Lessons from abroad - what can be learned from poorly run socialized medical plans in other countries - National Review Second Opinions: Health-Care Supplement - Cover Story

National Review, Dec 13, 1993 by John C. Goodman

AS PART of his health-care plan, President Clinton has proposed price controls on insurance premiums and "global budgets" to limit how much people can spend on health care each year. The concept is not new. Most other developed countries limit how much doctors and hospitals have to spend, thereby indirectly forcing them to ration health care. For example, Britain, New Zealand, and Canada--English-speaking countries with cultures similar to our own--all impose global budgets, and all have long waiting lists for hospital surgery. In Britain (pop. 57 million), the number of people waiting for surgery is more than 1 million; in New Zealand (pop. 3 million), more than 50,000; and in Canada (pop. 25 million), about 177,000.

On the surface, the number of people waiting seems relatively small--ranging from less than 2 per cent of the total population in Britain to less than 1 per cent in Canada. However, considering that only 16 per cent of people enter a hospital each year in developed countries and that only about 4 per cent require the most serious (and expensive) procedures, these numbers are quite high. In New Zealand, for example, there is one person waiting for every three surgeries performed each year.

In Britain and New Zealand, elderly patients in need of a hip replacement can wait in pain for years, and those awaiting heart surgery often are at risk of their lives. Perhaps because Canada has had a national health-care program for only half as long, the rationing problems are not as great. Even so, an estimated 1,379,000 Canadians are waiting for some kind of medical service, and 45 per cent of those waiting for surgery say they are "in pain."

Why So Popular?

IF THESE health-care systems are so bad, why are they so popular? Because most people are reasonably healthy most of the time, and developed countries with national health-care systems do provide adequate primary care. Physicians are relatively easy to see for minor aches and pains. Serious rationing occurs only among the few people who are really sick. And even they may never learn what treatments they are not getting. Who, after all, has an incentive to tell them?

Global budgets have unquestionably reduced patients' access to lifesaving but expensive care. Compare the United States with Canada. Per capita, the United States has ten times as many magnetic resonance imaging (MRI) units (which use magnetism instead of X-rays) as Canada; three times as many computerized axial tomography (CAT) scanners; three times as many lithotripsy units (to destroy kidney stones and gallstones with sound waves); three times as many open-heart surgery units; and eleven times as many cardiac catheterization units.

What happens when people can't get access to the technology their doctors say they need? They wait. In British Columbia patients wait up to a year for routine procedures such as cholecystectomies, prostatectomies, hip replacements, and surgery for hemorrhoids and varicose veins. In Ontario, patients wait up to six months for a CAT scan, up to a year for eye surgery and orthopedic surgery, up to a year and four months for an MRI scan, and up to two years for lithotripsy treatment. All over Canada, patients wait for coronary bypass surgery, and heart patients have died after waiting more than a year.

Like Bill Clinton, the leaders of other industrialized countries have proclaimed health care to be a basic human right. Yet in most national health systems, not only do ordinary citizens have no enforceable right to any particular medical service, they don't even have a right to a place in line when health care is rationed. The 100th person waiting for heart surgery is not "entitled" to the 100th surgery. Other patients can jump the line for any number of reasons.

In Canada, for example, Americans who pay out of pocket can go to the head of the line because they add to cash-starved hospitals' revenues. Since Canadians cannot legally pay for care they are supposed to get free, in this sense they have fewer rights in Canada than Americans do. They also have fewer rights than pets. In an 18-month period, York Central Hospital in a Toronto suburb did more than seventy CAT scans on animals suspected of having such problems as tumors. The tests were done at night for a charge of $300 per scan. The practice was stopped only in response to outrage generated by the observation that, except in emergencies, people could not get a CAT scan quickly, but cats could.

Members of the Canadian Parliament and high-ranking federal bureaucrats also can avoid lengthy waits--just as politicians used to do in Communist countries--because they have access to the National Defense Medical Center, a military hospital. In 1990, the Canadian auditor general reported that 61 per cent of the center's in-patient days were for nonmilitary patients.

If Americans, dogs, and politicians can jump the waiting line, who gets pushed to the end of it? Often it's the poor, the elderly, members of racial minorities, and residents of rural areas. Per capita, the United States performs twice as many coronaryartery bypass operations on elderly patients as Canada does: and among 75-year-olds, the ratio is 4 to 1. The life expectancy at birth for both male and female Indians is almost ten years less than for non-Indians in Canada, compared to a difference of only about three years in the United States. And urban residents in Canada receive 45 per cent more services from specialists per capita than rural residents; for some specialties the discrepancies are even greater.