Left-wing Democrats in Congress have decided on a new version of “Medicare for All.” Turns out its going to be nothing like the Medicare program seniors are used to. What they have in mind is what we see in Canada.
Everyone (except American Indians and veterans) will be in the same system. Health care will be nominally free. Access to it will be determined by bureaucratic decision making.
Here’s what to expect.
Overproviding to the Healthy, Underproviding to the Sick.The first thing politicians learn about health care is this: most people are healthy. In fact, they are very heathy – spending only a few dollars on medical care in any given year. By contrast, 50% of the health care dollars will be spent on only 5% of the population in a typical year.
Politicians in charge of health care, however, can’t afford to spend half their budget on only 5% of the voters, including those who may be too sick to vote at all. So, there is ever-present pressure to divert spending away from the sick toward the healthy.
In Canada and in Britain, patients see primary care physicians more often than Americans do. In fact, the ease with which relatively healthy people can see doctors is probably what accounts for the popularity of these system in both countries.
But once they get to the doctor’s office British and Canadians patients receive fewer services. For real medical problems, Canadians often go to hospital emergency rooms – where the average wait in Canada is four hours. In Britain, one of every ten emergency room patients leave without ever seeing a doctor.
A study by former Congressional Budget Office director June O’Neill and her husband Dave O’Neill found that:
- The proportion of middle-aged Canadian women who have never had a mammogram is twice the U.S. rate.
- Three times as many Canadian women have never had a pap smear.
- Fewer than 20% of Canadian men have ever been tested for prostate cancer, compared with about 50% of U.S. men.
- Only 10% of adult Canadians have ever had a colonoscopy, compared with 30% of US adults.
These differences in screening may partly explain why the mortality rate in Canada is 25% higher for breast cancer, 18% higher for prostate cancer, and 13% higher for colorectal cancer.
A study by Brookings Institution scholar Henry Aaron and his colleagues found that:
- Britain has only one-fourth as many CT scanners as the U.S. and one-third as many MRI scanners.
- The rate at which the British provide coronary bypass surgery or angioplasty to heart patients is only one-fourth of the U.S. rate, and hip replacements are only two-thirds of the U.S. rate.
- The rate for treating kidney failure (dialysis or transplant) is five times higher in the U.S. for patients age 45 to 84 and nine times higher for patients 85 years of age or older.
We can see the political pressure to provide services to the healthy at the expense of the sick in our own country’s Medicare program. Courtesy of Obamacare, every senior is entitled to a free wellness exam, which most doctors regard as virtually worthless. Yet if elderly patients endure an extended hospital stay, they can face unlimited out-of-pocket costs.
Rationing by Waiting. Although Canada has no limits on how frequently a relatively healthy patient may see a doctor, it imposes strict limits on the purchase of medical technology and on the availability of specialists. Hospitals are subject to global budgets – which limit their spending, regardless of actual health needs.
In addition to having to wait many hours in emergency rooms, Canadians have some of the longest waits in the developed world for care that could cure diseases and save lives. The most recent study by the Fraser Institute finds that
- In 2016, Canadians waited an average of 21.2 weeks between referral from a general practitioner to receipt of treatment by a specialist – the longest wait time in over a quarter of a century of such measurements.
- Patents waited 4.1 weeks for a CT scan, 10.8 weeks for an MRI scan, and 3.9 weeks for an ultrasound.
Similarly, a survey of hospital administrators in 2003 found that:
- 21% of Canadian hospital administrators, but less than 1% of American administrators, said that it would take over three weeks to do a biopsy for possible breast cancer on a 50-year-old woman.
- 50% of Canadian administrators versus none of their American counterparts said that it would take over six months for a 65-year-old to undergo a routine hip replacement surgery.
Jumping the Queue. Aneurin Bevan, father of the British National Health Service, declared, “the essence of a satisfactory health service is that rich and poor are treated alike, that poverty is not a disability and wealth is not advantaged.” Yet, more than thirty years after the NHS was founded an official task force (The Black Report) found little evidence that the creation of the NHS had equalized health care access. Another study (The Acheson Report), fifty years after the NHS founding, concluded that access had become more unequal in the years between the two studies.
In Canada, studies find that the wealthy and powerful have significantly greater access to medical specialists than less-well-connected poor. High-profile patients enjoy more frequent services, shorter waiting times and greater choice of specialists. Moreover, among the nonelderly white population, low-income Canadians are 22% more likely to be in poor health than their U.S. counterparts.
These results should not be surprising. Rationing by waiting is as much an obstacle to care as rationing by price. It seems that the talents and skills that allow people to earn high incomes are similar to the talents and skills that are useful in successfully circumventing bureaucratic waiting lines.
No Exit. The worst features of the U.S. health care system are the way in which impersonal bureaucracies interfere with the doctor-patient relationship. Those are also the worst features of Canadian medical care. In Canada, when patients see a doctor the visit is free. In the U.S., the visit is almost free – with patients paying only 10 cents out of pocket for every dollar they spend, on average. In both countries, people primarily pay for care with time, not with money. The two systems are far more similar than they are different.
In Britain, private sector medicine allows patients to obtain care they are supposed to get for free from government. Middle and upper-middle income employees frequently have private health insurance, obtained through an employer. A much larger number of Britons use private doctors from time to time. The rule seems to be, “If your condition is serious, go private.”
Canada, by contrast, has basically outlawed private sector medical services that are theoretically provided by the government. If doctors, patients and entrepreneurs think of better ways of meeting patient needs they have no way of acting on those thoughts.
This is where the U.S. system is so much better—even though, as in the Canadian system, U.S. Medicare pays doctors the same way it did in the last century, before there were iPhones and email messages. Many U.S. employer plans are just as bad.
But because U.S. employers are free to meet the needs of their employees rather than live under the dictates of a politically pressured bureaucracy, one of the fastest growing employee benefits is concierge care. For as little as $50 a month for a young adult, patients can have 24/7 access to a doctor by phone and email and all the normal services that primary care physicians provide.
Uber-type house calls, consultations by phone, email and Skype, cellphone apps that allow people to manage their own care and other innovations in telemedicine are taking some parts of the private sector by storm.
These are the kinds of innovations that would be outlawed if the congressional Democrats have their way.
For more on these and other issues, interested readers may want to consult my congressional testimony, delivered with Linda Gorman, Devon Herrick and Robert Sade.