An expensive way to die - criticism of national health insurance

National Review, April 16, 1990 by John C. Goodman

Adopt a system of national health insurance, we are told, and we can have health care more cheaply and more equitably. But we'd never live to see it.

COUNTRIES with national health insurance spend less on health care than the U.S. does. It is all too easy to assume that the U.S. can therefore control health-care costs through national health insurance without any loss of benefits. And this mistake is encouraged by a number of myths. Myth #1: Although the United States spends more on health care per capita than countries with national health insurance, the U.S. does not get better health care for the extra dollars it spends.

This myth rests upon the fact that life expectancy hardly differs among the developed countries and that infant mortality in the U.S. is actually higher than in most other developed countries.

In fact, a population's general mortality is affected by a great many factors over which doctors and hospitals have little influence. For those diseases and injuries for which modern medicine can affect the outcome, however, which country the patient lives in really matters. Life expectancy is not the same among developed countries for premature babies, for children born with spina bifida, or for people who have cancer, a brain tumor, heart disease, or chronic renal failure. Their chances of survival are best in the United States.

Consider the availability of modern technology in the U.S. and in Canada, a country with comprehensive national health insurance. There are eight times more magnetic-resonance-imaging units (the latest improvement on X-rays), seven times more radiation-therapy units (used in the treatment of cancer), about six times more lithoptripsy units (used for nonsurgical removal of kidney stones), and about three times more open-heart surgery units and cardiac-catheterization units per capita in the United States than in Canada.

It is sometimes argued that countries with national health insurance delay the purchase of expensive technology in order to see if it really works and is cost effective. Even if true, patients will be denied access to life-saving treatment while government bureaucracies evaluate it. For example, during the 1970s, life-saving innovations were made in the fields of renal dialysis, Cat-scan technology, and pacemaker technology. Yet the implant rate of pacemakers in the U.S. during the mid 1970s was more than four times the rate in Britain, and almost twenty times the rate in Canada (see chart, page 31). The availability of CAT scanners in the U.S. was more than three times that in Canada and almost six times that in Britain. The treatment rate of kidney patients in the U.S. was more than 60 per cent greater than in Canada and Britain.

There is considerable evidence that cost effectiveness is not what drives the bias against modern medical technology abroad. Cat-scan technology was invented in Britain, and until recently Britain exported about half the CAT scanners used in the world. Yet the British government has purchased only a handful of CAT scanners for use in the National Health Service. Brittish scientists also co-developed kidney dialysis. Yet Britain has one of the lowest dialysis rates in all of Europe, and as many as nine thousand British kidney patients per year are denied the treatment. In the United States we pay more for health care. But we also get more. And what we get saves lives.

In Britain and New Zealand, hospital services are completely paid for by government. Yet both countries have long waiting lists for hospital surgery. In Britain, with a population of about 55 million, the number of people waiting for surgery is almost eight hundred thousand. In New Zealand, with a population of three million, the waiting list is about fifty thousand. In both countries, elderly patients in need of a hip replacement can wait in pain for years. Patients waiting for heart surgery are often at risk of their lives.

In response to rationing by waiting, both Britain and New Zealand have witnessed a growing market in private health insurance-where citizens willingly pay for prompt private surgery, rather than wait for "free" surgery in public hospitals. In Britain, the number of people with private insurance has more than doubled in the last ten years, to about 12 per cent of the population. In New Zealand, one-third of the population has private health insurance, and private hospitals now perform 25 per cent of all surgical procedures.

Canada has had a national-health program for only a few decades. But because the demand for health care has proved insatiable, and because the Canadian government has resolutely refused to increase spending beyond about 8.5 per cent of GNP, the waiting lines have been growing. In Newfoundland the wait for a hip replacement is about six to ten months, the wait for cataract surgery is two months, for pap smears up to five months, for "urgent" pap smears two months (see chart, page 32). All over Canada, heart patients must wait for coronary bypass surgery, and the Canadian press frequently reports episodes of heart patients dying while on the waiting list. Unlike Britain and New Zealand, however, Canada does not allow patients to turn to the private sector, although Canadian patients who can afford to do so sometimes travel to the U.S. for medical services they cannot get in their own country.