Healthcare, in the U.S., Britain and Canada?

When it comes to healthcare, the U.S., Britain and Canada are hurting
Healthcare in all three countries has the same problem. They just feel it in different places.
By Ezra Klein

April 7, 2009

When asked by the New England Journal of Medicine to detail his healthcare vision during the campaign, John McCain concluded with a rousing denunciation of "new government bureaucracies that will translate into higher taxes, reduced provider payments and long waiting lines."

Long lines come up frequently in the American healthcare discussion, the symbol of all that is to be feared about a government-run system. And it's true that in Canada and Britain, the two countries most often cited in discussions of what nationalized healthcare might mean, some patients report having to wait months for some elective treatments. Sometimes.

But we've got waiting lines too -- along with 50 million uninsured and a system that costs more than twice as much per person as that of any other country. We've just managed to hide our lines through clever statistical gimmickry.

Britain and Canada control costs in a very specific fashion: The government sets a budget for how much will be spent on healthcare that year, and the system figures out how to spend that much and no more. One of the ways the British and Canadians save money is to punt elective surgeries to a lower priority level. A 2001 survey by the policy journal "Health Affairs" found that 38% of Britons and 27% of Canadians reported waiting four months or more for elective surgery. Among Americans, that number was only 5%. Score one of us!

Well, sort of. American healthcare controls costs in another way. Rather than deciding as a society how much will be spent in the coming year and then figuring out how best to spend it, we abdicate collective responsibility and let individuals fend for themselves. So although Britain and Canada have decided that no one will go without, even if some must occasionally wait, the U.S. has decided that most of those who can't afford care simply won't get it.

When that very same survey also looked at cost problems among residents of different countries, 24% of Americans reported that they did not get medical care because of cost. Twenty-six percent said they didn't fill a prescription. And 22% said they didn't get a test or treatment. Those latter numbers are probably artificially small: If you can't afford to see a doctor, you never know that you can't afford the treatment she would recommend. In Britain and Canada, only about 6% of respondents reported that costs had limited their access to care.

Moreover, surveys conducted by the Organization for Economic Cooperation and Development have found that most countries don't have waiting lines or the uninsured. Not Germany or France or Japan or Sweden, all of which have more of a mix of public and private options. But Canada is next door, and Britain speaks our language, so we tend to spend a lot of time comparing our system with these systems and not a lot of time thinking through the full range of options.

In light of the "Health Affairs" data, smugness about our speedy access to care seems a bit peculiar. If someone can't afford care, we record their waiting time as zero. You don't wait for what you can't have. But a more accurate accounting would record that wait as infinite, or it would record when the patient eventually ends up in the emergency room because the original ailment went untreated. Research like this raises a simple question: Would you rather wait four months for a surgery or be unable to get it altogether?



Just last week, House Republicans expressed their preference for the latter. Their long-awaited budget document was admirably specific about changes to Medicare. They call for "a new Medicare program" in which enrollees are given a check "equal to 100% of the Medicare benefit," which they can then take to the private market to purchase their own care.

This proposal has a purpose beyond dismantling a popular government entitlement program. Currently, Medicare does not abide by a budget. It is not run like the Canadian or British healthcare systems. Instead, it pays whatever is deemed "reasonable and necessary." Because of that, costs are shooting through the roof: The Congressional Budget Office estimates that Medicare spending will more than triple by 2050.

The Republican plan gives Medicare a budget. Costs grow only as fast as the check grows. And because the check grows more slowly than health spending does, the program saves money. But this is, in effect, almost precisely the strategy of Britain and Canada: It is the government imposing an arbitrary budget on its healthcare spending.

The difference is that the British and Canadian governments try to apportion that health spending so that the whole population gets care. That can mean, alongside other cost-saving measures, longer waits for services. The Republican budget simply would give individuals a fixed check. That will mean that patients who exceed that sum and don't have money of their own go without needed care.

So Americans will continue to brag that no one waits, and Canadians and Britons will continue to brag that no one goes without. And somewhere, the French and the Germans and the Japanese and the Swiss and many others will wonder why we insist on choosing between such awful extremes.

Ezra Klein is an associate editor at the American Prospect.