also occurred in the national
health systems of France, Australia, New Zealand, and the Czech
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." According to
projections, the NHS will not reach the European average for
physician staffing until at least 2024. Not surprisingly, the
remaining staff are "ludicrously overburdened."
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.
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.
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.
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. 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. 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.
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." 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.
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." For example, nursing shortages forced a
Vancouver hospital to outsource 980 surgeries to private clinics in
2004. 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. 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. 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.
For similar reasons, the recruitment and retention of general
practitioners and specialists is considered a chronic and
widespread problem in Britain as well. Job dissatisfaction has
grown due to low pay, overwork, stress, medical litigation,
bullying, racism, and underfunding of the health service. As
a result, British physician and other staff shortages have forced
the NHS to recruit abroad.
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
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.) 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
In the United States, the debate over physician supply has
careened from dire predictions of oversupply to more recent
predictions of shortages. 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."
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."
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. Moreover, reduced and fixed salaries for
nurses, mid-level providers, physicians, and pharmacists, among
others, affect recruitment and retention across these
Attracting talented young people may prove more difficult with
lower wages, especially considering the median medical student debt
of $135,000. 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. 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" when 70 percent of
medical students already come from upper classes.
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.
Moreover, as many as one in four medical graduates in Great
Britain never practice medicine, opting for more lucrative careers
in other fields. According to the 2001 census, over
26,000 medical doctors in England and Wales were employed but not
working as medical practitioners.
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. 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. By 2002, nearly half of the 10,000 new
doctors in Britain were from non-EU overseas countries, 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. 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."
Expectation #6: Outdated facilities and medical
In government-run industries, the equipment purchasing, facility
upgrades, and technology investments are dependent on politics,
either in the form of legislative determinations or through
bureaucratic central planning. The consequences of this politicized
process are particularly acute in Britain. Economists Daniel Yergin
and Joseph Stalislaw note that:
Every kind of decision [in Britain] ran the risk of
becoming a political decision, driven not by the interests of the
firm but by the desires of politicians in power, whether it was
wage settlements or new investments in plant location, major
projects, and equipment.
By 2000, one-third of NHS buildings had been built before the
NHS was created in 1946, and many were out of date and poorly
located. The maintenance backlog was at $4.3 billion, because when
NHS funding was tight, hospitals would reduce maintenance or
postpone replacement, eventually leaving outdated equipment that
was often in disrepair. Frequently, the British facilities
"leave a lot to be desired."
Indeed, a shortage of intensive care unit (ICU) beds in the NHS
has contributed to patient deaths. In 2000, the NHS had nine
critical care beds per 100,000, compared to 31 per 100,000 in the
United States. In a review of deaths following surgery in the
NHS, some 40 percent of hospitals with perioperative deaths had no
ICU beds at all. In 61 cases (5 percent of those who died), the
patients were denied access to ICU beds because no bed was
available. In another study, patients undergoing
major surgery in the NHS were four times more likely to die than
were those undergoing surgery in the U.S. The difference in
mortality rates was blamed on restricted ICU access and a shortage
of units providing intermediate and intensive care.
Although Britain has recently seen an increase in imaging
technology, the number of MRIs in 2004 was five per million
population, well below the OECD average of eight per million, and
the number of CT scanners stood at seven per million, less than
half the OECD average of 18 per million. According to Henry
Aaron, a prominent health care economist at the Brookings
Institution in Washington, D.C., "the British spend too little on
imaging, with the result that physicians often lack the information
to provide patients lifesaving or pain-relieving care," and the
scarcity of machines, staffing, and money has reduced availability
and eroded quality.
Researchers writing in a recent edition of Health
Affairs were critical of U.S. health information
technology (IT) efforts and touted Britain's National
Programme for IT as "the most expensive and perhaps the most
comprehensive HIT system in development worldwide," providing
an integrated care record service, electronic appointment system,
and electronic prescription system. Yet after four years,
the project has become a classic government boondoggle with missed
deadlines and cost overruns. Two years behind schedule and
more than three times over the original £6.2 billion budget,
it remains "a low-tech hotch-potch," and a recent audit found that
"corners were cut so that political deadlines could be met." The
final cost of the program is estimated to be £20 billion
by 2010, the revised delivery date.
The problems are similar in Canada. For example, Canada has
fewer MRIs per capita than Iceland, Hungary, South Korea, and the
Czech Republic. Further, much of the country's
diagnostic equipment is "so outdated it would be not be used
by radiologists in the United States." Indeed, it is estimated
that 60 percent of radiologic equipment is technically outdated,
and aging equipment is replaced only when it is no longer
functional. For example, a CT scanner in a Montreal
hospital is so medically primitive that replacement parts are no
longer available, including the on-off switch; thus it bears a note
stating: "Please Do Not Shut Down," because once turned off, it
cannot be restarted.
Prominent Canadian radiologists report that despite $1
billion of federal spending, there remains a scarcity of new
equipment and that monies earmarked to replace outdated and
broken imaging machines were instead diverted to purchase new beds
and increase wages. Dr. Paul LeBrun, chief radiologist at the Queen
Elizabeth II Health Sciences Centre in Halifax, says that some
of his colleagues are working with 34-year-old x-ray machines and
estimates that almost half of the province's imaging equipment
needs to be replaced. Dr. Giuseppe Tarulli describes "limping
along" with 2,400 outdated imaging machines, and an
experienced cardiologist described using "an ancient,
fluoroscopic imaging machine" to insert a pacemaker:
It was next to impossible to see anything.... I have
never worked with a worse piece of equipment in my career,
including cases I have done in small towns in Brazil, Chile, and
Uruguay. It is unsafe.
Some modern imaging procedures that are commonplace around
the world either cannot be done or are rarely performed because of
"dilapidated scanners" or equipment scarcity. The shortage of
imaging technology "creates a dangerous backlog that is all too
common across the country." Dr. John Mathieson says he has stopped
reviewing professional radiology journals because the articles
deal with procedures done on imaging equipment that is unavailable
to him. He cites examples of old radiology equipment so
outdated that he has never seen them used and equipment ready for
replacement that is instead made to last at least another five
years. "In effect," he says, "government policy was based on the
assumption that medical equipment would last forever."
Similarly, Canada's 16 medical schools and their associated
teaching hospitals have been described as "saddled with outdated
facilities and equipment." As a result, some $6 billion in tax
increases was sought to finance capital and technology
overhauls. To trim $269 million from federal
spending, Health Canada planned to cut the science library
budget by 50 percent and reduce the number of staff members
from 26 to 10 at department libraries over the next three years.
Many of the journals are used for basic science research and are
According to the Ontario Hospital Association, reductions in
government funding and hospital capacity in the 1990s led to a
decline in the physical condition of their hospitals. Due to
aging facilities and deferred capital projects, the need for
upgrades of buildings (including structures,
electrical/mechanical systems, and information
technology) was considered urgent. Implementing these changes
in Ontario alone would cost an estimated $7.8 billion.
In the past three decades, Canada has significantly
underinvested in its health capital. Additions to Canada's
medical infrastructure expanded rapidly between the mid-1950s and
the early 1960s and then stabilized to just under 0.4 percent of
GDP in the late 1960s. Since then, except for a brief jump in the
early 1980s, hospital capital stock declined steadily as a share of
GDP from 1970 to 2000, recovered slightly, and now stands at about
0.3 percent. This 0.1 percent reduction represents approximately
$12 billion in hospital capital. Without exception, current
capital commitments are relatively unplanned, primarily funded
from year-end budget surpluses-when present.
The consistent decline in annual investment in public capital
over a 25-year-30-year period has created a backlog of unmet needs
for new hospitals, equipment, machinery, technology, and
maintenance; and because rapidly evolving technologies have
short economic lives, the capital investment shortages accelerate.
According to Hugh Mackenzie, the weakness of Canada's
"periodically rediscovered commitment to funding for health
care" is that "it clearly fails to recognize that funding for
hospital capital is an on-going requirement of the health care
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. 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.
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).
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
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.
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.
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. 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. 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."
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. 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. 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. As of 2006,
the maximum wait for surgeries remained at six months. 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.
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." 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."
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.
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
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. 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. 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.
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.
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
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. 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." 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." However, in
nationalized health care systems, politicians and
bureaucrats-rather than patients-continue to decide which health
care options are available.
Expectation #8: Significant variations in patient
Single-payer proponents often promise national equality in
patient care. The reality, however, is very different.
In Canada, the allocation of resources is skewed by a persistent
socioeconomic bias against rural residents and the poor.
(Presumably, national health care was meant to address this.) A recent study found significant
regional inequities in access to cardiac procedures after
myocardial infarction (MI). In Alberta, 36 percent of people had
bypass surgery or angioplasty within a year after MI, while only 6
percent of Prince Edward Island residents had one of the
procedures. In Alberta, the average wait for surgery following a
heart attack was found to be a mere eight days, compared to 29 days
in Nova Scotia. Notably, elderly women tend to wait the longest for
In spite of an aging population, access to long-term care and
home health services for the elderly has decreased significantly,
and cuts in services affect some Canadian provinces more than
others, creating "significant inequality in access to services
between the health regions." Even after accounting for new assisted
living units, there has been a net decrease of 1,464 long-term care
beds since 2001. Home "personal care" services have also been cut,
with a 13 percent decline in hours and a 21 percent reduction in
clients. Home nursing hours and clients declined by 8 percent.
Joyce Jones of the BC Seniors' Network states, "Those who can't
afford to pay or who don't have families to support them often
simply go without until they are admitted to a hospital emergency
ward in crisis."
In Britain, an analysis of the NHS showed that the location of
the health board of first treatment independently predicted whether
or not cancer patients would receive adjuvant systemic therapy
(additional anti-cancer treatment given after a cancer is
surgically removed). In fact, survival rates varied significantly
among regional health boards, with estimated five-year survival
rates ranging from 67 percent to 84 percent. Similarly, NHS
rates of cardiology consultations, heart bypass, and
angioplasty are lower in poorer socioeconomic areas despite
higher rates of heart disease. Residents of northern England,
primarily the old and poor, were twice as likely to die of cancer
as were patients from the south. According to a report
in The Guardian, "Where you live is a predictor of
poor health over and above personal and social characteristics such
as employment history."
Other factors discriminate as well. In addition to laying off
1,000 hospital employees, North Staffordshire is tackling its
£30 million of NHS debt by restricting access to surgery
among obese patients. People classified as clinically obese will be
denied hip and knee replacement surgery. The cutoff point will be a
Body Mass Index measurement of 30, representing a quarter of
joint replacement patients.
Administration errors have also caused unwarranted
variations in care. NHS price setting for surgeries has failed
to account for orthopedic operations that incur extra costs and
require more difficult work. As a result, the five specialist
orthopedic hospitals in England may have to abandon more
complex procedures on hips and bones due to insufficient
reimbursement. For example, a four-hour hip operation followed by
eight days of inpatient physiotherapy cost £13,791, but
the Department of Health paid only £4,967.
Expectation #9: Financial waste.
American physicians who favor a single-payer system argue that
"public money now routed through private insurers would be used to
fund public coverage" and that during a transition period,
employers would simply transfer existing money for health benefits
to the single-payer program. They argue further that a
single-payer national health insurance system would be cheaper and
more efficient and "would save at least $200 billion annually (more
than enough to cover all of the uninsured)."
This prediction of huge cost savings resulting from shifting
current insurance premiums to new taxation and income
redistribution, which would fund an American version of national
health insurance, is overly optimistic. An unavoidable loss of
efficiency is inherent in the redistribution process and results in
unanticipated losses. Arthur Okun, a nationally prominent
economist, has observed: "The money must be carried from the rich
to the poor in a leaky bucket. Some of it will simply disappear in
transit, so the poor will not receive all the money that is taken
from the rich." These losses are attributable to the administrative
costs of taxing and transferring.
Single-payer advocates also predict a dramatic reduction in
administrative costs because administration costs in private
insurance are reported to be higher than the costs of single-payer
systems as a result of underwriting, marketing, and varied
requirements from multiple insurers. They allege that implementing
a Canadian-style health care system could save these
"superfluous" administrative costs. However, as Henry Aaron
of the Brookings Institution has argued, this comparison is
exaggerated and not terribly useful. A lower figure seems likely as
current privatized expenses for meeting public regulations
In 2001, for example, it was reported that the British NHS lost
up to £7 billion annually through "waste, fraud and
inefficiency," representing a stunning 20 percent of the total
budget and consuming recent extra spending meant for improved
services. By 2004, this figure reached £15
billion, and it was estimated that "the NHS loses 16 to 20 percent
of its budget through waste, mismanagement, incompetence and
The NHS employs 1.3 million workers across England, including
679,000 clinical staff, such as doctors and nurses, and 220,000
support staff, such as managers, finance, and IT. Since 1997, the
NHS has added 18,549 management positions, so there are now more
administrators than consultants (39,391 administrators vs.
31,993 consultants). Nevertheless, NHS Confederation chief
executive Gill Morgan said that "if anything the health service was
Single-payer advocates in the United States often point to the
officially low administrative costs of Medicare and Medicaid, the
huge federal government programs that cover the elderly and the
poor. However, Medicare and Medicaid administrative costs have been
seriously underestimated because their budgets omit the
administrative expenses incurred by the legislative and
executive branches at both the state and federal levels. Beyond
these omitted costs, there are the administrative expenses borne by
Medicare and Medicaid providers and, depending on the
particular circumstances, the patients. If all of these
currently omitted costs are factored into the computation, the
costs are closer to 27 percent for these government programs,
compared to 16 percent in private insurance.
Some analysts believe that centralized and computerized
health care records and billing would reduce paperwork and costly
medical errors, but careful estimates put the savings at no more
than about 3 percent. In addition, the burden of government
regulation of health care is often neglected. While providing
tangible benefits, the net cost to U.S. citizens is $169.1
billion-greater than the entire budget deficit in 2002. This
amounts to $1,546 for each household annually and is blamed for 7
million people lacking health insurance.
As some advocates of national health insurance frankly
acknowledge, funding a single-payer system in the United
States would likely require large income tax and other progressive
tax increases. These tax increases would incur additional
administrative costs and introduce negative incentives that,
in turn, would reduce tax receipts. Little evidence suggests
that ordinary taxpayers will view their payroll taxes for national
health insurance as a simple exchange for employer-paid health
benefits, which is currently a form of untaxed compensation.
In other words, they may view national health insurance funding as
a tax rather than as a benefit, a net loss rather than a net gain.
This will limit future attempts to increase national health
insurance outlays by further tax increases.
Higher taxes have an economic impact. They reduce revenues
because higher marginal tax rates lower the incentive for the
relatively better off to work as taxes take a larger fraction of
their additional income. Indeed, European nations are
currently wrestling over how to finance their large state
health care and pension programs. The demographic trends of
low birth rates and an aging population mean that these
countries can no longer finance welfare state programs simply
through the traditional means of increasing taxes on current
Spending on British health care has doubled since 1997, but the
high rate of increase in health spending in England will not be
sustainable if annual GDP growth falls to 2 percent or if other
priorities emerge. Increases thus far have been funded in part
"by a reduction in the growth of social security spending and
an actual reduction in defence spending." Public
spending now consumes 42 percent of GDP, and estimates are that
Britain may have to raise taxes by up to £7 billion to meet
existing spending plans. As a result, households will have to
"pay twice for a tax financed increase in health spending-they will
have to pay the tax itself and then pay the economic cost in lower
incomes or reduced job opportunities."
Canada's health care spending reached an estimated $142
billion in 2005, up from $123 billion in 2003 and $90 billion in
1999. In 1975, health care expenditures in Canada accounted for 7
percent of GDP. This percentage increased for most of the
1970s and the 1980s and reached 10 percent in 1992. From 1992
to 1996, the health care to GDP ratio fell to 9 percent, but after
2000, the share of GDP devoted to health care rose again, reaching
10.2 percent in 2004 and 10.4 percent in 2005. In 1992, health care
spending accounted for about 34 percent of all
provincial-territorial program expenditures. By 2002, this ratio
reached 41 percent.
Worse, health care spending by the public sector in Canada has
risen at a much faster rate than government revenue. "The way
things are going," observed Quebec Premier Jean Charest, "there
will be just one government department in 15 years, the department
of health.... [T]he others will no longer exist." According to the
Department of Finance, "Cost increases that continuously exceed the
growth of government revenues will eventually require
governments to resort to tax increases, a move that could
undermine Canada's competitiveness."
Expectation #10: Loss of personal liberty.
While securing health care services can sometimes be an
urgent necessity, on most occasions it is wholly discretionary. In
a single-payer system, a person may not exercise such
The effectiveness of medical interventions is varied. Personal
freedom in health care means that patients can choose their
treatments, what they will pay for them, and which doctors will
provide them. Freedom carries an element of risk. When patients can
spend their own money as they see fit, they can choose to spend a
great deal on medical services, even on treatments unrelated
to clinical need and often without proven benefits. Yet health care
necessarily involves fundamental questions about personal freedom:
Who gets to decide? How should they decide? Why should a government
official be preferred over an individual patient in making these
Authoritarian governance is intrinsic to government central
planning, and national health insurance is impossible without
government central planning. Given widely varying opinions over
what the "right" amount of health care is (or even whether such a
term is meaningful), it is difficult for a government
official, or a group of government officials, to decide on the
quantity and the standard of care to be provided to millions of
different patients. Under single-payer systems, however,
persons are often frustrated in pursuing personal choice in
purchasing or producing novel health care products and
services, except where approved by the government.
This occurs because under a government health care monopoly,
unelected health authorities make the decisions, and patients are
not customers to be served, but "negative burdens and cost
centers." For example, in Canada, the government
is unaccountable for the allocation of funds and for policy
choices, such as closing hospitals and setting medical school
enrollment. Canadian regional health boards are appointed, not
elected, and lack direct accountability to the public. The British
Columbia Medical Association states that appointments to regional
health authorities are often "based on gender, ethnicity and
regional concerns rather then expertise" and are accountable only
to the Ministry of Health. Only very recently in
Canada, as the result of an historic Canadian Supreme Court
decision, have patients been allowed spend their own money on
privately provided medical services of their choice.
To reduce health care spending, officials in a single-payer
system would likely increase controls over what previously were
personal health choices. Traditionally, promoting public
health referred primarily to controlling or preventing communicable
diseases. However, private behavior is no longer simply
private behavior when taxes are paying everyone's health
bills. Smoking, overeating, and using alcohol become quite arguably
everybody's business. Under a single-payer system, government
officials would arguably have a direct interest in one's personal
vices, including choices of food and drink.
Further, the demand for compliance in "public health measures"
might engender a relentless expansion of government rules,
such as requiring weigh-ins for the overweight or universal blood
tests for drugs and tobacco. Indeed virtually any personal activity
could be viewed through the public health care lens, and government
officials might decide to forbid, favor, or penalize anything that
could reasonably be seen as a matter of "public" health.
Moreover, factors that might affect health or access to health
care can also come under government control. A "determinants
of health perspective" means that health care provided by hospitals
and clinics is only one of many factors that influence health.
Health care needs that are unmet due to a lack of transportation
are one example. However:
Health is also influenced by a broad range of
community-based services, supports and programs, and by
relationships between and among people's personal health practices
and coping skills, living and working conditions, and
socio-economic, political, and physical environmental contexts.
Senator Hillary Clinton (D-NY) expanded on this concept of "our
collective health." Citing productivity losses, health
expenses, and national security, she endorsed a national policy to
take into account social and environmental factors in
designing neighborhoods and schools, to "control
dangerous behaviors," and to implement "required
responsibility" for individual health concerns.
In Britain, the annual cost to the NHS of diet-related diseases
is estimated to be in excess of £15 billion. "Eventually, the
UK will not be able to afford the health care made necessary by
inappropriate lifestyles and diet." Thus, the
British are seriously entertaining a proposal for a "national
nutrition strategy," including an independent agency with
regulatory powers. Quite beyond simple nutrition education,
such a national approach would also consider a "fat tax" or
imposing legislation on the food industry to achieve the
desired product development, marketing, and pricing goals. This might include "using government
purchasing power to expand the market for fresh healthy foods while
counteracting the current subsidies supporting the ingredients
in high fat/sugar/ salt products" and placing restrictions on "the
marketing of junk food to children."
In addition, television shows and Internet sites would be
altered "to ensure the support of active, healthy lifestyles." This might also entail compulsory
consumption of a specified diet or, as suggested in the NHS,
population-wide use of a "Polypill" or even a "Polymeal" to reduce the national rate of heart
disease. Expansion of government control over "transport and
rural development policies" was also recommended to increase
the level of physical activity.
Indeed, a program of government surveillance of all children is
being introduced in Britain: "a £224 million database
tracking all 12 million children in England and Wales from birth."
Doctors, schools, and the police will have to alert the database
for a wide variety of concerns, including information on whether
children are eating five portions of fruit and vegetables a day. If
a child fails to meet state targets, this could start an
investigation. The information gathered "would include
subjective judgments such as 'Is the parent providing a
positive role model?', as well as sensitive information such as a
parent's mental health."
The political demand for public regulation of private behavioral
choices may be expanded to meet certain economic targets as well.
In Britain and Canada, for example, options for health care such as
renal dialysis are restricted by age.
Traditional medical ethics are likely to be subordinated to
political fashions. For example, euthanasia is often promoted
by its champions as a last resort to alleviate suffering, but the
Netherlands already has moved "from assisted suicide to
euthanasia, from euthanasia for the terminally ill to
euthanasia for the chronically ill, from euthanasia for physical
illness to euthanasia for psychological distress and from voluntary
euthanasia to nonvoluntary and involuntary euthanasia."
Such "termination without request
or consent" has been applied to Dutch infants as well. The concern
has been that public health system rationing may exert pressure not
just to limit spending on certain individuals, but also,
either subtly or overtly, to coerce them to be euthanized.
Once again, prominent health policy experts are calling for the
establishment of national health insurance through a single-payer
health care system. In effect, these experts want the government to
control the financing and delivery of health care services for the
American people. They favor such an alternative because, among
other things, they believe that government control of health policy
and funding would result in a superior system of universal
coverage, eliminate the selfish pursuit of profit that
characterizes capitalist economic arrangements, and provide
equality of access and care for all Americans.
Yet the striking feature of the command economy, as Alain
Enthoven has observed, is "the contradiction between system and
pretensions on the one hand, [and] performance on the other." The single-payer approach has
detrimental secondary effects far in excess of the primary
beneficial effects alleged by its proponents.
Policymakers should go beyond the promises of single-payer
advocates and closely examine the performance of these systems. The
empirical evidence generally shows that such a system would result
in government rationing and waiting lines for care, reductions in
the quality of care, chronic funding crises, slower adoption of and
reduced access to advanced medical technology, labor strikes and
personnel shortages, creation of new sources of inequality in
access to care, expanded bureaucratic power, politicization of
personal health care decisions, and a loss of personal freedom.
Professor Michael Porter of the Harvard Business School and
Professor Elizabeth Teisberg of the University of Virginia argue
that "a single-payer system would create serious, and in our view
fatal problems for health care value." Because of skewed incentives
and irresistible budget pressures, a single payer would inevitably
ration services, compromise patient care, limit patient rights,
retard improvement and innovation, and shift costs to providers,
suppliers, and patients. They add:
It simply strains credulity to imagine that a large
government entity would streamline administration, simplify prices,
set prices according to true costs, help patients make choices
based on excellence and value, establish value-based competition at
the provider level, and make politically neutral and tough choices
to deny patients and reimbursement to substandard providers.
Given the persistent call for a nationalized health care system
despite the evidence, economist Charles Schultze once observed that
this demand appears to be "more for the purpose of gaining social
control over the health care system than of providing better
There is an abundance of practical alternatives to a
single-payer system. Policymakers could adopt new policies that
would dramatically expand coverage, promote innovation and economic
efficiency, and eliminate existing market distortions in the health
care system. There are comprehensive policy initiatives that would
accomplish these objectives. Real market competition would allow
more efficient and productive providers to thrive, while less
productive providers would either become more efficient or go out
Americans would benefit significantly from this liberalization
as medical goods and services improved and prices stabilized or
even declined. Where the market fails to reach the uninsured,
direct government help can fill the gaps. Only reliance on the
market can create enough wealth to fund care for the poor and
uninsured properly. Meanwhile, the American people should not be
asked to repeat the unavoidable lessons of socialism.
Kevin C. Fleming, M.D., is an internist and geriatrician in the
Division of General Internal Medicine at the Mayo Clinic in
 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.
 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,
]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).
 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).
]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.
 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).
 American Medical Student Association,
"AMSA's Universal Health Care Leadership Institute 2005: Training
Tomorrow's Leaders in the Health Care Justice Movement," 2005, at
(September 28, 2005).
 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).
 Liz Kowalczyk, "Universal Health Plan
Is Endorsed," Boston Globe, August 13, 2003, p.
 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.
 Physicians' Working Group, "Proposal of
the Physicians' Working Group for Single-Payer National Health
 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.
 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).
 Green and Casper, "Delay, Denial and
 BBC News, "Woman Loses Herceptin Court
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