Myth #5

In Countries With National Health Insurance, All People Have Equal Access To Health Care.

Table 6

One of the most surprising features of European health care systems is the enormous amount of attention given to the notion of equality and the importance of achieving it. Aneurin Bevan, father of the NHS, declared that "everyone should be treated alike in the matter of medical care." [44] The Beveridge Report, a blueprint for the NHS, promised "a health service providing full preventive and curative treatment of every kind for every citizen without exceptions." [45] The British Medical Joumal predicted that the NHS would be "a 100 percent service for 100 percent of the population." [46]

The goal of NHS founders was to eliminate inequalities in health care based on age, sex, occupation, geographical location and – most importantly – income and social class. As Bevan put it, "the essence of a satisfactory health service is that rich and poor are treated alike, that poverty is not a disability and wealth is not advantaged." [47] Similar statements have been made by politicians in virtually every country that has established a national health insurance program.

Inequality in Britain.

Such rhetoric rarely relates to the facts. Britain's ministers of health have long assured Britons that they were leaving no stone unturned in a relentless quest to root out and eliminate inequalities in health care. But, although an unofficial government campaign tried to suppress it, an official task force report (the Black report) concluded that there was little evidence of more equal access to health care in Britain in 1980 than when the NHS was started in 1948. [48] Virtually every scholarly study of the issue has pointed to a similar conclusion. [49] For example­

  • One study of health care spending across geographical areas of England found no relationship between any measure of medical need and the amount spent. [50]

  • Another study found that people in Britain's highest social class received 40 percent more medical care (in relation to their need for it) than people in Britain's lowest social class. [51]

Other studies have documented widespread inequalities in health care in Sweden, [52] Canada, [53] New Zealand [54] and elsewhere. For example, New Zealand's health care system is virtually identical to Britain's and the goal of equal access to health care ranks just as high. Yet as Table VI shows:

  • Among the geographical regions of New Zealand, spending on health care per person varies by a factor of almost two to one.

  • Surgeries per capita vary by a factor of more than six to one, doctors per occupied bed by almost six to one and the number of patients waiting for surgery by almost two to one.

Inequality in Canada.

Canada is another country that puts a high premium on equality of access to medical care. if the official rhetoric is to be believed. How well have the Canadians done? Table VII compares the amount of spending on the service of physician specialists for two areas in British Columbia: Vancouver, the largest city with a population in excess of one million, and Peace River, a rural area of about 51,000. As the table shows:

  • Residents of Vancouver receive about three times more specialist services per person than residents of Peace River, and this inequality holds for both males and females across all age groups.

  • The differences are even more striking for specific specialties, with an eight-to­one difference in the services of internists and a 35-to-one difference in the services of psychiatrists.

One might suppose that the lower level of specialist services in Peace River would be offset by a higher level of general practitioner (GP) services. That is not the case. As Figure VII shows, Vancouver residents also enjoy about 50 percent more GP services.

Effects on Low-Income Families.

There is substantial evidence that when health care is rationed, the poor are pushed to the rear of the waiting line. In general, low-income people in almost every country see physicians less often, spend less time with them, enter the hospital less often and spend less time there – especially when the use of medical services is weighted by the incidence of illness. In Canada [55] and other countries with national health insurance. there is no national waiting list to assure that the sickest people get care first. Even in the same hospital there are instances where elective patients get surgery while those in much greater need are forced to wait. [56] Moreover, anecdotal evidence suggests that the wealthy and powerful do not wait as long as others. As one study of the Canadian system noted:

"Critics charge that those who are rich, influential, or 'connected' often 'jump the queue,' which changes Canadian health care into a two-tiersystem – precisely what the government wanted to avoid." [57]

Interestingly, among the patients who jump the queue in Canada are Americans who pay out-of-pocket for care. U.S. patients add to hospital revenues, so hospital administrators value them. Since Canadians cannot legally pay for care at a national health insurance hospital, the typical Canadian patient must wait in line. [58]

How does access to health care for low-income people in the United States compare with access in countries with national health insurance? Our poorest citizens – those on Medicaid – probably have more access to better health care than low-income citizens in any other country. Being on Medicaid usually means access to all the technology of the U.S. health care system; such technology is more available in the United States, and Medicaid will usually pay for it. Even though Medicaid rationing is becoming more prevalent, the U.S. probably has far less rationing than most other countries.

International opinion surveys show that, in the U.S., 7.5 percent of people say they do not receive needed care for financial reasons compared to only 0.6 percent in Canada and 0.1 percent in Britain. A somewhat smaller percent of people in the United States (5.1 percent), but a much larger percent in Canada (3.1 percent) and Britain (4.6 percent) say they cannot get care for nonfinancial reasons, including inability to get an appointment, unavailability of services, lack of transportation, etc. [59]

It is not clear what these responses mean. In the United States we more frequently ask people to choose between money and health care. In Britain and Canada, people more frequently must choose between health care and other (rationing) costs. We do not know if those surveyed would have obtained health care if they had perceived their medical needs as being more urgent. However, that must have been the case quite often. Two-thirds of the people in the United States who said they did not get needed care for financial reasons had health insurance. [60]

A different way of comparing the United States and Canada is to look at medical care received by income group. As Table VIII shows, the differences are not that great. Low-income Canadians make more trips to physicians, but low-income Americans are slightly more likely to spend time in a hospital.

In every country, some people slip through the social safety net. But for the most part, the United States has already achieved the goal of socialized medicine: the removal of financial barriers to health care. And, considering the rationing of medical technology in countries with national health insurance, the U.S. health care system may have gone further in removing barriers to medical care than any other country in the world.