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Single-Payer Shortcomings

woman in hospital bed, out-of-focus monitor in foreground.

A colleague and I recently visited Nova Scotia on business, and while I was there I picked up an issue of the local newspaper. On the first three pages of the issue, three stories about health care caught my attention.

The headline story on the cover was “Mom with cancer challenges premier.” Inez Rudderham spent two years repeatedly visiting the hospital due to severe pain. Because the 33-year-old lacked access to a family doctor, it took that long to diagnose her problem as anal cancer. By that time, the cancer had progressed to stage 3. Adding insult to injury, Rudderham requested counseling from Canadian Mental Health Services in January and recently discovered she would have to wait until July to receive any. This news prompted her to create an emotional Facebook video. In it, she dared Nova Scotia Premier Stephen McNeil to tell her in person that the province did not face a health care crisis. By the time I wrote this column, 4.7 million people had watched her video.

On page 3, two more items jumped out at me. The first detailed public anger over a change to nurses’ overtime pay, making it harder to secure last-minute coverage when a nurse is out sick. The second concerned the potential that pregnant women in Yarmouth, a town I visit on every trip to the province, may have to travel two or three hours to give birth because of an anesthesiologist shortage.

All of this made me think of the Rolling Stones.

I realize the connection is not obvious, but stick with me. My wife and I had tickets to see the Stones in late April, when their “No Filter” tour was due to kick off its North American leg in Miami. But the concert never happened. The band delayed its appearances in the U.S. and Canada because Mick Jagger needed a valve replaced in his heart. As a citizen of the United Kingdom, Jagger is entitled to surgery provided by that country’s National Health Service. NHS care is funded by taxes, but free at point of use. But Jagger, who is in a position to have surgery anywhere he wants, chose to have the procedure in New York City. The Stones have said the tour will be rescheduled, so we are holding on to our tickets.

As primary season heats up, many of the Democrats hoping to secure their party’s presidential nomination have championed universal health care, these days often branded “Medicare for All.” But as my recent trip to Canada and our unexpectedly uncommitted evening in Florida both illustrate, those who see single payer as a panacea either are unaware of such a system’s drawbacks or are choosing to ignore them. These drawbacks should inform the discussions of the future of health care in the United States.

A government can only spend so much of its budget on health care at any one time. This means that a system where the government pays for all health care services necessarily constrains capacity and rations services. The result is that citizens must wait, sometimes at length, for medical care.

Tom Holland, the president of Doctors Nova Scotia, told the CBC that Rudderham’s experience is common in the province and elsewhere in Canada. In Quebec, for example, 26% of the population has no family physician (the equivalent of a primary care physician in the U.S.). I have written before about a tragic individual instance where Britain’s NHS failed its U.K. participants. But like Canada’s system, it also faces systemic issues. The NHS employs an aging workforce, with 47% of staff over age 45. A lack of hospital beds, staff and operating theaters led health care providers to cancel one in seven NHS surgeries just before their scheduled time. One in 10 patients undergoing nonurgent operations have had their procedure canceled at least once, according to research published in the British Journal of Anaesthesia. (NHS England disputed these figures.) University Hospital Southampton FT wrote a letter to NHS England late last year calling for a “national awareness message” about the significant backlog of patients waiting for eye appointments. NHS Scotland, too, faces a shortage of general practitioners, especially in rural areas.

This is not to say that there are not all kinds of things wrong with the current approach to health care in the United States. Costs are high, both for individuals and for the country as a whole. Many people who need care can’t access it at all, with or without a wait. Female patients often face medical professionals who inaccurately dismiss their pain, much as Inez Rudderham described experiencing in her initial emergency room visits. Some of these problems were caused or exacerbated by the Affordable Care Act, and many predate it.

But adopting a single-payer system will not automatically fix these issues. Instead, it will trade existing problems for others. You will not get hit with a $150 bill for an office visit if you lack insurance and only need a strep test. But if you need a hip replacement, or psychological counseling, or anesthesia, you may have a long wait until someone is available to help you. A single-payer system also doesn’t cover ancillary costs, such as lodging for family members when treatment is far from home or ways to pay bills when patients are unable to work, as Rudderham’s story illustrates. The financial pressure of becoming seriously ill, while eased, is not absent in these systems.

U.S. voters should also bear in mind differences in geography. The United Kingdom is a small country, and most of its major cities are relatively close to one another. In a country like the U.S. – or Canada – where funding for government-provided health care must cover vast geographical areas, rural places like Yarmouth, Nova Scotia will suffer even more acutely.

The systems in which the government provides health care in this country also point to problems with widespread implementation. The Indian Health Service and the Veterans Administration provide clinics and hospitals where Native Americans and veterans, respectively, can access care. In 2018 the IHS budget was $5.5 billion to cover 2.3 million patients, or roughly $2,391 per patient for the year, including those with serious problems. And many Native Americans report that they cannot access private care at all, especially later in the year as budgets run out. A USA Today analysis found that at around 70 percent of VA hospitals, median wait times between arrival at the emergency room and admission were longer than at other hospitals – sometimes by hours. Dozens of the 146 VA medical centers also had higher rates of preventable infections and severe bedsores than the industry average.

A recent report from the Congressional Budget Office suggests that economies of scale will not erase these problems. A Medicare for All system could reduce administrative costs, though its effect on overall health care spending would depend on the system’s design. Regardless, the report found that such a system could produce longer wait times and reduced access to care if the health care work force was not sufficient to meet demand.

Many Americans have a poorly informed and romanticized vision of health care in foreign countries. Even when those systems actually are better for patients, there are hidden costs. In countries with lower-cost prescription drugs than ours – that is, all of them – those lower costs are due to price controls. Such controls shift those costs, mainly to the U.S., the only major industrialized nation without laws limiting drug prices. This means we are shouldering the cost of pharmaceutical research and development for much of the rest of the world.

We will have to take off our rose-colored spectacles before we can make an effective overhaul of our current system. Fortunately, in the U.S. we don’t have to wait to get a decent eye exam.

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