• On a per capita basis, the United States has eight times as many magnetic resonance imaging (MRI) units " which use magnetism instead of x-rays as Canada.
• The United States has seven times as many radiation therapy units (to treat cancer) per person.
• The United States also has about six times as many lithotripsy units (to destroy kidney stones and gallstones with sound waves) per person.
• And, per capita, the United States has about three times as many open-heart surgery units and cardiac catheterization units (for the treatment of heart disease).

Note that the figures contrast the United States with Canada two years later. Contrasting the two countries in the same year would reveal an even greater disparity. While critics of the U.S health care system claim that we have too much technology, all the evidence suggests that Canada has too little - as a result of the conscious decisions of government officials. Doctors in British Columbia have taken out full-page newspaper advertisements warning that their patients’ lives are endangered by government’s refusal to purchase lifesaving medical technology.

"There are more MRI scanners in Washington state than in all of Canada."

It is easy to understand why these and other Canadian doctors are complaining. Consider what the shortage of diagnostic equipment means for patients:

• Seattle, Washington (pop. 490,000) has more computerized axial tomography (CAT) scanners (used, for example, to detect brain tumors) than the entire province of British Columbia (pop. 3 million).
• There are more MRI scanners in Washington state (pop. 4.6 million) than in all of Canada (pop. 26 million).
• The province of Newfoundland (pop. 570,000) has only one CAT scanner, causing patients who need a CAT scan to wait an average of two months.
• Prince Edward Island (pop. 128,000) has no CAT scanner, and patients who need a CAT scan must leave the province in order to obtain one.
• Because of a shortage of laboratory testing equipment in 1988, women in Newfoundland wait up to five months for a Pap smear (needed to detect cervical cancer) and two months for an "urgent" Pap smear.
• Also because of an equipment shortage, women in Newfoundland waited as long as 2 1/2 months for a mammogram (used to detect breast cancer).
• Women on Prince Edward Island wait from four to eight months for mammograms, and even "emergency" patients can wait as long as one month.

Access To Modern Medical Technology in Britain.

"The British system denies treatment to 9,000 kidney patients, and as many as 15,000 cancer and 17,000 heart patients each year."

Table II presents these estimates, along with estimates of what it would cost the NHS to bring British treatment up to U.S. standards. As Table I shows:

• Each year, about 9,000 British kidney patients fail to receive renal dialysis or a kidney transplant - and presumably die as a result.
• As many as 15,000 cancer patients and 17,000 heart patients fail to receive the best treatment modern medicine can offer.
• As many as 1,000 British children fail to receive lifesaving total parenteral nutrition (TPN) therapy and about 7,000 elderly patients are denied pain-relieving hip replacements.

Willingness to Adapt to New Technology.

"The United States adopts lifesaving medical technology more rapidly than most other countries."

During the 1970s, for example, lifesaving innovations were made in kidney dialysis, CAT scanning and pacemaker technology. Yet as Table II shows:

• The rate of implants of pacemakers in the United States during the mid-1970s was more than four times that of Britain and almost 20 times that of Canada.
• CAT scanners in the United States were more than three times as available in the United States as in Canada and almost six times as available as in Britain.
• The treatment rate of kidney patients in the United States was more than 60 percent greater than in Canada and Britain. There is considerable evidence, however, that cost-effectiveness is not what drives the bias of other governments against modern medical technology:
• CAT scan technology was invented in Britain, and until recently Britain exported (probably with government subsidies) about half the CAT scanners used in the world. Yet the British government has purchased only a handful of the devices for the National Health Service and has even discouraged private gifts of CAT scanners to the NHS.
• Britain also was the codeveloper of kidney dialysis, a lifesaving method of treating patients with chronic renal failure; yet Britain has one of the lowest dialysis rates in Europe.

One could argue that the "need" for technology varies from country to country. For example, the incidence of chronic renal failure may be higher in the United States than in other developed countries. Even if this were true, however, a comparison of Tables II and III shows that every country had substantially increased the number of patients being treated by 1984, when even East Germany was treating more patients than Britain or Canada had treated eight years earlier.

The Politics of Medical Technology.

In 1970, before a dialysis benefit was extended to the entire population under Medicare, the U.S. treatment rate for patients with renal failure was on a par with Britain’s and less than half that of Sweden and Denmark. Only after Medicare provided a virtual blank check did the U.S. treatment rate soar.

"Kidney patients who do not receive dialysis or a transplant presumably die."

How we treat kidney patients was also dictated by government reimbursement policies. Studies show that home dialysis is less expensive than dialysis in a hospital or clinic and, prior to the Medicare expansion, about 40 percent of U.S. dialysis treatment was home-based. But because Medicare gave physicians incentives to avoid home-based dialysis, the rate fell to 12 percent by 1978. There is also evidence that kidney transplants are more cost-effective (over the long run) than dialysis. But because Medicare reimbursement policy favored dialysis, the United States was 12th of 20 developed countries in the percent of kidney patients treated by transplant in 1985.

A more recent technological innovation is extracorporeal shock wave lithotripsy (ESWL) to disintegrate kidney stones and gallstones and eliminate the need for surgery. In 1989, the U.S. rate of lithotripters per capita was exceeded by rates in Germany (where ESWL was invented) and Belgium.

Overall, the best way to think about government policies toward technology is in terms of the politics of medicine. As the role of government expands, health care tends to evolve from a pro-technology phase to an antitechnology phase. In the first stage, government tends to spend on items perceived as under-provided by the market or by conventional health insurance. Thus, practically every less-developed country has used government funds to build at least one modern hospital, usually in the largest city, and to stock it with at least one example of each new technology - even though the vast majority of citizens lack basic medical care and public sanitation.

As government’s role in medicine expands, more and more interest groups must be accommodated. In this stage, government policy tends to be antitechnology because the small number of people who need the technology are so heavily outnumbered. Along the way, these general trends may be violated with respect to any particular technology because of the varied, even random, ways in which special interest pressures are exerted. We analyze the politics of medicine in more detail below.

"Because of the politics of medicine, governments have a bias against modern medical technology."

When the United States had a pure cost-plus health care system, technology tended to be adopted quickly because physicians " unconstrained by considerations of cost " found the technology useful. When the role of government was minimal, it was easier to acquire public funds where conventional insurance coverage was lacking (e.g., kidney dialysis and organ transplants). It is not surprising that the United States made great use of technological innovations.

Our experience in the future may be very different, however. In the United States we pay more for health care. We also get more. And what we get may save our lives. But increasingly, our health care system is acquiring the characteristics of the health care systems of other countries, in which access to medical technology is determined by rationing and politics.

Rationing by Waiting.

"People waiting for surgery: 25,000 in New Zealand, 250,000 in Canada and more than one million in Britain."

By U.S. standards, one of the cruelest aspects of government-run health care systems is the degree to which these systems engage in non-price rationing. Take the health care systems of Britain and New Zealand, for example. In both countries, hospital services are completely paid by government. Both also have long waiting lists for hospital surgery:

• In Britain, with a population of about 57 million, the number of people waiting for surgery is more than one million.
• In New Zealand, with a population of about three million, the waiting list is more than 50,000.
• In Canada, with a population of about 25 million, the waiting list is more than 250,000.

"Patients can wait in pain or discomfort for years, and the wait for many is risking their lives."

"Canadians wait as long as five months for a Pap smear, eight months for a mammogram and a year and four months for an MRI scan."

In Britain and New Zealand, elderly patients in need of a hip replacement can wait in pain for years, and those awaiting heart surgery often are at risk of their lives. Perhaps because Canada has had a national health care program for only half as long, the rationing problems are not as great as they are in Britain and New Zealand, although all three countries have similar cultures. But because the demand for health care has proved insatiable, and because Canadian provincial governments severely limit hospital budgets, the waiting lines for surgery and diagnostic tests are growing:

• As Table IV and Figure II show, patients in British Columbia wait up to a year for routine procedures such as cholecystectomies, prostatectomies, hip replacements and surgery for hemorrhoids and varicose veins.
• In Ontario, patients wait up to six months for a CAT scan, up to a year for eye surgery and orthopedic surgery, up to a year and four months for an MRI scan and up to two years for lithotripsy treatment.
• All over Canada, patients wait for coronary bypass surgery, while the Canadian press tells of heart patients dying on the waiting list.