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Jul 23, 2007
Is there rationing by waiting under government-provided health care? Of course there is.
- In Britain, where the government has been measuring these things for years, up to one million people are waiting to enter British hospitals; and the waiting lists are an issue in every election.
- In Canada, where the Fraser Institute keeps the best records, people are waiting for 771,000 procedures; and the Canadian Supreme Court, after declaring such waits a violation of basic human rights, ruled that residents of Quebec can buy private care when they are denied prompt service from the government.
However, in the documentary "SiCKO," Michael (if-you-disagree-with-me-you-must-be-on-the-drug-industry-payroll) Moore claimed there was no serious waiting problem in Canada. On CNN and his Web site, he claims there is more waiting in the United States. Source of that claim? The Commonwealth Fund. Paul (if-you-disagree-with-me-you-must-be-evil) Krugman has now joined the fray, making the same claim in the New York Times. He too cites the Commonwealth Fund.
Since our friends at Commonwealth are serious researchers, it must not be pleasant for them to see their work used as cannon fodder by people who are basically in the business of character assassination. But in a way, they have brought this on themselves. Commonwealth has no economic theory of waiting. They also have no political theory of waiting. The term economists use for testing without theory is "junk in, junk out." At Commonwealth, they don't test theories. They collect data. But data collection without a theory is almost as bad.
What is a theory of waiting? More than 30 years ago I proposed a theory of how governments ration health care (elements of it are reproduced in Lives at Risk: http://www.ncpa.org/pub/lives_risk.htm). Basically, the political incentive is to overprovide to the healthy (who have 80 percent of the votes) and underprovide to the really sick (who have 4 percent of the votes, assuming they can get to the polls and vote at all). This theory is broadly consistent with evidence collected in several Commonwealth surveys:
In Britain and Canada, it is easier to see a physician and there are more visits than in the United States.
- However, once at the doctor's office, Americans with real problems get more services and get more attention (almost one in three spend more than 20 minutes with the physician in the United States compared with one in five in Canada and one in 20 in Britain).
- For more serious care, only 8 percent of patients wait more than four months for surgery in the United States, compared with more than one in three patients in Canada and 41 percent in Britain.
In making international comparisons, however, one must be careful because:
- We basically pay doctors in the United States the same way Canada pays its doctors; as a result both countries have similar problems: no telephone or email consultations, very few electronic medical records, etc.
- In the United States, we pay only 13 cents out of pocket every time we spend a dollar on health care (about the same as the average European country!); as a result, we ration our doctors' time by waiting as well.
- Almost half of our health care dollars are spent by government; and Medicare, for example, exhibits the same political pressures evident in Britain and Canada - for example, covering inexpensive items and leaving seniors exposed to catastrophic expenses.
- Anecdotal evidence suggests that many of our Medicaid patients wait as long for specialist care and surgery as Canadians wait.
In comparing our system to others, we are mainly comparing private sector socialism to public sector socialism. For a theory (as opposed to a random accumulation of facts) of how waiting works under our system, see my "What Is Consumer-Directed Health Care?" in Health Affairs at
http://www.ncpa.org/email/hlthaff.25.w540v1.pdf.
Finally, we have a new Michael Moore site: http://sicko.ncpa.org/. At his own site, Michael invites visitors to send him health horror stories - but only about the U.S. system! To add balance, our site has horror stories about Canada, France and Britain (easily obtained from a Google search).
7 Responses to “The Waiting Game”
July 23rd, 2007 at 2:11 pm
[…] Transformers Link to Article sicko The Waiting Game » Posted at The John Goodman Health Blog on Monday, July 23, 2007 The Waiting Game Is there rationing by waiting under government-provided health care? Of course there is … from the government. However, in the documentary "SiCKO," Michael (if-you-disagree-with-me-you-must View Entire Article » […]
July 24th, 2007 at 10:18 am
When we talk about our system vs nationalized health care and attempt to compare the longer wait times to access the system in countries such as Britain and Canada; everyone tends to miss explaining why. I think we might start winning some minds over if we can explain why you have to wait in Britain. The uninformed everyday consumer sees no correlation to national health care and having to wait — they probably are just thinking we can do it better — that Britain and Canada just don;t know how to do nationalized health care. If you could include in your messaging why it is that Britain and Canada restrict access, you might make more hay.
Thanks for listening.
July 24th, 2007 at 10:19 am
Don’t disagree with you. However, not sure facts and logic will dictate the outcomes. If the “right” does not move to strike a negotiated deal with the “left”, most likely the latter wins, and the nation loses.
August 2nd, 2007 at 10:38 am
How true. In the UK shortly after WWII, there were enough folks who not like the National Healht Scheme. There were also physicians who felt the same way. Theses physicians became known as the Harley Street Doctors, which was the street where their offices were located. Concierge medicine in the US is nothing more than a replication of that 1945 model, driven by free market forces. In the UK today, almost all care is delivered by PCPs. Access to specialists is restricted, and only on referral from a PCP. As you correctly state, the delays for surgery are unconscionably long, to the point where the National Health folks are importing surgeons form other EU countries to relieve some of the burdens and delays.
And why do you think so many Canadian docs are coming to the US? The Canadian health plan runs out of money in November every year, those who can afford private care will preferable come to the US and Canadian courts have now mandated that if delays endanger a patient, they can opt for private insurance.
The transplant surgery situation is even more frightening, but no more so that in the US. 85% of patients waiting for surgery die waiting. This is not only due to bureaucratic delay, but to the scarcity of organs. If cutting edge medicine is to continue, the entire infrastructure must be in place. Ethical concerns must be addressed which are presently sorely deficient. The discrepancy between recipients based on race or ethnicity is as much a problem (and maybe even more) of the availability of compatible organs as it is to cost concerns, short-changing minorities or intentional denial.
August 2nd, 2007 at 10:45 am
I think it would be better psychology to state that half of our health care dollars are controlled by the government, meaning citizens earn these dollars and the government takes them by taxation and determines how they are spent. We need to convince citizens that the vast majority have the ability to provide for their own health care needs if government would just permit them to do so.
August 3rd, 2007 at 12:23 pm
Mr. Goodman, Regarding "Moore’s polemic hardly a model for health-care reform," an article you authored that appeared in the July 29 Wisconsin State Journal. A great American, President Ronald Regean, once used the term Trust but verify when talking about negotiating with the Russians. I find myself asking the same questions while reading your article. A series of assertions are made.(In Britain about 1 million patients are waiting to admitted to hospitals at any one point in time… doctors in other countries often don’t tell their care is being rationed. Instead they say there is nothing we can do. Yet, no source is provided for this information or description offered as to the context in which such information was acquired. You extoll the virtues of typical private healthcare plans were treatment of less than 4% pf tje enrollees accounts for more than half of medical expenditures. The presumption is that those receiving care are tuly the most in need. Healthcare expenditures concentrated on a small portion of the population will bring about the best results. However, you have to go no further than the recent Tenet Health System case to realize that some runups of medical expenses are of questionable validity. Even when the need and delivery of services is valid, one has to wonder if the treatment was truly effective. Or are avalanches of medical tests and medical and drug treaments meant to mask inefficient and ineffective care? Regards, Tony Cooper
January 29th, 2008 at 3:35 am
Physicians in Wisconsin
Once again an awesome post - problem is every time I read your blog more ideas are presented and I just can’t keep up with it!!! However don’t for one moment stop!