Lives at Risk: Single-Payer National Health Insurance Around the World

by John C. Goodman, Gerald L. Musgrave, and Devon M. Herrick

The Journal of the American Medical Association

Vol. 293

If you're looking for intellectual ammunition to refute the perennial myths about the triumph of socialized medicine in the rest of the developed world, this book is essential. It is an updated, expanded, well-referenced version of Twenty Myths About National Health Insurance, published in 1991 by the National Center for Policy Analysis.

Because single-payer advocates assert that enough funding to expand coverage to all will flow painlessly from the elimination of private insurers, the administrative cost myth is a crucial one. Goodman et al demolish it decisively. Private administration really is more efficient than public. Moreover, the key to eliminating both waste and perverse incentives is to get all third parties out of the majority of medical encounters-not to make a federal case of every single episode of medical care. True insurance is a method for indemnifying subscribers for a catastrophic loss, not a bill-paying service.

Despite the inconveniences of queues, socialized medicine is claimed to result in better health. Life expectancy and infant mortality are better in some countries with socialized medicine than in the United States. A more extensive treatment of this issue would be desirable, but the authors do make telling points. In situations in which medical care makes the most difference, such as chronic renal failure and cancer, Americans live longer. Furthermore, confounding variables complicate the analysis of the vital statistics.

Life expectancy is significantly different in various ethnic groups, ranging in the United States from an average of 80.9 years for an Asian American male, to 77.2 for a Hispanic white, to 74.7 for a white non-Hispanic, to 68.4 for an African American. (For women, life expectancy is about 6 years longer in each group.) Genetic and socioeconomic factors, rather than different medical treatment, are the primary explanation: persons of Japanese stock live just as long in the United States as in Japan, and white Americans live as long as white Western Europeans. Differences in infant mortality are largely a function of the prevalence of low birth weight, which is higher in the United States. Again, race is the most significant risk factor, even controlling for socioeconomic status, age, and the number of prenatal visits. The reasons for the ethnic differences are not entirely understood and cannot be assumed to result from different methods of financing medical care. The book cites twin studies suggesting that 40% of the variation is attributable to genetic factors.

Health "disparities" are a central feature of the "fairness" argument. But does socialized medicine eliminate them? The authors expose some startling inequities, belying the 1942 claim that the British National Health Service would be a "100 percent service for 100 percent of the population." Various London hospitals have a four-fold difference in number of physicians per 100 beds, a 2.5-fold difference in number of nurses, and a risk-adjusted mortality index ranging from 68 to 112 (Table 2-1). The mortality differences are probably not explained entirely by differing risks, as the better-staffed hospitals tend to have the lower mortality.

Rights, equality, needs, outcomes, technology, quality, costs, and the rest of the 20 issues are expertly dissected, confounding the claims of the social engineers who advocate a socialized utopia in medicine. At this point, the authors probably should have rested their case. Instead, they too succumb to the temptation to design the Ideal Health System. Although federal tax policy is largely responsible for the perverse economic incentives that created the current monster, as Goodman and Musgrave have explained at length in their previous book Patient Power, the authors still want to use this blunt-force social engineering tool, only in a better way.

Goodman et al understand correctly that it's not a choice between "single payer" and the status quo, and that we do have urgent problems. Many of their proposals for insurance reform are valuable, and barriers to their implementation need to be removed. Ideas include replacing state mandates for covering particular services with a casualty model; two-way long-term commitments to diminish adverse selection and the "death spiral"; and a better division of direct and third-party payment. The caveat is that there is no single product that is "ideal" for everyone-only an optimum choice among available products for each individual. In a free market, a variety of products could develop, some still unimagined. Avoiding the top-down command and control of the single payer, these authors would allow innovation to flourish. The outcome would not be Perfection, but it would be better-rather than worse-than now.

The authors might have pointed out plainly that single payer means that money cannot be allowed to buy better or more timely care, not even to save a life. Canada is the only one of the countries under discussion that has forbidden a private market, and it is now being forced to backtrack somewhat. Yet Physicians for a National Health Program specifically calls for the Canadian model.

The quest for equality, carried to its logical conclusion, implies equal, zero-sum-game misery. As in the French Revolution, the Ideal translates to " Liberty, Equality, Fraternity-or Death!" The only possible equality of outcome occurs in death.

For this reason, the book's title is right on target although the content, in my view, understates the case. Lives truly are at risk.

Jane M. Orient, MD, Reviewer Association of American Physicians and Surgeons University of Arizona College of Medicine Tucson