As we consider the following attempted solutions, observe that in each case health care is treated as an entitlement rather than a commodity, and that health insurance (or “coverage”) is conflated with health care. We will look first at attempted solutions in Canada; then we will turn to similar efforts in Tennessee, Hawaii, and Massachusetts.
In Canada, the government health care system evolved over several decades, starting in 1947 and culminating in the 1984 Canadian Health Act. The goal of the system was and is to provide “universal guaranteed” access to medically necessary health care services for all Canadians. This is a “single payer” system, which means that (with rare exception) the government, rather than patients or insurance companies, pays for everyone’s essential medical services. Doctors and hospitals provide medically necessary care to patients, and the government pays the bills. Further, doctors cannot charge patients separately for the services they provide; they can only accept the fees paid by the government. In leftist theory, all medical care is “free”; everyone has equal “access” to it; and no one is denied health care because he is unable to pay. In practice, however, this theory proves wanting.
In Canada, each citizen is forced to pay for his neighbors’ medical care in the form of taxes that are higher than he would otherwise pay. The Canadian health care system consumes nearly a quarter of total federal, provincial, and local tax revenues, which is more than in any other Western country except Iceland.40
In the name of “equal access” to health care, doctors (with rare exception) are forbidden to provide essential care to patients outside of the system, and citizens are forbidden to spend their own money on medically necessary care for themselves or their loved ones. Doctors are penalized for accepting money from patients for medical services that are covered by the government system. Private spending for state-covered medical care is illegal; everyone is forced to wait his turn on the government waiting list or “queue.”
There are waiting lists for MRI scans, heart surgery, chemotherapy, and every other essential medical service. The government uses these waiting lists to control costs. For instance, to avoid paying too much for heart surgery, the government limits the number of surgeries it will pay for each year. This imposes another cost on patients, one in addition to the money they have already paid in higher taxes: the cost of their time.
According to the Vancouver-based Fraser Institute, “Canadian doctors say patients wait almost twice as long for treatment than is clinically reasonable, . . . almost 18 weeks between the time they see their family physician and the time they receive treatment from a specialist.”41 Consequently, mortality rates for treatable conditions such as breast cancer and prostate cancer are substantially higher in Canada than in the United States.42 A Canadian woman who discovers a lump in her breast might wait several months before she receives the surgery and chemotherapy she needs, with the cancer cells multiplying rapidly all the while.43 If she lived in the (as yet) less-socialized United States, she could receive treatment within days.
Canadian waiting lists routinely deprive patients of crucial, irreplaceable time, and this burden falls hardest on the sickest patients, those with the least time to spare. In some cases, it can cost them their very lives. Canadian patients routinely suffer and die while waiting for their “free” health care. The National Center for Policy Analysis notes: “During one 12-month period in Ontario, . . . 71 patients died waiting for coronary bypass surgery while 121 patients were removed from the list because they had become too sick to undergo surgery.”44
Of course, certain Canadians can and do attain preferential placement on the lists; politicians and celebrities use their pull to move up the waiting lists—something that ordinary Canadians bitterly refer to as “queue jumping.” And wealthy Canadians can avoid the waiting lists altogether—by traveling to the United States to purchase the care they need.
On the patient side of the equation, the people most harmed by the single-payer system are average Canadians and “the poor.” On the doctor side of the equation, we find further problems.
In 2003, then-president of the Canadian Medical Association, Dr. Sunil Patel, reported: “Physicians across Canada are in an advanced stage of burnout due to work conditions. . . . That burnout causes them to retire early or pull away from certain kinds of work or simply leave.” According to the New York Times, specialists have been leaving Canada to practice in the United States because of deep unhappiness with “Canada’s health care system, which is driven by government-financed insurance for all . . . [and which] increasingly rations service because of various technological and personnel shortages.”45 According to the Canadian Institute for Health Information, in just six years, between 1996 and 2002, this “brain drain” amounted to “a net migration of forty-nine neurosurgeons from Canada . . . a large loss given that there are only two hundred forty-one neurosurgeons in the country.” “It’s not about the money,” says neurosurgeon Dr. Siva Sriharan; “[rather, it’s that] we can’t do our job properly with operating room time so extremely limited here.”46
The flight of doctors from Canada to the United States has become a serious problem for Canadians. A recent study by the Canadian Medical Association (CMA) reports that one in nine doctors trained in Canada now practices in the United States: “[T]his is equivalent to having 2 average-sized Canadian medical schools dedicated to producing physicians for the United States”—and there are only seventeen medical schools in Canada.47 This exodus of Canadian physicians involves not only primary care physicians but also specialists, who can make two to three times more money in the United States than in Canada.
Walter Rosser, M.D., head of the department of family medicine at Queen’s University in Kingston, Ontario (and one of the coauthors of the CMA study), correctly blames the loss of primary care doctors on Canadian government policy.
[T]he majority of Canadian-trained family physicians in the United States left Canada because they were dissatisfied with the policies of the Canadian government. In the late 1990s, the country’s Ministry of Health and Long-Term Care said it was going to make all new medical graduates practice in underserved areas, a pronouncement that convinced a lot of family physicians to leave Canada for the United States. . . .48
When the only reward that Canadian doctors can look forward to after many long, hard years of study and training is a job in a government system that dictates where they can live, how they must practice, and how much they can earn, it is no surprise that many of them refuse to work in Canada.
The Fraser Institute summarizes the key differences between Canadian and American health care as follows:
Health care appears to cost less in Canada than in the United States largely because Canadian public health insurance does not cover many advanced medical treatments and technologies that are commonly available to Americans. Canadian patients do not get the same quality or quantity of care as American patients. On a comparable basis, Canadians have fewer doctors, less high-tech equipment, older hospitals, and get fewer advanced medicines than Americans.49
These differences are a direct result of the fact that Canada is a worse violator of the rights of doctors and patients than is the United States. To guarantee Canadians “free” health care, the Canadian government forces individuals to pay for their neighbors’ medical care and limits their freedom to pay voluntarily for their own. With bureaucrats deciding who receives what, individuals are forbidden to spend their money according to their own judgment (and the advice of their doctors) as to what is best for their health. Since an individual’s own judgment is his basic means of living, when the government forces individuals to act against that judgment, unnecessary suffering and death naturally follow.
These problems are not unique to Canada. Similar problems abound in other countries, such as Sweden and the United Kingdom, that have adopted their own versions of government-run “universal health care.” And not only are the problems similar; the means by which the problems arise are similar. In each case, on the grounds that people have a “right” to health care (or cheaper health care), the government violates the rights of businessmen, doctors, and patients by interfering with the free market, which results in rising costs. Then the government further violates individual rights, via rationing, in order to control the increasing costs caused by its earlier rights violations. And so on. All the while, the commodity that is health care becomes more expensive and less available for everyone.
In Sweden, when the prime minister decided to go through the national system for his hip replacement surgery, he suffered for eight months in great pain, affecting both his ability to work and his ability to enjoy life. This kind of waiting and suffering is typical for Swedes in need of medical care—including heart surgery.50
In the UK, government intervention has led to such a shortage of health care that the British Medical Association has explicitly acknowledged that health care must be rationed: “British doctors will take the historic step of admitting for the first time that many health treatments will be rationed in the future because the NHS [the government-run National Health Service] cannot cope with spiraling demand from patients.”51 Such rationing is the inevitable outcome of a government-run health system.52
Observe that all of these allegedly ideal systems guarantee health “coverage,” but they do not and cannot guarantee actual medical care. Health “coverage” (or health insurance) and health care are not the same thing, and, as economist David Hogberg explains, the distinction between the two is of crucial importance:
Believing health care and health insurance are the same thing easily leads to some mistaken, if not dangerous, notions. It leads to the beliefs that (1) universal health care and universal health insurance are the same; and (2) that if a nation has universal health insurance, where the government pays for every citizen’s health care, that nation will have universal health care, where citizens will have ready access to health care whenever they need it. As the experience of other nations shows, however, universal health insurance often leads to very restricted access to health care.53
Failing to recognize this distinction, various U.S. states have attempted to guarantee “universal coverage” for their residents. Although their specific methods of implementation have differed, they have all run into similar problems.
In the 1990s, Tennessee attempted to provide universal coverage by expanding the state Medicaid program to include people earning up to 300 percent of the federal poverty line (i.e., a middle-class family of four making about $55,000 a year). This new program was called TennCare. The state also forced insurance companies to offer expensive additional benefits and forced employers either to buy health insurance for their employees or to pay into a state fund for the uninsured. Many employers chose the second option, shifting their employees’ health costs onto taxpayers. Because of these regulations, many insurance companies withdrew from Tennessee, and, consequently, more people fell into the state’s “health” plan.54
Predictably, costs rose (in part) because patients had no incentives to spend prudently. In response, the government attempted to control costs by slashing payments to doctors and hospitals. Hospitals closed, and doctors left the state. Many doctors who remained stopped seeing TennCare patients, because they lost money on each one.55 Families with sick children often had to drive long distances to find a doctor who would see them. They had no alternatives to TennCare because the state regulations had all but destroyed the insurance market. Ironically (though predictably), TennCare ended up causing the most harm to the very people it was intended to help—rural patients and “the poor.” The program also nearly bankrupted the state.56
Hawaii recently received praise from the left-leaning Commonwealth Fund for being the top U.S. state with respect to health care coverage.57 In theory, Hawaii provides nearly universal coverage for all of its residents through a combination of employer mandates and a state program called QUEST, which is an expanded version of Medicaid. In practice, however, many patients in Hawaii are unable to get essential care in a timely fashion. As the Honolulu Star-Bulletin reported:
A Commonwealth Fund survey said Hawaii has the best access to health care in the country, primarily because of a high number of residents with health insurance. But the study didn’t consider availability of doctors, Hawaii Medical Association members say. “If we don’t have doctors available to see them, what good does insurance do you?” said HMA President Linda Rasmussen, a Kailua orthopedic surgeon. High malpractice premiums and low insurance reimbursements have created a “state of crisis” in Hawaii with physician shortages limiting access to health care, she said. . . . “If I have a patient who needs a total joint (replacement) and has an abnormal EKG (electrocardiogram) and needs to see a cardiologist, it’s almost three months to get an appointment before he gets cleared,” she said. “If a person calls when they’re 50 for a colonoscopy, they’re almost 51 before they get in.” . . . “People are frustrated,” said HMA Executive Director Paula Arcena. “They have insurance coverage but they can’t find doctors.” The neighbor islands and rural Oahu are affected the worst, especially in specialty and trauma care, she said.58
Patients in Hawaii know the difference between “coverage” and actual care.
The Massachusetts plan, which is barely a year old, is already giving rise to the economic problems that follow logically from the government violating the rights of patients, doctors, employers, and insurance companies. The plan, which was signed into law by former governor (and current Republican presidential candidate) Mitt Romney, relies heavily on a combination of mandates requiring individuals to purchase health insurance and employers to offer it. In the name of “comprehensiveness,” the state has also imposed numerous mandates on insurance companies, requiring their policies to include specific coverage that would not be sustainable in a free market. The poorest residents are given government subsidies to offset the costs, but everyone else is required to pay for coverage regardless of whether they need or desire it. This is the health care equivalent of the state requiring everyone to purchase a car, requiring car dealers to sell only expensive models such as Mercedes and Lexus, outlawing the sale of all inexpensive models, and giving subsidies to the poor so that they too can participate in the charade.
The New York Times has reported numerous complaints about the Massachusetts plan from small business owners, doctors, and patients. Restaurateur Deb Maguire said, “This is going to bring me to my knees,” because the cost of the mandatory insurance would be “astronomical.” Dr. David Torchiana, chief executive of the Massachusetts General Physicians Organization, stated that the plan “will strain what is already a shortage of primary care physicians.” (In other words, it will not improve access to actual medical care.) Linda Impemba, a 58-year-old marketing company employee, said “she would remain uninsured, pay penalties, and, as soon as her ailing mother dies, will leave Massachusetts.” In her words, “There’s no way in heaven I can possibly survive in this state . . . Now not only is my cost going to go up, everything’s going to be raised so I can pay for the other people to be insured.” In response to these and similar concerns, Massachusetts Governor Deval Patrick has stated, “Ultimately we are going to have to explain to people that this is an obligation, that it is not optional.”59
Because the Massachusetts state government does not and cannot produce actual health care, it cannot meet its goal of guaranteed high-quality, low-cost health care for all residents. Thus, until the state repeals the plan and ceases to violate individual rights, it will necessarily seek some compromise between “universal coverage,” raising taxes, and rationing care. As a recent report from MSNBC.com notes:
The state has already backed off of “universal.” About 160,000 uninsured people in the state have incomes that are too high to qualify for subsidized health insurance—but too low to afford the lowest-cost unsubsidized plans. About 60,000 of these working poor won’t face a penalty for not getting insurance, but the 100,000 others are in a bind. “What I’m starting to see,” [single mother] Maureen Linehan said, “is the people have to pay for their health care, and now they can’t afford to pay their rent.”60
As is predictable, the individual insurance mandates imposed by the state cause the most hardship for those who were supposed to benefit the most from the government program: “the poor.”
Government-run health care systems do not and cannot work, because they improperly treat health care as a “right.” Health care, like food and clothing, is a need, but not a right. It is a commodity that is created by the intelligent thought, creativity, and hard work of producers, such as doctors, nurses, allied medical professionals, and hospital administrators. When the government treats health care as a right, it necessarily violates the genuine rights of the providers who produce those goods and should be free to offer them for exchange on whatever terms they see fit, not forced to serve people against their own judgment. And it necessarily violates the rights of consumers, who should be free to trade with providers by mutual consent to mutual benefit. As we have seen repeatedly, good doctors cannot and will not continue working under a system that enslaves them.
A final (and often unacknowledged) consequence of government interference in medicine is that it leads to violations of individual rights in other areas of life, such as violations of the right to free speech and mandates regarding what people may and may not eat. When the government pays our health care bills, in order to save money, it inevitably demands greater control in how we lead our daily lives. Some of the “universal health care” proposals in Colorado, for instance, include “sin taxes” on foods and products deemed unhealthy.61 And in Great Britain, the government Advertising Standards Authority recently banned television reruns of some 1950s-era commercials featuring the slogan “Go to work on an egg” on the grounds that they were promoting an unhealthy lifestyle. Eggs are, of course, legal in Great Britain, but, says the government: “Eating eggs every day goes against what is now the generally accepted advice of a varied diet. We therefore could not approve the ads for broadcast.”62
A Genuine Solution
The solution to America’s health care problems is not more government intervention. Government violations of individual rights through government interference in the marketplace are the source of the problems. Government meddling in health insurance has all but eliminated choice, competition, and innovation, and has driven up the cost of health insurance. Government interference in medicine has caused incalculable harm to both patients and doctors, and driven up the cost of health care. Government controls have bred more controls, as politicians and bureaucrats have tried to “solve” the problems created by one set of regulations by imposing another set, and so forth, in a vicious spiral of increased costs, rationing, suffering, and death. Just as a doctor would not attempt to treat a burn victim by exposing him to more heat, so we should not attempt to solve our health care problems through more government intervention.
The only moral and practical solution to this now-behemoth problem is to acknowledge that government intervention in health care and in health insurance is wrong, and to start in earnest to eliminate all such interference. This is the moral approach to solving the problem because it recognizes that the producers of health care goods and services have an inalienable right to dispose of the fruits of their thought and labor as they see fit, seeking their best interests through free trade in the marketplace. And it is the practical approach to solving the problem because it will lead to high-quality medical care at the prices that make such care possible—the prices on which providers and patients voluntarily agree.
A first step in the right direction would be to repeal EMTALA, allowing doctors and hospitals to decide whom they will treat and on what terms, and whether they will treat a given patient at all. As a matter of moral fact, doctors have the same rights as plumbers, accountants, grocers, and lawyers—rights that include the right to decide which patients they will treat and to refuse patients who cannot afford them.
As to the question of how those who cannot afford medical care will receive it, we must bear in mind that government is not taking care of them now and is logically incapable of ever doing so, for the simple reason that government does not and cannot produce goods or services. Insofar as people who cannot afford medical care are receiving it, the care is being provided by productive American citizens, doctors, and hospitals. And we must bear in mind that, in the words of Philosopher Leonard Peikoff, Americans who cannot afford medical care “are necessarily a small minority in a free or even semi-free country. If they were the majority, the country would be an utter bankrupt and could not even think of a national medical program.”63
Those unable to afford any particular medical services would have to rely on voluntary charity, not on the empty promises of government. Individually, Americans are the most generous people in the world, and they have always been so. For example, American individuals, corporations, and foundations gave $1.5 billion to aid victims of the December 26, 2004, Sumatra earthquake and tsunami, more than double the amount any government provided, including the United States.64
Quoting Dr. Peikoff again:
And such charity, I may say, was always forthcoming in the past in America. The advocates of Medicaid and Medicare under LBJ did not claim that the poor or old in the ’60s got bad care; they claimed that it was an affront for anyone to have to depend on charity.
But the fact is: You don’t abolish charity by calling it something else. If a person is getting health care for nothing, simply because he is breathing, he is still getting charity, whether or not any politician, lobbyist or activist calls it a “right.” To call it a Right when the recipient did not earn it is merely to compound the evil. It is charity still—though now extorted by criminal tactics of force, while hiding under a dishonest name.65
As shown, charity already abounds in America and would be even more abundant if the government removed its coercive hands from the health care and health insurance industries and consumers. Even with the government violating rights to the extent that it currently does, many examples indicate the sufficiency of charity in this regard. Here are just a few: The Shriners’ Hospitals provide free care to children and adults with orthopedic, spinal cord, and burn injuries. St. Jude’s Hospital provides free catastrophic care for children. Pharmaceutical companies provide enormous quantities of prescription drugs to those who are unable to afford them; for instance, they provided free (or nearly free) prescription drugs to about 6.2 million people in 2003 alone, and have been providing free prescription medicines to those unable to afford them for years.66 And there are hundreds of other examples.
With sufficient cultural support, eliminating EMTALA would be easy and would cause little disruption of services. It could be phased out over the course of a year with no difficulty. By setting a definite date in the future, for example, December 31, 2008, at which EMTALA would end, everyone would have ample opportunity to learn the law, and willing doctors, hospitals, and philanthropic organizations would have time to ramp up their charity care.
We must also eliminate the preferential tax-exempt status of employer-provided health insurance. The tax code must be changed to treat all Americans equally with respect to how they purchase health insurance and medical services. The existing unjust tax provision could also be phased out over a relatively short time, perhaps two or three years. But we must begin today by recognizing that this tax law is unjust both to those without employer-sponsored insurance and to those with such insurance. It gives preferential tax treatment to those with health insurance, and it treats those same employees as helpless dependents by making it economically unsound for them to choose and pay for their own insurance plans.
Further, we must eliminate all insurance mandates—including mandatory community rating, guaranteed issue, guaranteed renewability, and benefit mandates—and we must emphatically reject any call for individual or employer mandates. Insurance companies have a moral right to offer whatever policies and terms they deem marketable. Under a free market in health care, the types of insurance plans and coverage will undoubtedly change, but such changes will be the result of insurers and consumers acting according to their best judgment—by mutual consent and in each party’s best interest. That is the beauty of a truly free market.
Some states have already begun to curtail benefit mandates. As we mentioned above, Kentucky called for a three-year moratorium on all new mandates; consequently, the market in that state has begun to revive. To enact such measures across the country and to sustain them over time, however, Americans must come to understand that mandates are immoral and impractical and that, consequently, they do harm, not good.
We must work toward the elimination of Medicare, Medicaid, and all other government insurance programs that allegedly benefit the aged and the poor. As we have seen, these programs provide illusory “coverage,” while actually reducing or eliminating patients’ access to doctors. These programs could be phased out over several years beginning with the passage of a law to the effect that no person under the age of thirty-five will pay into or receive any benefits from Medicare. This would enable those under thirty-five to begin planning for their own future, long-term medical costs and enable insurers to plan for the future as well. Likewise, we could start reducing both the extent of Medicaid benefits and the number of beneficiaries, by limiting the number of years that a person could receive Medicaid benefits, in ways similar to those methods used very effectively by the Clinton administration to reduce welfare rolls.
Finally, we must repeal HIPAA and all other government regulations involving health insurance or medical care. It is immoral for doctors to be subject to criminal penalties for documentation errors that violate no rights and have nothing to do with the quality of patient care. These laws do nothing but increase the amount of time spent on useless, or nearly useless, paperwork. Eliminating HIPAA and many other regulations would enable doctors to return to the practice of medicine, providing patients with more access to quality care. Again, eliminating these laws could be done easily, by setting forth a future time at which the law would expire.
One innovative insurance solution that is likely to become commonplace in a truly free marketplace is a combination of Health Savings Accounts (HSAs) and high-deductible, low-cost catastrophic insurance. HSAs enable individuals to save money for possible future medical expenses and to spend their own money on routine health care according to their own best judgment. Catastrophic insurance provides an economical way to protect against low-probability but highly expensive accidents and serious illnesses. Economic analyses have shown that a combination of these two kinds of plans provides high-quality care at a lower cost than traditional insurance plans.67 The Whole Foods grocery chain, for example, has been successful in using HSAs in conjunction with high-deductible catastrophic insurance policies to cut costs, while encouraging individual responsibility and preserving quality of care. This program is extremely popular with Whole Foods employees.68
Although the goal of these proposed changes—a fully free market in health care and health insurance—cannot be achieved overnight, movement in the right direction can and should begin immediately. The only moral and practical way to proceed is to recognize the proper end and to consciously and consistently move toward that end by taking whatever steps in that direction are possible at any given time. What we must not do is shy away from recognizing and proclaiming the proper goal—the complete eradication of every trace of government interference in medicine and health insurance—or the fundamental moral justification for pursuing that goal: the individual’s moral right to his life, liberty, and property.
Only the ideal of the free market—based on the principle of individual rights—provides a solid foundation for genuine and practical reform. And only a free market in medicine can deliver the properly (i.e., voluntarily) priced high-quality health care that Americans deserve. This last point is evident in the sectors of medicine with the least government regulation, such as cosmetic surgery and LASIK eye surgery. The clear pattern in these sectors is a continual decrease in prices and improvement in quality. As health economist Devon Herrick stated in testimony before the U.S. Congress:
[D]espite a marked increase in demand between 1992 and the present, cosmetic surgeons’ fees remained relatively stable. The average increase in prices for medical services from 1992 through 2005 was 77 percent. The increase in the price of all goods, as measured by the consumer price index (CPI), was 39 percent. Cosmetic surgery prices only went up about 22 percent. Thus, while the price of medical services generally rose almost twice as fast as the CPI, the price of cosmetic surgery went up slightly more than half as much. Put another way, while the real price of health care paid for by third parties rose, the real price of self-pay medicine fell. Another example of price competition is the market for corrective eye surgery. In 1999, only a few years after LASIK was approved, the price was about $2,100 per eye, according to the ophthalmic market research firm MarketScope. Within a short time, competition drove the price down to slightly more than $1,600. The cost per eye of the standard LASIK is now about 20 percent lower than six years earlier. Competition held prices in check until a new innovation arrived for which patients were willing to pay more. By 2003 surgeons began to perform a newer, more-advanced custom wavefront-guided LASIK procedure.69
In other words, the market can and does bring down health care costs while improving services when allowed to operate without government interference.
A free market in health insurance and health care works because it recognizes that health care is a commodity produced by individuals who have a right to offer that commodity for trade on whatever terms they see fit—and that consumers have the right to accept or reject those terms as they see fit. When all parties are free to trade voluntarily, according to their own best judgment, the result is lower costs and higher quality—a fact that is evident throughout the economy and recognized by all reputable economists.
The relatively-free American marketplace has done a magnificent job in providing other necessities of life such as food, shelter, and clothing; it can do the same for health care and health insurance—if we free up these markets.
In a truly free market, other creative and innovative solutions will arise—solutions that have not yet been conceived by any politician, policy analyst, or by the authors of this article. The fact that we cannot foresee all the possible good ideas is not an undesirable “bug” of the free market but rather one of its marvelous features. Just as someone twenty years ago could not have imagined the specific innovations and benefits that would arise from a free market in the then-fledgling internet industry (consider eBay, Amazon.com, Google, iPhones, etc.), so people today cannot imagine the specific innovations and benefits that would arise from a free market in medicine and health insurance. What is certain is that the freer the market, the more innovation and benefits will arise.