1. See Patricia Day and Rudolf Klein, "Britain's Health Care Experiment." Health Affairs, Fall 1991, pp. 39-59; and Alain C. Enthoven, "Internal Market Reform of the British Health Service,: Health Affairs, Fall 1991, pp. 60-70.

  2. Jeremy W. Hurst, "Reforming Health Care in Seven European Nations." Health Affairs, Fall 1991, pp. 18-19.

  3. Ibid., p. 18.

  4. A blueprint for the reforms maybe found in Patricia Danzon and Susan Begg, Options For Health Care in New Zealand (Wellington: New Zealand Business Roundtable, 1991).

  5. For general changes in Europe, seethe discussion in Bengt Jonsson, "What Can Americans Learn From Europeans?", Symposium: International Comparisons of Health Care Systems, Health Care Financing Review, Annual Supplement, 1989, pp. 79-93.

  6. See Clyde H. Farnsworth, "Economic Woes Force Canada to Reexamine Medical System," New York Times, November 24, 1991; and Edward Neuschler, Canadian Health Care: The Implications of Public Health Insurance (Washington, DC: Health Insurance Association of America, 1989), p.52.

  7. See Diane Rowland and Alexandre V. Telyrikov, "Soviet Health Care From Two Perspectives, " Health Affair, Fall 1991, pp. 71-86.

  8. For a description of Chile's health care reforms, see John C. Goodman and Peter A. Ferrara, "Private Alternatives to Social Security in Other Countries," National Center for Policy Analysis, NCPA Policy Report No. 132, April 1987; and Tarsicio Castaneda, "The Chilean Health System: Organization, Operation and Financing," in Health Economics: Latin American Perspectives (Washington, CD: Pan American Health Organization, 1989), pp. 3-25.

  9. The regression equation is: HEXP = -5.99 + 1.36 GDP (R = .89) (-5.6) (11.9)

    Where HEXP is the logarithm of per capita health care spending, GDP is the logarithm of per capita gross domestic product, and the numbers in parenthesis are t values. The U.S. figure falls near the upper bound of a 95 percent confidence interval. Figures for the higher-income countries, such as Denmark, Luxembourg and Norway fall closer to the lower bound, possibly because of underreporting of certain types of expenditures, such as nursing home care. See Bengt Jonsson, "What Can Americans Learn from Europeans?", p. 83.

  10. The analysis that follows is based on Neuschler, Canadian Health Care, pp. 37-53. For a critique of this approach see Morris L. Barer, W. Pete Welch and Laurie Antioch, "Canadian/U.S. Health Care: Reflections on the H IAA's Analysis," Health Affairs, Fall 1991, pp. 229-236.

  11. Ibid.

  12. Ibid.

  13. Jacques Krasny, The Canadian Health Care System in Perspective (Morristown, NJ: Bogart Delafield Ferrier, Inc., 1989) and Jacques Krasny and Ian R. Ferrier, "A Closer Look at Health Care in Canada," Health Affairs, Summer 1991, pp. 152-158. See, however, a critique of this approach in Daniel R. Waldo and Sally T. Sonnefeld, "U.S./Canadian Health Spending: Methods and Assumptions," Health Affairs, Summer 1991, pp. 159-164.

  14. Leroy L. Schwartz, "The Medical Cost of America's Social Ills," Wall Street Journal, June 24,1991. See also Spencer Rich, "Tracing Medical Costs to Social Problems," Washington Post, August 28,1991.

  15. See the discussion in Neuschler, Canadian Health Care, p. 50.

  16. This section is based on Dale A. Rublee and Markus Schneider, "International Health Spending: Comparisons With the OECD," Health Affairs, Fall 1991, pp. 187-198. See, however, a critique of this approach in George J. Schieber and Jean-Pierre Poullier, "Advancing the Debate on International Spending Comparisons," Health Affairs, Fall 1991, pp. 199-201.

  17. Finn Diderichsen, "Health and Social Inequities in Sweden," Social Science and Medicine, 1990, Vol. 31, No. 3, Table IV, p. 363.

  18. Per Maseide, "Health and Social Inequities in Norway," Social Science and Medicine, Vol. 31, No. 3,1990, pp. 331-342.

  19. Maseide, "Health and Social Inequities in Norway," Table 1, p.333.

  20. Michael Walker (Fraser Institute), "Why Canada's Health Care System Is No Cure for America's Ills," Heritage Foundation Backgrounder, November 13,1989, pp. 7-8.

  21. The treatment for patients with chronic renal failure and the use of CAT scanners continued its rise in virtually every country throughout the 1980s – an acknowledgment of the medical value of these innovations. Some have argued that the U.S. went too far in its use of pacemaker implants, however.

  22. See John C. Goodman, National Health Care in Great Britain (Dallas: Fisher Institute, 1980), pp. 96-104.

  23. Jonsson, "What Can Americans Learn From Europeans?", Table 8, p. 88.

  24. Ibid., pp. 88-89.

  25. lbid., Table 10, p. 89.

  26. See John C. Goodman and Gerald L. Musgrave, Patient Power: Solving America's Health Care Crisis (Washington, DC: Cato Institute, forthcoming).

  27. Day and Klein, "Britain's Health Care Experiment," p. 43. For discussion of British hospital rationing, see Goodman, National Health Care in Great Britain, ch. 6. Enoch Powell, former Minister of Health, has argued that waiting lines are inevitable under the NHS, regardless of the resources devoted to health care. See Enoch Powell, Medicine and Politics, 1975 and After (New York: Pitman, 1976).

  28. For an analysis of the waiting list in New Zealand, see Choices for Health Care: Report of the Health Benefits Review (Wellington: Health Benefits Review Committee, 1986), pp. 78-79.

  29. Estimate of the Fraser Institute (Vancouver) based on sampling in five Canadian Provinces.

  30. Hospital admissions as a percent of the total population average 16.1 percent for all OECD countries. The figures are 15.9 percent for the United Kingdom, 13 percent for New Zealand and 14.5 percent for Canada. See Schieber et al., "Health Systems in Twenty-four Countries," Exhibit 4, p.27.

  31. Health insurance industry officials in the United States report that about 4 percent of the population consumes about 50 percent of health care costs. See Blue Cross/Blue Shield, Reforming the Small Group Health Insurance Market (Chicago: BC/BS, 1991), p. 6.

  32. For example, in Ontario in 1989 the number of people waiting for open-heart surgery equaled more than 25 percent of the total surgeries performed. Because of special efforts to reduce the waiting lists, Ontario achieved a rate of one person waiting for every seven surgeries by January 1991. See C. David Naylor, "A Different View of Queues in Ontario," Health Affairs, Fall 1991, pp. 115­116.

  33. Danzon and Begg. Options for Health Care in New Zealand, Table 2-3, p. 26.

  34. General Accounting Office, Canadian Health Insurance: Lessons for the United States, June 1991, Table 4. 1, p. 55.

  35. See, for example, Joan Breckenridge, "Grief, Frustration Left in Wake Of Man Who Died on Waiting List," Globe and Mail (Ontario), January 25, 1989.

  36. For Britain, see the discussion in Enthoven, "Internal Market Reform of the British Health Service." A Canadian observer reports that "Ontario hospitals lag at least a decade behind their U. S. counterparts in expenditure tracking and management information systems. "See Naylor, "A Different View of Queues in Ontario, "p.112.

  37. Enthoven, "Internal Market Reform of the British Health Service," p. 62

  38. For New Zealand, estimate of the New Zealand Department of Health. OECD Statistics show an occupancy rate of 74.8 percent for New Zealand in 1983 and 83.3 percent for Canada. See Organization for Economic Cooperation and Development, Financing and Delivering Health Care (Paris: OECD, 1987), Table 29, p. 67. The most recent OECD statistics are expected to show an occupancy rate of 80.3 percent for acute care hospitals and 82.7 percent for all hospitals in Canada for 1987. See George J. Schieber et al.. "Health Care Systems in Twenty-four Countries," Exhibits 4 and 5, pp. 27.29.

  39. Hospital occupancy rates are 74 percent for acute beds and 82 percent for all beds. See Office of Health Economics, Compendium of Health Statistics: 7th Edition, 1989 (London: OHE, 1989) section 3, p. 39. The most recent OECD statistics are expected to show an occupancy rate of 76.4 percent for acute care hospitals and 80.6 percent for all hospitals in 1986. See Schieber et al.. "Health Care Systems in Twenty-four Countries," Exhibits 4 and 5, pp'. 27, 29.

  40. In Canada, the latest estimate is 23 percent. See Neuschler, Canadian Health Care, p.18.

  41. See Rosie DiManno, "Hard Choices Facing Health Care System," Toronto Star, January 28,1989; "Ceiling System Needs Radical Surgery." (Sunday) Toronto Star, March 27,1988; and Robert G. Evans et al., "Controlling Health Expenditures: The Canadian Reality." New England Journal of Medicine, Vol: 320, No. 9, March 2. 1989, p. 5

  42. For an analysis of international length of stay statistics, see Rita Ricardo-Campbell, The Economics and Politics of Health (Chapel Hill, NC: University of North Carolina Press, 1982), Table 3, p.85: and Cotton M. Lindsay et al., National Health Issues: The British Experience (Nutley, NJ: Hoffmann-LaRoche, Inc., 1980), pp. 74-78.

  43. See the discussion in Schieber et al., "Health Care Systems in Twenty-four Countries," pp. 28-30.

  44. Quoted in Economic Models, Ltd., The British Health Care System (Chicago: American Medical Association, 1976),p.33.

  45. Quoted in Harry Swartz, "The Infirmity of British Medicine," in Emmett Tyrrell, Jr., ed., The Future That Doesn't Work: Social Democracy's Failures in Britain (New York: Doubleday, 1977), p. 24.

  46. British Medical Journal, December 12,1942, p. 700.

  47. Aneurin Bevan, In Place of Fear (London: Heinemann, 1952), p.76.

  48. Inequalities in Health (Black report), (London: Department of Health and Social Security, 1980).

  49. See Julian LeFrand, "The Distribution of Public Expenditure: The Case of Health Care," Economica, Vol. 45, No. 178, 1978: Anthony J. Culyer, Need and the National Health Service (Totowa, NJ: Rowman and Lettlefield, 1976); Michael H. Cooper, Rationing Health Care (New York: Halstead Press, 1975); Michael H. Cooper and Anthony J. Culyer, "Equality in the N.H.S.: Intentions, Performance and Problems in Evaluation," in M. M. Houser, ed., The Economics of Medical Care (London: Allen and Unwin, 1972); J. Noyce, A. A. Snaith and A. J. Trickey, "Regional Variations in the Allocation of Financial Resources to the Community Health Services," The Lancet, March 30,1974; and Goodman, National Health Care in Great Britain, ch. 9. For a recent update on government failures to make any progress in achieving equality of access to health care, see "Dying of Inequality," The Economist, April 4,1987, p. 52.

  50. Noyce, Snaith and Trickey, "Regional Variations in the Allocation of Financial Resources to the Community Health Service," Table III, p. 556.

  51. Julian LeGrand, "The Distribution of Public Expenditure: The Case of Health Care," Economica, Vol. 45, No. 178, May 1978.

  52. See Ingemar Stahl, "Can Equity and Efficiency Be Combined: The Experience of the Planned Swedish Health Care System," in Mancur Olson, ed., A New Approach to the Economics of Health Care (Washington, DC: American Enterprise Institute, 1981), pp. 187-190.

  53. Cotton M. Lindsay, Canadian National Health Insurance: Lessons for the United States (Nutley, NJ: Hoffmann-LaRoche, 1979).

  54. Choices for Health Care, pp. 19-22.

  55. General Office of Accounting, Canadian Health Insurance, pp. 53 ff.

  56. Areview of the hospital records of open-heart surgery patients in Toronto found that while physicians generally assign sensible priorities, there were "many instances of relatively short waits for elective cases while more urgent cases waited inappropriately long periods of time." See Naylor, "A Different View of Queues in Ontario," p.121.

  57. Public Health in the Provinces," p. 14.

  58. Walker, "Why Canada's Health Care System Is No Cure for America's Ills," p. 9.

  59. Robert J. Blendon and Humphrey Taylor, "Views on Health Care: Public Opinion in Three Nations," Health Affairs, Sprint 1989, p.156.

  60. Ibid.

  61. Day and Klein, "Britain's Health Care Experiment," pp. 43-44.

  62. Choices for Health Care, p. 75.

  63. Neuschler, Canadian Health Care, pp. 17-18 and p. 20.

  64. Ibid.

  65. DiManno, "Hard Choices Facing Health Care System."

  66. Tracey Tyler, "Frustrated Heart Patients Head to Ohio For Surgery," Toronto Star, January 22.1989.

  67. Neuschler, Canadian Health Care, p. 50.

  68. Ibid.

  69. John K. Iglehart, "Canada's Health Care System Faces Its Problems," New England Journal of Medicine, Vol 322, No. 8, p. 566.

  70. Milan Korcak, "US Cash Registers Humming as Canadian Patients Flock South," Canadian Medical Association Journal, Vol. 144, No. 6, February 1991, pp. 745-747.

  71. David Caplan, letter to the editor of New England Journal of Medicine (July 13,1989), p.115. Reprinted in the House Wednesday Group, "Public Health in the Provinces," September 22,1989, p.12.

  72. Public Health in the Provinces," p. 14.

  73. "The Crisis in Health Care: Sick to Death," Macleans, February 13, 1989, p. 32.

  74. Walker, "Why Canada's Health Care System is No Cure for America's Ills," p. 9.

  75. "Canadians Cross Border to Save Their Lives," Wall Street Journal, December 12,1990 - Cited in Michael Tanner, "Canadian Health Care in American: Prescription for Disaster," American Legislative Exchange Council, State Factor, Vol. 17, No. 8. June 1991,p.1.

  76. Ottawa Citizen, February 4, 1989. Cited in "Public Health in the Provinces." p. 15.

  77. "The Crisis in Health Care," p. 32.

  78. Ibid.

  79. Ibid.

  80. Ibid., p. 33.

  81. Globe and Mail (Ontario), May 28, 1988. Cited in Neuschler.Canadian Health Care. p.48.e2

  82. Toronto Sun, September 14.1989. Cited in Neushler, Canadian Health Care, p. 93.

  83. Edmonton Journal,January 6, 1990. Cited in Neuschler, Canadian Health Care, p. 96.

  84. Winnipeg Free Press, July 5, 1989. Cited in Neuschler, Canadian Health Care, p. 94.

  85. St. John's Evening Telegram, June 28, 1989. Cited in Neuschler, Canadian Health Care, p. 94.

  86. Canadian Broadcasting Company radio show, "As It Appears," January 25,1989. Cited in Neuschler, Canadian Health Care, p. 95.

  87. Robert H. Brook, "Practice Guidelines and Practicing Medicine: Are They Compatible?", Journal of the American Medical Association, Vol. 262, No. 21, December 1, 1989, p. 3028.

  88. A summary of Rand research may be found in Mark R. Chassin, ed., The Appropriateness of Selected Medical and Surgical Procedures (Ann Arbor; Health Administration Press, 1989).

  89. George Telling Smith, Patterns of Prescribing (London: Office of Health Economics, 1991).

  90. Office of Health Economics, "Variations Between General Practitioners." OHE Briefing, No. 26, July 1990.

  91. Brook, "Practicing Guidelines and Practicing Medicine: Are They Incompatible?", p. 3021.

  92. See, for example, Adam L. Linton, "Guidelines for Medical Practice: The Reasons Why," Canadian Medical Association Journal, Vol. 143, No. 6. pp. 485-490.

  93. For example, one study claimed that administrative costs in the United States were between 19.3 percent and 24.1 percent of total health care spending and accounted for more than half the difference in cost between the U. S. and Canadian systems. See Steffie Woolhandler and David Himmelstein, "The Deteriorating Administrative Efficiency of the U. S. Health Care System," New England Journal of Medicine, Vol. 324, No. 18, May 2,1991, pp. 1253-1258. See also a critique of the study's methodology by the Health Insurance Association of America in Medical Benefits, Vol. 8, No. 10, May 30, 1991, p. 5. In another study, a national health insurance advocacy group, Citizen Fund. claimed that 33.5 cents of every dollar spent by private health insurance was for overhead expenses. See Richard Koenig. "Insurers' Overhead Dwarfs Medicare's," Wall Street Journal, November 15, 1990. The results of other studies are reviewed below.

  94. E. S. Savas. "How Much Do Government Services Really Cost?" Urban Affairs Quarterly, September 1979, p. 24.

  95. See John C. Goodman, Gary Robbins and Aldona Robbins, Employee Benefits Law: The Case for Radical Reform," National Center for Policy Analysis, NC PA Policy Report No. 147, March 1990.

  96. American Medical Association Center for Health Policy Research, "The Administrative Burden of Health Insurance on Physicians," SMS Report, Vol. 3, No. 2. 1989.

  97. See the description in Goodman and Ferrara, "Private Alternatives to Social Security in Other Countries."

  98. See John C. Goodman and Gerald L. Musgrave, "Controlling Health Care Costs With Medical Savings Accounts." National Center for Policy Analysis. forthcoming.

  99. See Burt Sims, "Cutting Health Care Costs: A Major Breakthrough," US Business to Business, Winter 1991.

  100. Currently, there are three competing technologies: magnetic striped cards, smart cards (with integrated circuits) and optical memory ;laser) cards. See C. Peter Waegemann, "Patient Cards – The Promise of the Future?". Medical Practice Management, Spring 1990, pp. 264-268.

  101. Ibid., p. 264.

  102. For critiques of these estimates, see 'GAO Report on Canadian Health Care Tainted by Charges of Partisanship," Health Benefits Letter, Vol. 1, No. 16, September 18, 1991; and the letters to the editor in the New England Journal of Medicine. Vol. 325. No. 18. pp. 1316-1319.

  103. End-Stage Renal Failure (London: Office of Health Economics, 1980), pp. 3 and 6.

  104. See G. M. Anderson, J. P. Newhouse and L. L. Roos, "Hospital Care for Elderly Patients with Diseases of the Circulatory System: A Comparison of Hospital Use in the United States and Canada," New England Journal of Medicine, Vol. 321, 1989, pp. 1443-1448: and the discussion in Naylor, "A Different View of Queues in Ontario," pp. 117-118.

  105. Jack A. Meyer and Marion E. Lewin, "Introduction," in Meyer and Lewin, eds., Charting The Future of Health Care (Washington, DC: American Enterprise Institute. 1987), p.5.

  106. Schieber et al., "Health Care Systems in Twenty-four Countries," pp. 36-37.

  107. See Walter Williams, "Legislating Black Unemployment." National Center for Policy Analysis, NCPA Policy Report No. 112. July 1984.

  108. Associated Press, May 20, 1989.

  109. Reported in the Dallas Morning News, August 19, 1990.

  110. Phillip J. Held, Ph.D. et al., "Access to Kidney Transplantation: Has the United States Eliminated Income and Racial Differences?", Archives of Internal Medicine, Vol. 148, December 1988, pp. 2594-2600. A possible reason for the discrepancy is Medicare reimbursement policies, which place greater burdens on lower-income patients. Prior to 1987 (the period covered by the study), Medicare did not pay for outpatient drugs such as cyclosporine – which can cost transplant patients up to $5,000 per year. It would be irrational to spend $50,000 on a transplant and have it rejected because the patient could not afford $5,000 in medication. Currently, Medicare pays for 80 percent of immunosuppressive drugs for one year.

  111. Jean-Pierre Thorrez, Peter Foggin and Andre Rannou, "Correlates of Health Care Use: Inuit and Cree of Northern Quebec," Social Science and Medicine. Vol. 30, No. 1, pp. 25-34.

  112. Canadian average life expectancy is for 1982.

  113. Malcolm Anderson and Mark W. Rosenberg, "Ontario's Underserviced Area Program Revisited: An Indirect Analysis," Social Science and Medicine, Vol. 30, No. 1, pp. 35-44.

  114. Ibid., p. 43.

  115. E. W. Pomare, "Groups with Special Health Care Needs," New Zealand Medical Journal, October 26, 1988, pp. 711-713.

  116. Ibid.

  117. Maseide, "Health and Social Inequities in Norway," p. 331.

  118. Office of Health Economics. Compendium of Health Statistics, 7th Edition, 1989, Table 3.36(a), p. 49.

  119. See John C. Goodman and Gerald L. Musgrave, "National Health Insurance and Rural Health Care," National Center for Policy Analysis, NCPA Policy Report No. 107, October 1991.

  120. Lajos Csaszi, "Interpreting Inequalities in the Hungarian Health System," Social Science and Medicine, Vol. 31, No. 3, p. 280.

  121. Naoki Ikegami, "Japanese Health Care: Low Cost Through Regulated Fees." Health Affairs, Fall 1991, p.104.

  122. "Dying of Inequality." The Economist. April 4, 1987, p. 52.

  123. Anderson and Rosenberg, "Ontario's Underserviced Area Program Revisited," Table 1, p. 37 and Table 4, p. 39. Statistics are for 1985-86.

  124. Arminee Kazanjian et al.. Fee Practice Medical Expenditures Per Capita and Full-Time Equivalent Physicians in British Columbia. 1987-88 (Vancouver: University of British Columbia, 1989), pp. 121-176.

  125. Ibid.

  126. Kwiko and Rodriguez Neto, "Brazil," The International Handbook of Health Care Systems.

  127. In Brazil, about 75 percent of hospital beds are in private institutions, although the public sector pays for most hospital care. In Venezuela, public sector care is provided only in public hospitals.

  128. Jesus E. Rodriguez and Carlos Sabino, Social Security in Venezuela (Caracas: Cedice). forthcoming.

  129. Joseph Bastien, "Community Health Workers in Bolivia: Adapting to Traditional Roles in the Andean Community," Social Science and Medicine, Vol. 30. No. 3,1990, pp. 281-287.

  130. Kenyon Rainier Stebbins, "Curative Medicine, Preventative Medicine, and Health Status: The Influence of Politics on Health Status," Social Science and Medicine. Vol. 23, No. 2, 1986, pp. 139-148.

  131. See Edmund Wnuk-Lipinski and Raymond Illsley, "International Comparative Analysis: Main Findings and Conclusions." Social Science and Medicine. Vol. 31, No. 8, pp. 879-889.

  132. Ibid., p. 884. See also Elena Mezentseva and Natalia Rimachevskaya, "The Soviet Country Profile: Health of the U.S.S.R. Population in the 70s and 80s: An Approach to a Comprehensive Analysis," Social Science and Medicine, Vol. 31, No. 8, pp. 867­877.

  133. Aldona Robbins and Gary Robbins, "What a Canadian-style Health Care System Would Cost U.S. Employers and Employees." National Center for Policy Analysis, NCPA Policy Report No. 145, February 1990.

  134. Ibid.

  135. Ibid.

  136. See Robbins and Robbins, "What a Canadian-style Health Care System Would Cost U.S. Employers and Employees", pp. 20­22.

  137. See Uwe Reinhardt, "Health Care Spending and American Competitiveness," Health Affairs, Winter 1989, pp. 5-21.

  138. These and other statistics in this section are taken from Department of Health an Social Security, Health and Personal Social Services for England, 1985 and 1991 editions (London: Her Majesty's Stationery Office, 1985 and 1991).

  139. New charges for these services were introduced in the spring of 1989, however.

  140. See John C. Goodman, "The Envy of the World?", in Arthur Seldon, ed., The Litmus papers: A National Health Disservice(London: Centre for Policy Studies, 1980), pp. 125-132; and Goodman, National Health Care in Great Britain, pp. 192-196.

  141. General Accounting Office, Canadian Health Insurance, p. 38.

  142. Neuschler, Canadian Health Care, p.18.

  143. Michael Walker, "Neighborly Advice on Health Care," Wall Street Journal,June 8, 1988. Cited in Neuschler, Canadian Health Care, p. 51.

  144. See Louise B. Russell, Is Prevention Better Than Cure? (Washington, DC: Brookings Institution, 1986).

  145. Goodman, National Health Care in Great Britain, pp. 55-87.

  146. Ibid., p. 70.

  147. Cooper, Rationing Health Care, p.13.

  148. See Patterns of Prescribing, pp. 21-22.

  149. Elizabeth Rosenthal, "In Canada, A Government System That Provides Health Care to All," New York Times, April 30,1991.

  150. International Journal of Epidemiology, November/December, 1990.

  151. Jon Gabel, Howard Cohen and Steven Fink, "Americans' Views on Health Care: Foolish Inconsistencies?", Health Affairs, Spring 1989, p.111.

  152. Blendon and Taylor, "Views on Health Care: Public Opinion in Three Nations," p.153.

  153. Gabel et al., "Americans' Views on Health Care: Foolish Inconsistencies?", p.110.

  154. Ibid., pp. 109-110.

  155. Ibid., p. 112.

  156. Ibid., p. 114.

  157. See the discussion in Jonsson, "What Can Americans Learn from Europeans?", pp.84-86.