Universal health care

By John V. Mackel

In recent months, there has been much talk of health coverage, and Barack Obama has committed to a new third-party system equal to the congressional plan for those currently not covered. I will call this Obamacare. Accessing this new plan would be an estimated 47 million people without coverage and an additional 50 million who have inadequate coverage with excessive deductibles, co-pays and exclusions, totaling 97 million people. They do not have enough coverage due to cost, so the new plan will have to be heavily subsidized for them by everyone else.

All systems, including health care, require a budget in order to function. The U.S. already has, by far, the largest health budget of any developed nation, not including the upcoming boomer generation joining Medicare and not including any new additions for Obamacare. Well before the recent talk of additional coverage, it was widely felt that the U.S. health budget was much too high and that costs must be controlled. This means, at minimum, the budget should be held constant and, if possible, reduced.

The total cost of a health system has two components; price per service, and volume. Control of health-care spending must, therefore, involve control of prices or control of volume, or both. If the total cost is held constant, then if one component goes up, the other has to go down.

The severity of this control flows from the desired budget target levels. The more severe the budget reduction, the more severe the effect on care.

In a free society, price controls are difficult to enforce. Although health plans, including Medicare, always attempted to do so, there comes a point where providers will leave the program. This is why governments use volume controls.

Control of volume means control of access to services, a polite way to say "rationing." All countries ration health care with varying degrees of severity. Only the method differs. There are only two main ways to accomplish rationing. One is affordability (if you can't afford it, you don't get it) as in the U.S. system. The other is availability, used by Canada and most others. This is because universal coverage takes affordability off the table and leaves only the one remaining option, availability.

This rationing is applied to everyone equally. It doesn't matter if you can afford it. You won't get it in any case. It is done by means of wait lists, especially for the most expensive services such as subspecialty surgery (open heart, joint replacement and similar procedures), complex imaging (CT and MRI) and expensive drugs. This is exactly where we see wait lists or exclusions in countries with universal health care.

Control of availability also requires government control of local use of these technologies. This means that governments approve the number of complex surgeries done in your local hospital, whether it can purchase a new MRI machine, which drugs are approved for the drug formulary and which hospital remain open and for which services. Just as some U.S. politicians use the defense budget to enhance their electability, I can assure you that governments will make these decisions from their own political perspective. I saw this happen to health care in Canada.

The fundamental difference in the two methods of rationing is that in the affordability approach, some people do without, depending on income level.

In the availability approach, all people do without, regardless of income level.

In my opinion, the Obama plan will not bring some up to the present level. It will reduce all to a lower level of service in the form of reduced access and waiting lists. This is what has happened everywhere else. Funding for $100 million-plus additional services makes it inevitable, unless accompanied by a large budget increase, an impossibility in the current economic situation. Owning a coverage policy does not matter if there are no providers able to accept it. Access is still limited.

In Canada, there is a mainstream organization called the Wait Time Alliance with a website you can visit. Its purpose is to pressure various governments to reduce the lists to a reasonable level. This situation is why we see high levels of patient dissatisfaction in universal systems. They still cannot access the system as needed. Only the main reason differs. Services become unavailable at any price.

Significant and sustained waiting lists such as are seen in Canada and in Britain are, by definition, failures of the health organization or system to meet patient needs in a timely manner. They are also, by definition, successful attempts to meet the budgetary needs of the organization or system. So the system is more important than the patient, a basic characteristic of socialism.

Truly universal access is a nice idea, but it has never worked anywhere it has been tried. Budget constraints make it impossible. In my opinion, those who tell you that we can have it all at little or no additional cost are at best ill-informed.

John V. Mackel of Cape Girardeau is a medical doctor who has practiced medicine in the United Kingdom's National Health Service, Canada's Medicare system and in the U.S. He also is an adjunct professor in the College of Business at Southeast Missouri State University.