This article was first published in 2003 in the journal Orthopedics. It was written in response to a fellow Orthopedist's call for government single party payer. Little did I know at the time how serious an attempt would be made within the next 7 years to "transform" medicine in America.
Lee D. Hieb, MD
Universal Healthcare Myths
Several superficially compelling reasons for universal healthcare are usually put forward. First, as the business of medicine becomes more complex, some physicians believe universal healthcare would be less of a hassle. Recently, a neurosurgeon commented, “I would be happy if the government would pay me $250,000 a year and took care of all running of the office so that I could see patients.” The second argument preys on physician ethics. It is often stated (and Dr Weiner discussed it in his article), that physicians under a capitalistic system fail to care for needy and sick patients. Presumably, universal healthcare, with the government looking after everyone, would somehow do charity better, and would “leave no patient behind.” The third myth is that the economy of scale would somehow cause medicine to cost less if run by a single-party payer. It is argued that the cost of the various insurance companies and government paperwork would be lessened if one unified form and one unified payer existed.
Universal Care Around the World
In the Soviet Union, medical care was free to all, but only the Polit Bureau (eg, high-ranking officials, their family, and friends) received any good care. When Boris Yeltsin required cardiac surgery, he went to a special hospital only for government officials, and was treated by American-trained surgeons. He even flew Dr Debakey from America to Russia to make judgements about his case. Why? Because he knew that he could not trust the physicians, nor the system he had helped create. As Ayn Rand wrote in Atlas Shrugged, “It is not safe to trust one’s life to a man whose life you have throttled.” According to Ann Ebeling (her husband, Dr Richard Ebeling, is President of the Foundation for Economic Education), who was raised in the Soviet Union, quality medical care was simply not available through state run medicine. To get help, patients would bribe doctors to come to their apartments and bring whatever equipment could be mobilized illegally from the hospital to perform lifesaving procedures. Black market private practice was the only effective medicine during the 70 years of economic decline and tyranny of Soviet Socialism.
Britain is known for its two-tiered system allowing private medical care and the National Health System (NHS). People can wait a year under the NHS, or days in private medical offices. British doctors are extremely unhappy with the NHS and most opt for paying malpractice insurance to staff their private “rooms.” Recently, the British government celebrated the fact that, for the first time in 10 years, <1,000,000 people were on the waiting list for surgery. The British are desperately short of cardiac surgeons. Prime Minister Tony Blair suggested several years ago that they begin training nurses to perform cardiac surgery. Socialism, whether it applies to medicine or other aspects of government must use “new speak” (language designed to hide the more horrible aspects of socialism in obviscatory verbage). Blair did not honestly report that training nurses was necessary because not enough doctors were willing to be cardiac surgeons in the oppressive NHS. Rather, Blair stated that nurses are being trained “to end job demarcation.”
Scandinavia has always been touted as a model of universal healthcare and socialism in all forms. Recently, when I visited Norway, Finland, Sweden, and Denmark, and asked people about healthcare, I received similar answers. Most believed that reasonable everyday care was given. However, it was clear that the care was not equally distributed. Older people felt more apprehensive about the situation than younger people. My Finnish contact summarized this feeling by saying, “If you are young and pregnant, you will get good care, but I will probably die before I get the care I need.” In Norway, although “universal healthcare” exists, a significant up-front fee is required, equivalent to $50-$60. This is paid for every outpatient visit, until reaching a cap.
In France, where medical care is free, the unions have threatened to strike over better medical care. How can this be if care is available to all? This year major news stations in the United States reported ≥10,000 died in a heat wave in France. The French Surgeon General resigned. Where were the emergency medical services? A young American woman was recently struck by a car while walking in Paris. She was taken to the Saltpetrie Hospital, a major French institution, where she received no pain medicine and no physical therapy. She was placed in a splint and placed on bed rest. She borrowed pain medicine from the patient in the next bed until she could extricate herself and be taken to the American hospital in Paris, where she received appropriate treatment. These examples exemplify “societal” healthcare. For low-level medical problems, France does a good job with essentially “feel good” service. But, as elsewhere in socialized medical systems, real medical care is insufficient. Socialized systems do not supply the kind of care that Americans have come to rely on, and they cannot mobilize to meet a sudden large crisis.
Closest to home, in Canada and Mexico, there is Universal Healthcare. Medical care is supposedly “free” for all, yet from both countries, patients cross the border to the United States to receive the care they need. It is only illegal to practice private care medicine in three countries—North Korea, Cuba, and Canada. In Canada, fewer magnetic resonance imaging (MRI) centers exist in the entire Province of British Columbia than in Seattle, Washington. Patients may wait 6 months to 1 year to get their MRI. They may wait >1 year for a total joint.
The average time for breast cancer treatment in the Canadian medical system a few years ago was noted to be 45 days. Recent studies have suggested that the breast cancer mortality in Britain and Canada is higher than it is in the United States, and this lag to treatment cannot be discounted as a causative factor. It is now the official policy of the Ontario Medical Society, that if patients require cardiac catheterization, they are advised to leave the country to get it, because they may die while waiting.
A recent paper published from the Toronto Western Hospital Research Institute in Ontario concluded that orthopedic care in Canada lags considerably behind the United States.1 The situation is expected to become significantly worse as the general and medical population ages. There is considerable regional variation in the number of surgeons, and the availability of orthopedic surgery. Not surprising, metropolitan areas fare better than rural areas. The authors note that, in their socialized single-payer system, “The availability of resources is limited by the global healthcare budget; therefore individual surgeons have limited ability to alter the relative proportion of their work week that is spent in the operating room.” The shortage of surgeons is magnified, because the average Canadian surgeon does far less actual surgery (1 day a week) than an American surgeon (2-3 days a week). For this reason, the availability of orthopedic surgery per capita is less than half that of the availability in the United States.
The cost of government run medicine today is 4%-5% of the gross domestic product. (In 1990, the entire cost of the government was 2% of the gross domestic product). The cost to society is much higher. Patients who are privately insured or pay cash are paying the price for the government taking care of our seniors and our indigent—paying the price in the excessive regulation, the excessive cost of administration, and inflated prices.
How do we best care for the less fortunate in our society? People fall through the cracks in all medical systems. The poor fair best in capitalist countries with fee-for-service medicine. Even the poor in this country, if they need dialysis, will get it. In contrast, if you are aged >55 years in Britain, you will die unless you can pay for dialysis. In America, the rich can purchase more varieties of medical care, and medical care is “prettier” than that given to the poor. Nevertheless, the differential in actual medical practice between rich and poor is not large. Most Americans who are at the poverty level have access to care that is essentially the same as that purchased by the rich. And emergency care is available to all. However, the difference between America’s poor and the poor in most countries is dramatic. In contrast, in truly socialized systems, only a very few at the center of the system obtain high quality care. Before castigating our system for failure to deliver quality indigent medical care, one should take a first hand look at the care given to the poor in India, the Sudan, South Africa, Mexico, etc.
Medical care may be a necessity, but it is not a right. Government is obligated to ensure the rights of its citizens. Our government ensures our right to life by protecting us from those who would take it, our right to liberty by protecting our property, and our pursuit of happiness by protecting our opportunity. If healthcare is a right, then somehow the government must ensure that the right is fulfilled and protected. In short, the government would be empowered to compel physicians to treat people, and if that were insufficient, would be able to compel its citizens to study medicine or to move to under-served areas–whatever it would take to guarantee this right. Enslavement of one group of people to provide for another is clearly not what the Founding Fathers had in mind. This is why neither medical care, gasoline, housing, nor food was listed as one of our “inalienable rights.”
One day, one of my patients complained about the public health hospitals in which he received care as a child in the 1950s. But when I pressed him, he admitted that he received the care he needed. He also admitted that, after working to improve his financial circumstances, he was able to rise above that care to something more to his liking. This is not possible in fully socialized medical systems since all except those in power are reduced to the lowest common denominator.
Ultimately, how we choose our medical system will determine how we structure our society, whether we maintain the liberty of our Founding Fathers, or we expect America to be our caretaker. As Thomas Jefferson opined, “A government large enough to supply everything you need is large enough to take everything you have.”
Otto Von Bismark in Germany is usually credited with creating the first government run health system. This system was created with the conscious intent of making the population “beholding” to the government, thereby solidifying the Imperial power. Although the German people benefited in some ways from this government run health system, ultimately the centralized record keeping was used by a subsequent German regime (Hitler’s Nazis) for purposes no one would today promote (euthanasia, for one).
Socialism has invariably led to despotism and special treatment of the few.--not to death by murder or by lost opportunity and neglect. Vladimir Lenin once said that medical care is the keystone in the arch of socialism. More recently, A. Tsipko in an article, “The Roots of Stalinism” wrote, “Why is it that in all cases without exception and in all countries…efforts to combat the market and commodity money relations have always led to authoritarianism, to encroachments on the rights and dignity of the individual, and to an all powerful administration and bureaucratic apparatus?” 2 We are at a crossroads. We can continue to create a welfare state where nobody pays for the education of his own children, but everyone pays for the education of everyone else’s children, where no one helps his own aging parents, but everyone help everyone else’s aging parents, and instead of paying your own medical bills, you will pay everyone else’s medical bills. Or we can return to a free market. There is no human endeavor that is done more cost effectively or efficiently by government than by the private sector.
Voltaire said history is philosophy that teaches us by example. Socialism has provided us an unending example of economic and social failure. In contrast, since the mid 19th century, no western capitalistic country exists in which the conditions of the masses have not improved in an unprecedented way. Medicine is another commodity. It follows the unseen economic rules of Adam Smith, just as faithfully as do other industries. As the medical system crumbles, we can fix it with private capitalistic alternatives in the highest traditions of our Founding Fathers, or we can turn to false philosophies. The course of history shows also that as government grows, liberty decreases.
“There’s no dishonor in being forced by a superior power into slavery, but it is an eternal disgrace to voluntarily surrender one’s liberty for a filthy bowl of oatmeal and promise of security by liars. ”—Charley Reese
- Shipton D, Badley EM, Mahomed NN. Critical shortage of orthopaedics services in Ontario, Canada. J Bone Joint Surg Am. 2003; 85:1710-1715.
- Tsipko A. The roots of Stalinism. In: Richard Ebeling, ed. Disaster in Red: The Failure and Collapse in Socialism. New York, NY: Foundation for Economic Education; 1995:246.