We’re going to start off the discussion about universal healthcare with one of the more common concerns voiced by opponents – Universal ‘coverage’ does not mean universal care, as it will lead to rationing of care, either overt or via extended waits for care.
Before we begin, lets not confuse ‘universal healthcare’ with ‘single-payer’. Single payer is one mechanism to deliver universal healthcare, but it is by no means the only one – as has been demonstrated by many European countries where private insurers are active and significant players in the market.
Let’s start with a key – if obvious – statement. No one I know would assume that universal coverage means anyone can get any medical service at any time from anyone they choose for free. Some ‘strict-intrepretarians’ may call that rationing, but the vast majority of people would undoubtedly say, “well, of course it isn’t!”
There’s a difference between rationing and appropriate buying behavior. According to Wikipedia, “Rationing is the controlled distribution of resources and scarce goods or services. Rationing controls the size of the ration, one’s allotted portion of the resources being distributed on a particular day or at a particular time.”
The operational word is ‘controlled’, and the question is by whom?
‘Rationing’ in today’s US health care system
In today’s non-elderly market, health plans ‘control the distribution’ of care; big insurance companies like United HealthGroup, Aetna, Wellpoint, CIGNA, Humana. Through their pre-certification processes, reimbursement arrangements, summary plan documents, provider agreements, and other business policies they try to make sure they only cover what they are legally required to cover (no cosmetic stuff) allow only those procedures that are appropriate for that condition delivered by an appropriate provider, and pay only what they have to for those procedures and services.
But there’s a big group of folks who don’t have access to any insurance (although they can access care on a limited basis through EMTALA) – the uninsured, a population that is likely pushing close to 50 million these days. Is their care ‘rationed’? No, they just can’t get any that’s not driven by an emergent condition. Hypertension medications, COPD treatment, asthma prescriptions are all not available (except in a few cases where provided by charity) unless and until the patient has to be admitted to an ER.
So, what do the data show? We’re living in a very expensive glass house. In 2007, Troy Brennan, Medical Director of Aetna, Inc, said “the (U.S.) healthcare system is not timely…” citing “recent statistics from the Institution of Healthcare Improvement … that people are waiting an average of about 70 days to try to see a provider. And in many circumstances people initially diagnosed with cancer are waiting over a month, which is intolerable…”
Conclusion? Today, Americans with coverage do not have unfettered access to any type of care.
‘Rationing’ in countries with universal healthcare
Opponents of universal healthcare often make the logical leap that somehow it will inevitably lead to extended waiting times. I’ve never understood the connection. How better access to care, leading to more preventive care, will lead to waiting lines for procedures has never been made clear to me. Moreover, the data refute that opinion.
The logic (an admitted misuse of that term) appears to go something like this: “In Canada (or the UK or France or wherever) they have universal healthcare and people have to wait forever for care, especially costly types of care”. We’ll leave aside the delays that exist in this country even for those with health insurance, the difficulty in finding a primary care doc who is still taking new patients, the waits to see specialists (god forbid you need specialty care from a chronic Lyme expert, the delays are months).
Or perhaps we won’t. In fact, A Commonwealth Fund study of six highly industrialized countries, the U.S., and five nations with national health systems, Britain, Germany, Australia, New Zealand, and Canada, found the United States ranked last on four measures of continuity of care and access problems reported by patients.
Here’s what a bit of specific data show (excerpted from the Commonwealth Fund report).
* The percentage of U.S. patients who waited six days or more for a doctor appointment when sick was not significantly different from the rate in Canada (23% v. 36%), the worst-performing country.
* Only 47 percent of U.S. patients were able to see a doctor on the same or next day when sick, versus 61 percent to 81 percent of patients in the four better-performing nations.
* U.S. patients were less likely than patients in Canada (12% v. 24%) but more likely than patients in Germany (4%) to wait four hours or more to be seen in the emergency department.
* U.S. patients were less likely than patients in four countries (except Germany) to wait four weeks or longer to see a specialist (23% v. 40%-60%) or to wait four months or longer for elective surgery (8% v. 19%-41%) (Schoen et al. 2005).
Another way to look at rationing is the volume of care delivered to those patients that actually receive care. Tom Lynch did a terrific comparison of the US to other OECD countries, within which he said this:
“Hospital discharges per 1,000 people in the US are 25% lower than the average for all OECD countries, and doctor visits are 42% lower.
Well, maybe people have significantly more intense and aggressive service while they are hospitalized in the US? One indicator of intensity is the average length of acute care hospital stay. In the US, the length of acute hospital stay is 5.6 days, which is less than all but eight of the other 29 OECD countries. But shorter stays could mean higher efficiency. A better way to look at it is to look at specific causes for hospital stays, like heart attacks, for instance. The US average hospital stay following acute myocardial infarction is 5.5 days, the lowest in the OECD.”
Clearly folks in countries with universal healthcare are not getting kicked out the door, or discharged “quicker and sicker” as we in the US do so well. Nor are they subjected to waiting times significantly different from those in the US.
What does this mean?
In several areas the US already has longer waiting times and poorer access to care than countries with universal healthcare. If the US adopts universal healthcare as practiced in other countries, the evidence indicates access will go up and waiting times may well go down.