An expensive way to die.

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.

By and large, countries that have succeeded in slowing the growth of health-care spending have done so by denying people services, not by making efficient use of resources.

How much does it cost a hospital to perform an appendectomy? Outside the U.S. it is doubtful that there is a public hospital anywhere in the world that could answer that question. One reason for Margaret Thatcher's health-care reforms is that even Britain's best hospitals did not keep adequate records, and it was not uncommon for the head of a hospital department to be unaware of how many people his department employed.

What about bed management? Consider that while fifty thousand people wait for surgery in New Zealand, one out of every five hospital beds is empty. While nearly eight hundred thousand people wait for surgery in Britain, at any point in time about one out of every four hospital beds is empty. In both Britain and New Zealand, about 25 per cent of all acute beds, desperately needed for surgery, are clogged by chronically ill patients who are using the hospitals as nursing homes-often at six times the cost of alternative facilities. In Ontario about 25 per cent of hospital beds are occupied by elderly chronic patients. Hospital administrators apparently believe chronic patients are less expensive than acute patients (because they mainly use the "hotel" services of the hospital), and thus are less of a drain on limited budgets. Myth #4: Under national health insurance money is allocated so that it has the greatest impact on health.

Even when resources are organized efficiently, they are still distributed with random extravagance under systems of national health insurance. These systems take millions of dollars that could be spent to save lives and cure diseases, and spend this money to provide a vast array of services to people who are not seriously ill. Take the ambulance service. English "patients" take more than 21 million ambulance rides each year-about one ride for every two people in all of England. About 91 per cent of these rides are for non-emergency purposes (such as taking an elderly person to a pharmacy) and amount to little more than a free taxi service. Yet for genuine emergencies, the typical British ambulance has little of the life-saving equipment considered standard in most large American cities.

While tens of thousands who are classified as in "urgent need" of surgery wait for hospital beds, the NHS spends millions on items that have only marginal effects on health and which could well be financed either by charges on the patients or by a low-cost limited private insurance. On the average, the NHS spends more than $70 million each year on tranquilizers, sedatives, and sleeping pills; almost $19 million on antacids; and about $21 million on cough medicine. If the NHS did nothing more than charge patients the full costs of the sleeping pills and tranquilizers they consume, enough money would be freed to treat ten thousand to 15,000 additional cancer patients each year and save the lives of an additional three thousand kidney patients.

Myth #5: Under national health insurance the elderly in the U.S. will receive at least the same benefits they now receive under Medicare.

The elderly have the most to lose from the adoption of national health insurance. Take chronic kidney failure. Across Europe generally, in the late 1970s, 22 per cent of dialysis centers reported that they refused to treat patients over 55 years of age. In Britain in 1978, 35 per cent of the dialysis centers refused to treat patients over the age of 55: 45 per cent refused to treat patients over the age of 65; and patients over the age of 75 rarely received treatment at. all for this disease.

How pervasive is denial of life-saving medical technology to elderly patients in other countries? Lacking hard data., one can only speculate. However, a white 65year-old male in the U.S. can expect to live 1.3 years longer than a 65-year-old British male. A white 65.year-old female in the U.S. can expect to live 1.4 years longer than a 65-year-old British female. For middleaged males, U.S. mortality rates are higher than European ones. During the retirement years, however, when medical intervention can make much more of a difference, the U.S. mortality rate is significantly below that of European countries.

Myth #6: The defects of national-health-insurance schemes in other countries could be easily remedied by a few reforms.

The characteristics described above are not accidental byproducts of government-run health-care systems. Instead, they are the natural and inevitable consequences of politicizing medical practice.

Why are elderly and poor patients discriminated against in the rationing of acute care under national health insurance? Because national health insurance is always and everywhere a middle-class phenomenon. Prior to the introduction of national health insurance, every country had some government-funded program to meet the health-care needs of the poor. The middleclass working population not only had to pay for its own health care, but it was also paying taxes to fund health care for the poor. National insurance extends the "free ride" to the middle-class working population, and it is designed to serve the interests of this population.

Why do national-health-insurance schemes skimp on expensive services to the seriously ill while providing a multitude of inexpensive services to those who are only marginally ill? Because numerous services provided to the marginally ill create benefits for millions of people (read: millions of voters), while acute and intensive care services concentrate large amounts of money on a handful of patients (read: small number of voters). Democratic political pressures dictate the redistribution of resources from the few to the many.

Why are sensitive rationing decisions left to the hospital bureaucracies? Because the alternative is politically impossible. As a practical matter, no government can afford to make it a national policy that nine thousand people every year will be denied treatment for chronic kidney failure and die. Nor can any government announce that some people must wait for surgery so that elderly patients can use hospitals as surrogate nursing homes, or that elderly patients must be moved so that surgery can proceed. Budgetary decisions made by politicians and administrators are transformed into clinical decisions made by doctors. Myth #7: Since national health insurance is very popular in other countries, it would also be popular in the Unites States.

National health insurance remains popular in other countries precisely because it does not function the way its advocates believe it should. It "works" in other countries for three reasons: 1) The wealthy, the powerful, and those who are most skilled at articulating their complaints find ways to maneuver to the front of the lines. 2) Those pushed to the end are generally unaware of the medical technologies denied to them. 3) There are no contingency fees, no generally recognized right of due process, and no lawyers willing to represent those who are systematically discriminated against-though these are beginning to develop, as, for instance, kidney patients learn the facts of their situation and organize into pressure groups on the AIDS model.

"Don't push me around" is a distinctively American phrase. In Europe, people have been pushed around for centuries. In the U.S. we have widespread access to information about modern medical technology, a legal system that encourages litigation, and a strong devotion to basic rights of due process. National health insurance, as it operates in other countries, would not survive the American cultural and legal system.

  Average Waiting Time In Newfoundland 1988...
       Procedure                Average Wait
    Mammogram                         2 1/2 months
    Bone scan                       1-1/2   months
    Myelogram                           3-4 months
    Brain shunt                         5   months
    Hip replacement                  6-10   months
    Cataract surgery                    2   months
    CAT scan                            2   months
    Pap smear                         2-5   months
    Urgent pap smear                    2   months

Based on physician surveys by the Fraser Institute. Michael Walker, "From Canada: A Different Viewpoint," Health Management Quarterly, Vol. XI, No. 1, 1989, p. 12.