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Five
Myths to Socialized Medicine
By
Dr.
John C. Goodman
President & CE0
National Center for Policy Analysis
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In the
United States there are about 14 million people - more than
a third of the uninsured - who are, in principle, eligible
to get free medical care by joining either the Medicaid program
or the State Children’s Health Insurance Program.
And yet they don’t bother to enroll.
To understand
why they don’t, you might go to the emergency room of
Parkland Hospital in my hometown of Dallas. The uninsured
and Medicaid patients come there to get their medical
care. They all see the same doctors. They get
the same treatment. If they’re admitted to the
hospital, they stay in the same beds. From the
patient’s point of view, there is no real reason
to join Medicaid, because they get the same care whether
or not they are formally insured. The doctors and nurses
get paid the same regardless of who is enrolled in what plan.
The only people who really care whether or not someone is
enrolled in Medicaid are the hospital administrators, because
that determines how they get their money. So they actually
have paid employees who go through the emergency room and
try to get people to sign up for Medicaid. Over half
the time they fail. Then they literally go hospital
room by hospital room, trying to get admitted patients to
enroll in Medicaid. And even then they don’t always
succeed. Now, it’s not that unusual for people
to go to hospital emergency rooms for their care. It’s
a common feature of health systems around the world.
It may not be an efficient way to deliver health care, but
the same thing happens in Toronto and London. Canadians
take pride in the fact that patients who get free care in
Toronto emergency rooms are “insured.” But
in Dallas, we’re ashamed to say that our patients are
“uninsured", even though the care they receive in
Dallas is probably better than the care they get in Toronto.
MYTH:
“A RIGHT TO HEALTH CARE”
People
who believe in socialized medicine have come to believe many
myths. One is that socialized medicine gives you a right
to health care. If you ask the head of Parkland Hospital
and his counterpart in Toronto or London what the difference
is in these systems, I think all three would say that in Toronto
and London people have a “right” to health care,
whereas in Dallas they do not. That is just not true.
If you’re a citizen of Canada, you don’t really
have a right to any particular health care service.
You don’t have a right to heart surgery. You don’t
even have a right to a place in the waiting line. If
you’re the hundredth person waiting for heart surgery,
you’re not entitled to the hundredth surgery. Other
people can and do get in ahead of you. From time to
time, even Americans go to Canada and jump the queue, because
Americans can do something that Canadians cannot - Americans
can pay for care. Canadian hospitals love to admit American
patients, because that means cash into their budgets.
The British government says that, at any one time, there are
about a million people waiting to get into hospitals.
According to the Fraser Institute, almost 900,000 Canadian
patients are on the waiting list at any point in time.
And, according to the New Zealand government, 90,000 people
are on the waiting lists there. Those people constitute
only about 1 to 2 percent of the population in those countries,
but keep in mind that only about 15 percent of the population
actually enters a hospital each year. Many of the people
waiting are waiting in pain. Many are risking their
lives by waiting. And there is no market mechanism in
these countries to get care first to people who need it first.
MYTH:
“HIGHER QUALITY”
Another
myth has to do with the quality of care that patients receive.
British ministers of health have told British citizens for
years that their health system is the envy of the world.
Canadian ministers of health say much the same thing.
In fact, Canadian and British doctors see 50 percent more
patients than American doctors do, and, as a consequence,
they have less time to spend with each patient. In Britain,
the typical general practitioner barely has time to take your
temperature and write a prescription. And even if they
discover something wrong with you, they may not have the technology
to solve your problem. Among people with chronic renal
failure, only half as many Canadians as Americans get dialysis,
and only a third as many Britons on a per capita basis.
The American rate of coronary bypass surgeries is three or
four times what it is in Canada, and five times what it is
in Britain. Britain is the country that invented the
CAT scanner, back in the 1970s. For awhile it exported
more than half the CAT scanners used in the world. Yet
they bought very few for their own citizens. Today,
Britain has half the number of CAT scanners per capita as
we do in the United States. A similar problem exists
in Canada.
MYTH:
“MORE BANG FOR THE BUCK”
Yet another
myth is that although the United States spends more on health
care, we don’t get more. That argument is often
supported by pointing to life expectancy, which is not that
much different among developed countries, and infant mortality,
which is actually higher in the United States than it is in
most other developed countries. What do we get for our
money? The first thing we need to do is separate those
phenomena that have little to do with health care from those
that do. In the United States, life expectancy at birth
for African American men is 68 years, while for Asian American
men it’s 81 years. We find wide differences in
life expectancy among women, too. Nobody thinks that
those differences are due to the health care system.
What, then, would we want to look at if we really wanted to
compare the efficacy of health care systems? We would
look at those conditions for which we know medical services
can make a real difference. Among women who are diagnosed
with breast cancer, only one fifth die in the United States,
compared to one third in France and Germany, and almost half
in the United Kingdom and New Zealand. Among men who
are diagnosed with prostate cancer, fewer than one fifth die
in the United States, compared to one fourth in Canada, almost
half in France, and more than half in the United Kingdom.
MYTH:
“EQUAL ACCESS”
Perhaps
no notion is more closely tied to national health insurance
than the idea of equal access to health care. Every
prime minister of health in Britain, from the day the National
Health Service started, has said that is the primary goal
of the NHS. Similar things are said in Canada and in
other countries. The British government - unlike most
other governments - studies the problem from time to time
to see what kind of progress they’re making. In
1980, they had a major report that said, essentially: “We
really haven’t made very much progress in achieving equality
of access to health care in our country. In fact, it
looks like things are worse today, in 1980, than they were
30 years ago when the British National Health Service was
started." Everybody deplored the results of that
report, and they all promised to do better. There were
a lot of articles written, a lot of conferences, and a lot
of discussions. Another 10 years passed and they pondered
another report, which said that things had deteriorated further.
Today we are long overdue for a third report, but no one expects
the situation to have improved. It’s true that
racial and ethnic minorities are underserved in the United
States. But we are hardly alone. In Canada, the
indigenous groups are the Cree and the Inuits. In New
Zealand, they are Maoris. In Australia, the Aborigines.
Those populations have more health care problems, shorter
life expectancies, higher infant mortality, more health care
needs, and they get less health care. When health care
is rationed, racial and ethnic minorities do not usually do
well in the rationing scheme. A Canadian study showed
vast inequalities among the health regions of British Columbia.
In some cases, there were spending differences of 10 to 1
in services provided in one area compared to another.
That probably would not surprise most health policy analysts;
you just don’t usually get this kind of data. But
if we had the data, we would probably find similar inequalities
in access to health care all over the developed world.
I’m especially interested in the elderly, because I find
that - not only in Britain and Canada, but also in the United
States - when people have to make decisions about who is going
to get care and who is not, they frequently choose the younger
patient. Surveys of the elderly show that senior citizens
in the United States say it’s much easier to get surgery,
see doctors, see specialists, and enter hospitals, than say
seniors in other countries.
MYTH:
“LESS RED TAPE”
Then we
have the myth that national health insurance is an efficient
way to deliver health care. I hear this frequently repeated
by advocates in the United States. Probably the most
telling statistic for hospitals is average length of stay.
In general, efficient hospitals get people in and out more
quickly. By that standard, the U.S. hospital sector
is the most efficient in the world. And I think by many
other standards it would not be much in dispute that the U.S.
hospital sector is far more efficient than the hospital sectors
of other countries. In Britain, where at any one time
there are a million people waiting to get into British hospitals,
15 percent of the beds are empty, and another 15 percent are
filled with chronic patients who really don’t need the
services of hospital; they’re simply using the hospital
as an expensive nursing home. So, effectively, almost
one-third of the beds are closed off to acute care patients.
A study compared Kaiser in California with the NHS and concluded
that, after you make all of the appropriate adjustments, Kaiser
spends about the same per capita on its enrollees as Britain
spends on its population. But the Kaiser enrollees were
getting more care, more access to specialists, and other services.
We often hear that Medicare and Medicaid are efficient.
The government says Medicaid only spends about 2 percent of
its budget on administration. But that ignores all the
costs that are shifted to doctors and hospitals. When
you incorporate all those costs, it turns out that actually
Medicare is not very efficient at all.
WHAT’S
MISSING IS CAPITALISM
While
our health care system is more market-oriented than in most
industrialized nations, we don’t really have a free market
in health care in the United States. Half the spending
is done by government. Most of the rest is done by bureaucratic
institutions. The cosmetic surgery market is about the
only market where patients are really spending their own money.
And guess what? It works like a real market. People
get package prices. They can compare prices. And
over the decade of the 1990s, the average price of cosmetic
surgery actually went down in real terms, even as there were
all kinds of technological innovations that we are told drive
up costs else where. Most of what I’m telling you
here today I learned, not from right-wing critics of national
health insurance, but from people who believe in it.
If you look at my book, there are probably a thousand different
references, and 95 percent of them are references to government
reports, academic studies, and newspaper investigations.
And in almost every case, the author of those reports is someone
who believes in national health insurance. No matter
how many problems they document, no matter how many failures
they write about, they don’t give up their faith in the
system.
They all
believe that all the failures that they write about can be
reformed away. They all believe that we just haven’t
tried hard enough to reform the system and make it work.
Sadly, they are wrong. Virtually all of these problems
are inevitable consequences of the politicization of medicine.
Why do these systems over provide to the healthy and under
provide to the sick? Well, in the United States, about
4 percent of the patients spend half the money. If you’re
a politician allocating health care dollars, you cannot afford
to spend half your money on 4 percent of the voters - 4 percent
who may be too sick to go to the polls and vote for you anyway.
Why is the hospital sector so inefficient? Because it’s
in the self-interest of hospital managers to be inefficient.
The chronic care patients and the empty beds are the cheap
beds. It’s the acute care patients that cost money.
Why can the rich and powerful jump to the head of the waiting
lines? Because those are the people who control the
sys-tem. They can change the system. If members
of parliament, the wealthy, and the powerful had to wait for
care along with everyone else, these systems would not last
for a minute.
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