Health Care Quality:
Would It Survive a Single-Payer System?
July 2001
There has been a lot of attention lately devoted to the issue of quality in the health care system. Most of this interest is a result of the widespread growth of managed care and concerns that it has harmed health care quality. But how does one determine what quality in health care really means? Is it an issue of access? Or is it related to "outcomes"? Does it mean the best care available? Or do convenience and cost play a role?
In an effort to provide quality health care for everyone, many states and some in the federal government have proposed adopting a single-payer health care system. But before taking that step, we need to ask what quality health care consists of, whether a single-payer system achieves that goal and whether adopting such a system in any one state or the whole country would actually ensure quality health care for everyone, as single-payer proponents claim.
This study discusses the definition of health care quality and looks at the impact single payer systems have on health care access, affordability, new technology, the role of doctors and patient satisfaction. The study examines rationing in single-payer systems, as the government makes the larger decisions about funding levels, and leaves to doctors and hospitals the tougher individual decisions about whose care to ration. These are usually the marginal cases: the very young, the very old and the very sick.
The study concludes that if Washington state wants to do something about expanding health insurance coverage, while at the same time expanding citizens' choice and control over their own care, there are free-market options that will increase the number of insured while maintaining the high quality of health care in our state. If instead state policymakers move toward a single-payer system that tries to impose universal coverage, they will find that Washington citizens will be left with neither care nor quality.
What do we mean by the word "quality"? Is quality something we can measure objectively, or is it subjective and largely dependent on the eye of the beholder? How do we know when we have a quality product? We often seem to know when we don't have one!
And is quality an absolute term, or is it relative? For example, some very expensive cars have almost no mechanical problems, but not many people can afford them. Would a car that costs, say, half as much with a very good maintenance record - though not as good as the aforementioned luxury cars - still be considered a quality product?
It is hard to answer those questions. When it comes to health care, it is even more difficult to identify quality. Dictionaries define quality as a high grade or level of excellence. For individuals, quality health care usually means a good outcome, conveniently obtained at a reasonable price. Of course, if insurance is covering most or all of the cost of the bill, a patient may not care about the "reasonable price" element, only the outcome and convenience.
In a normal market, people make quality tradeoffs, sometimes substituting less quality for lower costs or greater convenience. That is what is known as the quest for "value." However, when people are insulated from the cost of health care because the government, insurance company or an employer is paying the bill, the role of value declines. Patients want quality at any price - because someone else is paying that price. Ironically, when someone else is paying the bill, the insistence upon quality declines because patients - indeed, any type of consumer - are willing to tolerate bad outcomes and poorer service when they are free.
In an effort to provide quality health care for everyone, many states and some officials in the federal government have proposed adopting a single-payer health care system. But before taking that step, we need to ask what quality health care consists of, whether a single-payer system achieves that goal and whether adopting such a system in any one state or the whole country would actually ensure quality health care for everyone, as single-payer proponents claim.
There has been a lot of attention lately devoted to the issue of quality in the health care system. Most of this interest is a result of the widespread growth of managed care and concerns that it has harmed health care quality. But how does one determine what quality in health care really means? Is it an issue of access? Or is it related to "outcomes"? Does it mean the best care available? Or do convenience and cost play a role?
The Agency for Healthcare Research and Quality (AHRQ), an agency of the federal Department of Health and Human Services, says, "Quality health care means doing the right thing, at the right time, in the right way, for the right person - and having the best possible result." While this goal is certainly desirable, is it really attainable, and would we know if we had attained it? Good doctors often disagree on the best course of therapy. And all health care providers, being human, make mistakes. Considering the training, integrity and dedication of most health care professionals, it is doubtless true that many U.S. patients receive quality care, but can we extrapolate to say that the U.S., or any country for that matter, has a quality health care system?
The Institute of Medicine (IOM) has developed a less challenging definition of quality than the AHRQ: "Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with the current professional knowledge."
After accepting the IOM's definition, the bipartisan National Coalition on Health Care elaborated by saying, "Good quality means providing patients with appropriate services in a technically competent manner, with good communication, shared decision making, and cultural sensitivity."
However, quality in medicine is quite different from quality in a manufacturing process. Quality for patients "does not reside in precise abstract numbers but, rather, in vague and temperamental perceptions that reside within" the patients' minds.
Thus it appears that several factors must be considered before we can say we have a quality health care system. Some of those factors are objective, while others are subjective; some can be measured, some cannot. We attempt to identify those factors below and explain why they either are or should be part of any equation trying to evaluate health care quality.
Access. Many people believe that a health care system that does not provide equal access to everyone cannot be said to be a quality system. Thus proponents of a single-payer system decry that 44 million uninsured Americans "have no health care" and point to countries like Canada as the model for reform. In addition, they often claim that minorities do not have the same access to care as whites.
While there is some reason to question whether logically there is a connection between access and quality, it has nevertheless become part of the mantra that a quality health care system must, at least at some level, provide universal access.
Of course, saying everyone has access to health care is a lot easier than providing that care to anyone who needs it - just as the former Soviet Union had a constitution that promised its people many of the freedoms and benefits (including universal health care) that Americans enjoy, but never fulfilled those promises.
Virtually no country, whether under a single-payer system or not, provides all the care everyone could conceivably need, want or desire - unless individuals are willing to pay for it personally. In some countries and systems, buying health care privately is outright illegal, as in Canada, or severely restricted by regulators, such as in the American Medicare system. In a single-payer system, health care must compete with other claims on government funds, such as education, welfare and national security. That is, the government - not the patient in consultation with a doctor - must make the tradeoffs between cost and care.
In democratically elected governments, politicians try to please as many people as possible - a requirement in order to be elected to office. With regard to health care that means providing what the majority of people need given the limited funds available. Because most people are healthy at any given time, most people in an industrialized country with a single-payer system get relatively good primary care most of the time. They represent a lot of votes and require the least amount of medical care. However, medical care for the very young, the very old and the very sick often requires specialty and very expensive care. Because these people are much fewer in number as well as more expensive, their care is often rationed.
Any attempt to make access part of the quality equation must recognize that not everyone can get everything they want. A better standard, as indicated by the definitions cited above, is whether all patients have the opportunity to get "appropriate" care, not necessarily the best or most expensive care.
Defining "appropriate" care is also very difficult, as each individual or family makes tradeoffs with respect to time, convenience and expense. For example, many Americans are increasingly turning to "alternative care" - therapies often questioned or rejected by the traditional medical community. Can we say a patient is getting appropriate care if the outcome is good but the medical community rejects it? Or consider immunizations. Many parents have decided that some immunizations pose a threat to their children's health, and therefore refuse to have their children receive those immunizations. Yet many measures of health care systems use immunizations as one criterion. Should everyone be forced to receive "appropriate" care even if they don't want the care prescribed by the system?
Affordability. Critics of the U.S. health care system contend that the biggest barrier to access is cost. What good is it, they ask, to have the best health care quality available if many people are unable to afford it?
What does "affordable" mean? To an economist, "affordable" implies that an individual or family has resources that can be allocated to health care and chooses to allocate them that way. "Unaffordable" means that health insurance is not worth the expense compared to other things the individual or family wants or needs.
There is no question that patients in the U.S. system often have problems when it comes to affordability. About 84 percent of Americans have health insurance, which usually covers most or all of the cost of care. However, the employer-based health insurance system - which accounts for about 90 percent of those under age 65 with private health insurance - is in transition. Although it worked pretty well for the first 20 or 30 years after World War II, the demographics of the workforce are evolving. Workers change jobs frequently and often lose their health insurance in the process. Those who let their employer-based policies lapse and develop a medical condition during job transition may find themselves unable to pay the resulting bills or unable to get new coverage. So while health insurance has made health care affordable for millions of Americans, the system has its problems.
One of those problems is that some 44 million Americans are uninsured. For many of them, only basic or routine care is affordable, if they can afford even that. While it is true that public hospitals - i.e., those funded in part with tax dollars to provide care for the poor and indigent - are maintained to handle most of these cases, some studies indicate that indigent patients do not get as much care as paying patients. Getting care to those who need it at a reasonable price remains a formidable hurdle.
However, a "free" health care system that relies on very high taxes to fund it is not necessarily affordable - or any better. The benefit that comes from being able to buy a prescription drug in Canada at half the U.S. cost may be completely offset if additional taxes force people to pay twice as much for food and clothing.
Health care costs, like taxes, should be transparent. If people are paying higher taxes in order to get "free" care, they should know just how much such taxes cost them.
Strong Doctor-Patient Relationship. Historically, the doctor-patient relationship has been at the heart of the American health care system. Of course, the term "system" might be considered a misnomer, since American health care has had little or no formal organization or central planning and has been characterized by individuals (patients, insurers, doctors and other health care providers) making informed decisions based upon their own training, needs and values. On the other hand, if we think of a "system" as "a combination of related elements organized into a complex whole," then the complex relationships of physicians who typically have a personal network of hundreds of consulting physicians and other resources does approach a system.
However, that system has begun to disappear over the past decade as employers, insurers, managed care organizations (primarily HMOs, but to some extent Preferred Provider Organizations, or PPOs) and the federal and state governments have inserted themselves in between the doctor and patient, often overriding the doctor's orders or denying the patient's wishes. Such constraints have led to tremendous dissatisfaction, and it is doubtful that American doctors and other health care providers would have tolerated such control as recently as 10 or 20 years ago.
Ironically, the attempt to make the medical system more "efficient" resulted in much less efficiency, in terms of applying the most appropriate course of action for a given patient. Rather than hundreds of available consultants, doctors were limited to the few available within a managed care organization's (MCO) corporate structure. Accessing these resources often requires additional time and clerical involvement. Accessing resources outside the MCO structure is even more difficult.
Different patients want different things from a doctor. For some, technical competence and graduating from one of the top medical schools makes little difference. They want a doctor to spend some time, be polite and seem interested in the ailment. These patients may enjoy it when a doctor takes time to inquire about the family or job. For them quality health care has a warm, personal side.
Others want doctors to be quick, efficient and professional. They view the doctor as an analyst, not a friend. For them, precision, not time spent, is the key to quality care.
Patient response to these two opposite approaches is very subjective, largely depending on the personality and expectations of the patient. While a strong doctor-patient relationship is fundamental to any analysis of health care quality, measuring that relationship is almost impossible.
Patient Choice. Years ago, most insured patients had the option of virtually any therapy available. However, there were not that many options. They had choice, but not many choices.
Today, things are very different. There are many types of health insurance available from a wide range of companies, with varying deductibles, copayments and restrictions. For patients, there are a growing number of options for treating medical conditions.
However, as options have grown, patients' ability to choose from those options has declined. They have many choices, but little choice - and patients don't like it. They are increasingly expressing their dissatisfaction with a system that limits their insurance and treatment options, and that dissatisfaction translates into expressions that the quality of care has declined. Again, the attempt to make the medical system more "efficient" has significantly decreased efficient presentation of options to patients and physicians.
While it may be unrealistic to think patients should be able to get any medical service any time they want it, a quality health care system will necessarily provide people with a wide range of choices - in health insurance providers and effective medical care.
Physicians Are Free to Make Decisions. In the past, doctors gave the orders and hospitals, insurers or patients complied. If a doctor prescribed a certain drug, the pharmacist filled the prescription and the insurer paid for it (assuming there was a prescription drug benefit in the policy).
Today, doctors often find their recommendations denied or overridden by a non-physician working for an HMO. Or doctors are not able to prescribe the drug they want because it is not on the HMO's formulary.
In addition, there have been certain institutional impediments (e.g., gag rules, constraints because of pressure to see more patients, limits on doctors' choices, etc.) that keep doctors from having a close relationship with their patients. Doctors who feel their hands are tied with regard to treatment decisions cannot talk openly with their patients about all options available. Such limitations have increasingly frustrated doctors, who believe their training and their examination of the patients qualifies them to make decisions without having some "bean counter" override them.
That sentiment has found a growing acceptance in the policy community and among politicians, who seek to pass legislation that would limit HMO restrictions and return decision-making freedom to doctors. Although the managed care industry has been reluctant to give doctors complete freedom to treat and prescribe - fearing utilization, and therefore costs, would begin to rise significantly - many state and federal politicians, along with the medical community, are pressing for more physician autonomy to treat patients as they see fit.
Access to New Therapies and Technology. New therapies and technology are emerging almost daily. Some are very expensive, and may be prohibitively costly for some uninsured or low-income patients. A quality health care system must be able to provide access to most or all of these new treatment options on a relatively timely basis. That does not necessarily mean that insurers should be required to cover experimental and investigational care, since there is no guarantee that such care is effective. But it does mean that health care providers should be able to access new drugs and medical devices quickly when they promise to benefit patients.
Outcomes. Many health policy experts believe that outcomes - that is, analyzing the type of care delivered for certain medical procedures and their results - is the most objective way to evaluate health care quality, primarily because it is quantifiable. For example, the Institute of Medicine's National Roundtable on Health Care Quality says:
The quality of health care can be precisely defined. In many instances, quality measures have the same degree of accuracy as the majority of measures used in clinical medicine to make vital decisions about patient care. These quality measures have been used in a wide array of scientifically valid studies to access the nature and magnitude of specific quality measures.
This belief that health care outcomes indicates health care quality has led to a number of different measuring systems, often promoted by managed care organizations. The idea behind outcomes is to provide employers with a guide to show which providers deliver the "best" care, defined as those providers whose practices most closely follow the outcomes guidelines. It also provides MCOs with a justification for disenrolling physicians who vary from the guidelines.
While there is probably some useful information to be gained from analyzing outcomes, it may not be as objective as proponents contend. For example, someone has to determine what treatments to include and exclude and which results are appropriate. Although it is reasonable to include outcomes as a component of health care quality, the assertion that it can be objective and "precisely defined" is too strong.
Patient Satisfaction. Most health care experts recognize that patient satisfaction - or they may use the broader concept of consumer satisfaction - plays an important role in health care quality. To paraphrase an old saying that originally referred to mothers: "If the patients ain't happy, ain't nobody happy."
As a result, people are frequently surveyed on what they think about the health care system. Were they able to get care reasonably quickly? Did they receive good care? Are they satisfied with the system? Such surveys give health policy experts an idea of how the system is meeting people's needs and wants. And while such surveys are very important, it should be understood that they are very subjective, and can be influenced or tainted by the wording of the questions and by positive or negative media exposure.
Having identified the components of a quality health care system, we can ask whether single-payer countries like Canada - often cited as the model for U.S. reform - France, Germany and England live up to these standards.
Access. Canada is one of the most oft cited examples of a single-payer system that provides universal coverage AND quality care - so we will be referring to it frequently. However, even a cursory examination of Canada's health care system reveals numerous problems, raising questions about whether Canadians have either access or quality care.
One of the most touted benefits of a single-payer system is that it is more efficient than the U.S. system. People have a family physician who they can see regularly, rather than postponing needed care until they are forced to go to the emergency room - which is much more expensive.
However, getting to see a family physician under a single-payer system may not be as easy as proponents suggest. A recent flu epidemic in Toronto expanded the waiting times to see a family physician to five to six weeks - so far in the future that most patients either would have recovered from their illness and no longer need to see a doctor or would have become critically ill and gone to an emergency room.
Unfortunately, patients who need to see a doctor immediately often do not even have the emergency room option. In December of 1999 and in January of 2000, Toronto emergency rooms were so full that they were turning away patients - regardless of how sick they were. According to a story in the Toronto Star, 24 of 25 emergency rooms were closed on Monday, December 27, 1999. By the following Wednesday, "21 of 25 emergency wards were refusing to accept any new patients, no matter how ill or critically injured they might have been, or were accepting only the most serious cases." The story continues, "That meant that Toronto Ambulance's paramedics were working the phones like veteran travel agents, trying to find emergency room spots for their patients on a day when the demand was close to its peak." Only three weeks later, an 18-year-old boy, Joshua Fleuelling, died of asthma because the emergency rooms were on "critical care bypass" and could not accept him.
Or consider this example: One night Michael Madden, a young American living in Sweden, suffered bouts of extreme abdominal pain. When the bouts persisted and he noticed blood in his urine, he became quite concerned and went to an emergency room at the local hospital early the next morning. The staff gave him a wooden tab marked with the number 67, indicating his place in the waiting line. He took a seat in a big waiting room filled with patients in need of immediate care, some with rags over bloody wounds. Even though Madden was having extreme pain, "a lot were worse off than I was," he later reflected. After he had waited about half an hour, a nurse called out for "No. 3." He still had 64 ahead of him. He wanted the hospital to take care of the worst cases first. At 6:00 in the evening, another staff person came out and told those still waiting to "come in tomorrow, you'll keep your number in line." That night, after a final bout of excruciating pain, the problem went away. He felt great in the morning and didn't bother to go back to the hospital. After the fact, a medical friend concluded that he had passed a kidney stone.
In 2000 The New York Times reported problems all across Canada. According to the story:
"Further west, in Winnipeg, 'hallway medicine' has become so routine that hallway stretcher locations have permanent numbers. Patients recuperate more slowly in the drafty, noisy hallways, doctors report."
At Vancouver General Hospital, "Maureen Whyte, a hospital vice president, estimates that 20 percent of heart attack patients who should have treatment within 15 minutes now wait an hour or more."
Finally, "Last summer, as waiting lists for chemotherapy treatments for breast and prostate cancer stretched to four months, Montreal doctors started to send patients 45 minutes down the highway to Champlain Valley Physicians' Hospital in Plattsburgh, New York."
As The New York Times points out, "Canada has moved informally to a two-tier, public-private system. Although private practice is limited to dentists and veterinarians, 90 percent of Canadians live within 100 miles of the United States, and many people are crossing the border for private care."
But it gets worse. Canadians often wait weeks and even months to see a specialist. According to the Vancouver-based Fraser Institute's annual survey of waiting times in Canada:
The average total waiting time between referral from a general practitioner and treatment rose from 13.3 weeks in 1998 to 14 weeks in 1999.
Waiting times between specialist consultation and treatment (which excludes the time between seeing a general practitioner and getting in to see a specialist) increased from 7.3 weeks in 1998 to 8.4 weeks in 1999.
Waiting times for diagnostic tests also experienced some increases. For example, the median wait for a CT scan across Canada was five weeks in 1999, a 6.4 percent increase over 1998.
Is this really the model the U.S. should follow for providing access to care? The irony is that while single-payer proponents point to Canada as a model health care system, the only reason the system doesn't implode is the U.S. health care system provides Canada with a safety valve - access to care Canadians cannot get in Canada.
As noted above, the former Soviet government required universal medical care in its constitution. Yet that does not mean people are treated equally. Different classes of people get different levels of care. In the Soviet system, the "first duty of medical staff members is to please their supervising agency, which oversees plan fulfillment for the hospital or clinic. Patients' needs are a distant second."
The point is that there is a huge difference between saying patients have access to health care and actually making it available. The true standard for access should not be "Some of the people getting care some of the time," but "All of the people having an opportunity to get the care they need when they need it." Though the U.S. health care system struggles to live up to this goal, virtually none of the existing single-payer systems come anywhere close.
Affordability. Proponents of a single-payer system contend that when the government controls the cost of health care, the profit motive is removed, which means the same money can be spread over more people who can get care in a timely fashion, which saves even more money as well as lives. Thus, for them, there are no tradeoffs in moving to a government-run health care system, because everyone benefits.
Government-run systems spend less as a percentage of GDP than the U.S. The presumption is that if the country is spending less of its GDP on health care, the actual cost of care must be less. However, it may be that single-payer countries are not getting as much care or as high a quality of care. The real question is not whether a country spends more or less on health care; the question is whether patients get value for the dollars spent. And the fact is most do not.
That is because when most people enter the health care system, someone else - the government, an employer or an insurer - is picking up most or all of the bill. As a result, people are insulated from the cost of care and therefore tend to overconsume - driving health care spending much higher than it would be if patients were cost-conscious consumers. The irony here is that the process that makes health care affordable for the vast majority of people - a third party paying the bill - is the primary factor behind making the health care system unaffordable. In their effort to contain the cost escalation, single-payer systems and, in the U.S., employers and insurers, have stepped in to control health care utilization from the top down. How do they do it? Well, for government-run systems, administrators use spending limits and price controls.
When government provides or finances health care services, it creates a tension that may undermine the availability and quality of care. The reason is that health care is forced to compete with other important claims on government funds such as education, the criminal justice system and social services. As a result, there is never enough money to fund any program as much as proponents would like. Moreover, the decision on which programs get funded and by how much is often determined more by which group has the most political power rather than a program's true needs and merits.
Case Study: Canada's Budget Debate. Canada's health care system has reached a crisis over funding. In March of 2000, Canadian Health Minister Allan Rock told the House of Commons: "There are people who are waiting too long, waiting hours in the emergency ward, waiting months for referral to a specialist, waiting a year for a long-term bed, waiting what seems to be an eternity for someone to answer the call button in an understaffed hospital."
In this case, however, the crisis was not instigated by budget deficits, but by a budget surplus. Some Members of Parliament wanted to pass an income tax cut of at least 20 percent, which others opposed, saying that the proposed budget only offered two cents in health care funding for every dollar in tax cuts.
Ralph Klein, premier of Alberta, who wants to let for-profit clinics perform some of the procedures currently provided by Canadian hospitals, has offered one solution to the problem of waiting lines. The government health care program, known as medicare, would reimburse the clinics for the care.
Case Study: Prescription Drugs. U.S. proponents of a prescription drug benefit for the Medicare program have been very successful in creating an atmosphere of necessity. Something must be done, they say, and they constantly point to Canada as a model for making prescription drugs available at much lower costs than American consumers have to pay. True? Yes and no. Drug prices will vary by country, based on a number of factors, just as many other products will.
However, critics of the drug industry have vastly exaggerated those differences. A now well-known April 1999 comparison of drug costs in several countries by Professor Patricia M. Danzon of the University of Pennsylvania's Wharton School of Business found that "Canadian prices are between 13 percent lower and 3 percent higher than the U.S., depending on the price index used."
Some drugs in Canada do cost less, others do not. For example, the "superaspirin" Celebrex might cost 40 percent less in Canada than in the U.S. However, generic drugs - which make up about 45 percent of the prescriptions written in the U.S. - tend to be cheaper in America.
Perhaps more importantly, many drugs are simply not available in Canada. As a result, many Canadians come south for their drugs - just as they do for health care.
In Canada, a government agency known as the Patented Medicines Price Review Board (PMPRB) negotiates with pharmaceutical companies and sets the price based on those negotiations. According to Dr. William McArthur, a palliative care physician and former chief coroner for British Columbia, "Generally, the board does not allow a new drug to be priced higher than the most expensive existing drug used to treat the same condition." If that price is too low, drug companies may not sell their product.
In addition, both the federal government and the 10 provincial governments must approve drugs. According to McArthur:
-
"Of the 99 new drugs approved by the federal government in 1998 and 1999, only 25 were listed on the Ontario formulary," the province's official list.
Of course, Canadians are free to pay for non-approved drugs out of pocket, but they usually cannot get them because demand is so low for unapproved drugs that few pharmacies carry them. As a result, many Canadians are forced to travel to the U.S. - the place where single-payer proponents say affordability is the problem - to get the drugs they need.
The fact is that "affordable" care often means unavailable care. In many European countries, for example, the single-payer system simply does not have enough money to buy the care - and especially expensive new prescription drugs - that many patients need. One solution is that European doctors are sending patients to the U.S. to join in clinical trials of promising new drugs. In some cases, doctors are finding loopholes in the law that will let them get important new drugs to their patients - at least while the drugs are still in the testing phase.
"Affordable" does not always mean the best value. In fact, when it comes to health care, it very seldom means people are getting value for their dollars. What single-payer proponents mean by affordable is that people can get health care for little or nothing out of pocket.
However, Canadians and those living in other government-run health care systems are not getting anything for free. Single-payer countries pay for health care by taxing citizens, which can have an adverse affect on the whole economy. For example, a recent study by Industry Canada found that U.S. living standards are between 10 and 50 percent higher than Canada's, or an average of about 22 percent higher.
One reason for that difference is that the federal and provincial governments in Canada take a combined total of 41.8 percent of GDP in taxes, versus only 31.2 percent in the U.S. As a result, many Canadians hop on buses to come to the U.S., not just to buy prescription drugs and health care that they cannot get in Canada, but to buy the basics such as food and clothing in an effort to avoid Canada's excessive taxation. So even if Canada's health care system is affordable at the point of consumption, the fact that many Canadians cannot get the care they need when they need it and that they must pay significantly higher taxes for it constitutes a high price to pay for affordability.
Rationing. At a 1999 conference in England organized by the Institute for Public Policy Research, Alan Milburn, health secretary of England, said of the country's National Health Service, "The NHS - just like every other health system in the world, public or private - has never, or will never, provide all the care it might theoretically be possible to provide . . . . So within our expanding health system there will always be choices to be made about the care to be provided."
Thus the question is who does the deciding about who gets what? In a single-payer system, the government makes the larger decisions about funding levels, leaving the doctors, hospitals and other health care providers to make the tougher individual decisions about whose care to ration. And the targets of rationing are usually the marginal cases, and that often means the very young, the very old and the very sick. The patient is often simply told, "There's nothing more we can do for you," a true statement within the confines of the budget. The range of medical options is simply not discussed in this circumstance.
In England advocacy groups are forming. SOS NHS Patients in Danger, a group of family members concerned about rationing care for seniors, is taking the cases of 50 elderly patients to the European Court of Human Rights.
The London Times reported in 1993 that kidney patients were dying while kidney dialysis machines at 13 of 16 hospitals remained idle because "hospitals say they do not have the resources to keep the machines running full-time."
An 89-year-old woman died in London after waiting 12 hours for a bed.
A newspaper headline screams out "Am I Too Old to Be Treated?" telling the story of a 73 year-old U.K. citizen whose doctor told him he needed a pacemaker, only to be discharged from the hospital without one.
Finally, in Canada, the Canadian Medical Journal reported in May 1999 that during a 12-month period, 121 patients waiting for coronary bypass surgery were removed from the waiting list because their condition had deteriorated to the point that they were unlikely to survive surgery.
Such stories are not rarities, but commonplace even in the best of single-payer systems. The fact is that health care rationing is pervasive when the government controls health care. And as health care costs rise and government budgets tighten, rationing expands.
Recall that we started out this study by stating that for individuals, quality health care usually means a good outcome, conveniently obtained at a reasonable price. Any health care system that is routinely denying care to a large portion of its citizens simply because they are marginal members of society is not fulfilling that dictum.
The Role of Doctors. In the U.S. doctors historically have been independent practitioners, responsible to no one except their patients. That role has evolved as insurers and employers play a stronger role in health care decisions, but it is still nothing like single-payer systems where doctors, in effect, become bureaucrats - dependent on the generosity of politicians for their income.
About a year ago, 8,000 French doctors and other medical staff stopped work for three hours to attend rallies and march in protest of staff shortages and health budget restrictions imposed by the French government. They also denounced the "rationing of health care" imposed by the government in an effort to reduce the growing deficits in the country's health insurance program.
Ontario, Canada, is also having a problem with physicians. In this case there aren't enough to go around. A government report calls for an increase of 1,000 physicians. Part of the problem is a medical "brain drain." According to the president of the Canadian Medical Association, Dr. Hugh Scully, 50 percent of Canadian medical school graduates emigrate within 10 years of graduation and an additional 25 percent leave within 15 years. To make matters worse, 42 percent of family doctors are refusing to accept new patients.
The Ontario government has proposed several steps for increasing the number of physicians, including an attempt to "lure Canadian medical-school graduates back from the United States, where many have gone for post-graduate training." It might be worth adding here that with all of the problems the American health care system has, doctors do not go on strike and they do not emigrate en masse to single-payer countries in order to provide better care for their patients.
Access to New Therapies and Technology. In a single-payer system where health care budgets are tight, bureaucrats and politicians tend to see new technology as too costly for the benefit. As a result, they usually provide only enough funds to purchase a limited amount of the newest technology - if any at all. And the decisions on what to buy and when to buy it are often arbitrary and guided more by good politics than good medicine.
Even more importantly, these arbitrary limits usually enshrine the medical knowledge and techniques current at the time of their first imposition. A central control system cannot afford new medical discoveries and treatments because they were not in the budget and no funding or other resources were allocated. Thus, a single-payer system inherently tends to foster outdated medical techniques and resist new or innovative ones.
Although single-payer proponents cite Canada as a system that rivals the U.S. in the availability of new technology, the country lags behind many of the Organization for Economic Cooperation and Development (OECD) countries. While Canada ranks fifth in terms of total health care spending (as a percent of GDP), a recent study by the Fraser Institute in Canada comparing OECD data found the country:
It should be mentioned that these are not cutting-edge medical technologies - at least not in the U.S.
Stories abound of Canadians going to extreme measures in order to gain access to medical technology. For example, several years ago an enterprising hospital in Guelph, Ontario, decided to allow animals needing CT scans to enter the hospital in the middle of the night - charging pet owners C$300 apiece. There is nothing necessarily wrong with that except that thousands of people in Ontario were waiting up to three months for an appointment on the same machine.
"I'd go any time," said Greg Moulton, who was in the middle of a two-month wait to learn why he was having "excruciating" headaches. Because people are not allowed to pay out of pocket for medical procedures covered under the government-run plan, they have to wait. If you are a dog, you can get medical technology immediately.
When dogs get better treatment than people, then people will become dogs. In December 1999, The Washington Post reported that waiting lines for MRIs in Ontario had grown so long that one Ontario resident "booked himself into a private veterinary clinic that happened to have one of the machines, listing himself as 'Fido.'"
Outcomes. Do single-payer systems achieve good outcomes? Certainly many patients living in higher-income single-payer countries who enter the health care system get good care in a timely fashion - especially for routine and primary care. But those needing specialty care that requires expensive treatment or new technology may be out of luck.
Again in The Washington Post from December 1999: "In Quebec, they've sent more than 250 cancer patients over the border to the United States this year to get treatment and still there are 350 who have waited more than eight weeks for radiation or chemotherapy (waiting more than four weeks is considered medically risky)."
It would be very hard to argue that cancer patients waiting twice as long for radiation or chemotherapy than what is considered medically risky are getting quality care. Fortunately, these patients have a safety valve: the United States. Between April 1999 and April 2000, some 700 Ontario cancer patients came to the U.S. for care, paid for by the Ontario Health Plan. But is it quality care when you have to turn to another country to provide needed medical services?
And then there is a story from The New York Times that looked at cancer outcomes in Great Britain. According to the article:
Patient Satisfaction. For years defenders of Canada's single-payer system argued that the vast majority of Canadian citizens supported the country's socialized health care system. What the citizens themselves said was "The system is good...as long as you stay healthy." More and more Canadians' level of satisfaction is dropping as they personally experience the system.
A May 1999 poll found that 76 percent of Canadians believe their health care system is in crisis and 71 percent said that changes were necessary because the system was not meeting patients' needs.
In addition, a survey in January 2000 by Toronto-based Pollara found:
Not long ago, such support for user fees would have been unthinkable and in total contrast to Canada's philosophy of health care, which says that it should be free to all. However, as lines grow and people die, Canadians are increasingly willing to consider alternatives, even if that means abandoning the socialist ideal of "free" health care for all.
Britons are also growing dissatisfied with their National Health Service. According to a recent Mori poll, published in the Journal of the British Medical Association:
Single-payer health care systems are not a fantasy, they are a nightmare. They politicize the health care system, ration care and demoralize doctors and other providers. They are not a model to be emulated, but a disaster to be avoided.
While the U.S. health care system has its problems, it has largely avoided those created by single-payer systems. However, the U.S. is beginning to experience, at least on a small scale, some of the problems inherent in single-payer systems because Medicare and Medicaid are single-payer systems. In addition, employer-based health insurance and managed care incorporate some of the same incentives and structures as single-payer systems, so some of the problems arising from them will necessarily be similar to those in countries such as Canada and the United Kingdom.
If Congress, Washington state and other the states want to do something about expanding health insurance coverage, at the same time enhancing human freedom and choice, there are free-market options that will increase the number of insured while maintaining the quality of care most Americans have come to expect. If instead federal and state policymakers move toward a single-payer system that tries to impose universal coverage, they will find that Americans will get neither care nor quality.
About the Authors
Merrill Matthews Jr., Ph.D., is a visiting scholar with the Institute for Policy Innovation and policy director of the American Conservative Network, a project of the American Conservative Union. He is a public policy analyst specializing in health care, Social Security, welfare and Internet issues, and is the author of numerous studies in health policy, as well as other public policy issues. He is past president of the Health Economics Roundtable for the National Association for Business Economics, the largest trade association of business economists, and a health policy advisor to the American Legislative Exchange Council, a bipartisan association of state legislators.
Since 1992, Dr. Matthews has served as the medical ethicist for the University of Texas Southwestern Medical Center's Institutional Review Board for Human Experimentation, and has contributed chapters to two recently published books: Physician Assisted Suicide: Expanding the Debate (Routledge, 1998) and The 21st Century Health Care Leader (Josey-Bass, 1998).
He is a "Brain Trust" columnist for Investor's Business Daily and has been published in numerous journals and newspapers, including The Wall Street Journal, Barron's, USA Today and The Washington Times. He is the political analyst for USA Radio Network and an occasional commentator for National Public Radio. He received his Ph.D. in Philosophy and Humanities from the University of Texas at Dallas.
Dr. Robert J. Cihak, M.D., is a graduate of Notre Dame and received his medical degree from Harvard Medical School. He served his surgical internship at Stanford Medical Center and a Diagnostic Radiology residency at Massachusetts General Hospital. He was an Assistant Professor of Radiology at University of New Mexico Medical School before starting in private practice in Aberdeen, Washington. He is a founding board member of the Evergreen Freedom Foundation, and a past President of the Association of American Physicians and Surgeons.