Single-Payer National Health Insurance around the World Part IV

by admin on 06/19/2011 12:43 PM

Lives at Risk by John C. Goodman, Gerald L. Musgrave, and Devon M. Herrick
(Continued from the July 2014 HPUSA Newsletter)

American advocates of single-payer national health insurance propose to16

• Eliminate HMOs and most other forms of managed care
• Have all health care financed by the government, with no premiums or copayments from those covered
• Control costs by assigning global budgets to hospitals and setting fees and salaries for physicians
• Prohibit private insurance or personal payment for any service covered by the single-payer system. In advancing this idea, they point to other countries as examples of health care systems that are superior to our own. Are they right?

The promise of national health insurance is that government will make health care available on the basis of need rather than ability to pay. That implies a government commitment to meet health care needs. It implies that rich and poor will have equal access to care. And it implies that more serious needs will be given priority over the less serious. Unfortunately, these promises have not been kept.

• Wherever national health insurance has been tried, rationing by waiting is pervasive—with waits that force patients to endure pain and sometimes put their lives at risk.

• Not only is access to health care not equal, if anything it tends to correlate with income—with the   middle class getting more access than the poor and the rich getting more access than the middle class, especially when income classes are weighted by incidence of illness.

• Not only are health care resources not allocated on the basis of need, these systems tend to overspend on the relatively healthy while denying the truly sick access to specialist care and lifesaving medical technology.

• And far from establishing national priorities that get care first to those who need it most, these systems leave rationing choices up to local bureaucracies that, for example, fill hospital beds with chronic patients while acute patients wait for care.

It might seem that some of these problems could be easily remedied. Yet, as the years of failed reform efforts in Britain and Canada have shown, the defects of single-payer systems of national health insurance are not easily remedied. The reason: the characteristics described above are not accidental byproducts of government-run health care systems. They are the natural and inevitable consequences of placing the health care market under the control of politicians.17 It is not true that health care policies in countries with singlepayer health insurance just happen to be what they are. In most cases, they could not be otherwise.

Why do single-payer health insurance schemes skimp on expensive services to the seriously ill while providing so many inexpensive services to the marginally ill? Because the latter services benefit millions of people (read: millions of voters), while acute and intensive care services concentrate large amounts of
money on a handful of patients (read: small numbers of voters). Democratic political pressures dictate the redistribution of resources from the few to the many.

Why are sensitive rationing decisions and other issues of hospital management left to hospital bureaucracies? As a practical matter, no government can make it a national policy to let 25,000 of its citizens die from lack of the best cancer treatment every year, as apparently happens in Britain.18 Nor can any government announce that some people must wait for surgery so that the elderly can use hospitals as nursing homes or that elderly patients must be moved so that surgery can proceed. These decisions are so emotionally loaded that no elected official could afford to claim responsibility for them. Important decisions on who will receive care and how that care will be delivered are left to the hospital bureaucracy because no other course is politically possible. Why do low-income patients fare so poorly under national health insurance?

Because such insurance is almost always a middle-class phenomenon. Prior to its introduction, every country had some government-funded program to meet the health care needs of the poor. The middle-class working population not only paid for its own health care, but also paid taxes to fund health
care for the poor. Single-payer health insurance extends the “free ride” to those who pay taxes to support it. Such systems respond to the political demands of the middle-class population and serve the interests of this population.

Why do the rich and the powerful manage to jump the queues and obtain care that is denied to others? Because it could not be otherwise. These are the people with the power to change the system. If members of Parliament had to wait in line for their care like ordinary people, the system would not last for a minute. Follow this series . . .

Continued in the January 2015, HPUSA Newsletter . .

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