If the United States were to adopt the Canadian single--payer system of financing health care as some advocate, the change would not solve many of the problems attributed to the present system. Rather, it would replace one set of problems with another. According to a survey sponsored by the Harvard School of Public Health, which measured public opinion toward health care in five English--speaking countries, people in all five countries had roughly the same level of discontent with their system.
As the Harvard researchers wrote in the journal Health Affairs, "Amid widely divergent systems and cultural norms of health care, citizens express surprisingly similar concerns about the future."
The survey was conducted in 1998 by Louis Harris and Associates and funded by the Commonwealth Fund. It covered the United States, which has relied largely on employer--sponsored health care; Canada, with a single--payer government--run system; the United Kingdom, with a truly socialized system; and Australia and New Zealand, with hybrids of the above. It asked people for their general opinions of their health care system, and their specific personal experiences in that system.
Looking for Reform. A majority of people in all five countries said their health care system needs to be changed. As Figure I shows:
- In each of three countries -- the United States, Canada and Australia -- 79 percent of the population said their system needs either "fundamental change" or to be "completely rebuilt."
- The same sentiment was expressed by 89 percent of New Zealanders and by 72 percent in the United Kingdom.
Although the British health care system may be the least unpopular, the fact that more than seven out of 10 citizens want at least "fundamental change" is no endorsement.
A comparison with past surveys shows a substantial loss of public confidence in the Canadian health care system over the past decade -- far more than in the other countries studied. [See Figure II .]
- In 1988, 56 percent of Canadians said their system needed only minor changes.
- By 1998, only 20 percent of Canadians still said the system needed only minor changes.
In each country, people who needed to see a specialist during the year were asked whether they had difficulty doing so. In Canada, 16 percent said it was "extremely or very difficult" and another 30 percent reported it was "somewhat difficult"; in the United States 15 percent and 24 percent; in Australia 14 percent and 21 percent; in New Zealand 17 percent and 18 percent; and in the United Kingdom 10 percent and 19 percent.
Nine to 11 percent of people in all five countries who were hospitalized said their "overall hospital experience" was "poor."
Why So Much Dissatisfaction? How can people from so many different systems be so universally unhappy with their own national approaches to health care financing and delivery? Despite superficial differences in the financing systems among the countries, the fundamental system is the same. In all five nations, the population has been told, "When it comes to health care, you may have anything you want for free or nearly so." In all five, somebody other than the patient is paying the bill -- an employer, an insurance company, the government or a combination. In all five, there is a disconnect between the consumer of services and the payer of the bill.
The consumer--patient has been told that he or she has a right or an entitlement to the best care possible, whenever and wherever he or she may want it. In all five nations, the payer knows this is untrue but has not had the political courage to tell the truth -- that there is a limited amount of money to spend on health care, and when the money runs out, there is no health care unless the patient wants to pay for it personally.
Instead, all five countries try to stretch their funds by controlling the supply of services. They try to prevent patients from receiving the services they desire by limiting the number of providers, rationing the quantity of services allowed, creating waiting lists of patients or denying care outright.
But people know when services are being withheld, and they resent that someone else is deciding what they may and may not have -- especially when that same someone has promised to provide everything for free.
Facing the Facts. Considering the dissatisfaction of citizens, perhaps it is time for our health care systems to be honest and tell people, "Our system has limited resources for health care. We will try to allocate those funds fairly, but if you want more you will have to pay for it yourselves." People would then be free to make their own judgments about what is and is not important to them and to allocate their own funds. Instead of withholding available services, the countries could work on the demand side of the equation.
The United States could take a number of actions to develop the demand side of cost controls. Creating Medical Savings Accounts was an important step in that direction, and others should follow. Among them are individual choice and ownership of health plans; defined contributions or vouchers from employers and government payers; replacement of the current tax exclusion with a refundable tax credit; and reform of the insurance market, which would allow non--employees to form groups and would support a wide choice of benefits.
Such measures would allow health care consumers to seize control of their own health care resources and decide for themselves how to spend the resources. The approximately 80 percent who want "fundamental change" and "complete rebuilding" appear to be seeking just that. They want to be treated as adults capable of making their own decisions about health care.
This Brief Analysis is based on a speech by Greg Scandlen, a fellow in health policy at the Cato Institute, to the House of Delegates of the American Medical Association on December 6, 1999.