Managing health care quality

When the murderous attacks on America have been dealt with – and they will be – the country can return again to arguing with more common sense, we hope, over more mundane issues like health-care quality.

But these arguments will never be the same again. The recent attacks on the American homeland demonstrate that the federal government has been disastrously distracted from its primary duties, such as national defense, as spelled out by common sense and in the U.S. Constitution.

The energy and resources of the federal government would be best redirected to these primary concerns and away from alluring mirages, such as the “single-payer” medical-care vision. People in need of such governmental control, for example, foreign aliens living or visiting this country from countries and cultures hostile to American values should be the focus of government power – not the individual freedoms, needs and desires of almost 300,000,000 Americans.

In recent years, some caring – and apparently well-meaning – physicians and organizations have been promoting a government-managed, “single-payer” health-care system.

“Single-payer” simply means the government pays for all medical services. This necessarily means that the government controls medical services – including who gets what services, what quality they will be and when they can receive services. To not control services would neglect the government’s duty to account for spending of the taxpayers’ money.

What would a state-run system mean to the quality of American medical services and what does “quality” in medical care really mean?

In the course of usual life, people make innumerable daily tradeoffs among quality, cost and convenience in fulfilling their needs. However, when people are insulated from the cost of health care because the government is paying the bill, value for resources expended becomes much less important. Patients want quality at any price – because someone else is paying that price – driving health care spending much higher than it would be if patients insisted on value. The range of options can decrease when one option is perceived as “free” and competing with services which are not subsidized and outside the government system.

Would a single-payer system be more efficient than our current system, as argued by proponents? They say that people would be assigned a family physician whom they can see regularly and as needed, rather than postponing needed care until they are forced to go to the more expensive emergency room. However, getting to see a family physician under a single-payer system may not be so easy.

A recent flu epidemic in Toronto increased the waiting times to see a family physician to over five weeks – so far in the future that most patients would have either rapidly succumbed, recovered from their illness and no longer needed to see a doctor, or would have become critically ill and gone to an emergency room.

In a single-payer system, the government always makes the larger decisions about funding levels, often leaving bottom feeders such as doctors, hospitals and other health care providers to make the tougher individual decisions about whose care to ration. The targets of rationing are usually the marginal and more expensive patients such as the very young, the very old and the very sick.

• In Canada, 121 patients waiting for heart bypass surgery were removed from the waiting list because their condition had worsened to the point that they could no longer survive the surgery.

• In England, some kidney patients died while dialysis machines remained idle because hospitals said they did not have the resources to keep the machines running full time.

In a single-payer system, health care budgets always end up tight after the politicians discover that they can’t raise taxes to meet the demand for services. Mid-level feeders, such as administrators and bureaucrats, often limit adoption of new medical technology because they don’t have money available. Decisions on what to buy and when to buy it are often arbitrary and guided more by politics than good medicine.

For physicians, single-payer means single employer. Many proponents for a single-payer monopoly gripe about working for corporate HMOs. Yet any single-payer system will surely resemble a huge and monopolistic HMO, without any competing services. This would look like a U.S. Postal Service without competition from UPS, FedEx, e-mail or fax machines.

The best way to expand citizens’ control over their own care is to allow more choices and options by revising the tax code so that current tax penalties on the unemployed and self-employed are equalized. Medical Savings Accounts are one such simple step in this direction.

If policy makers move toward a single-payer system that tries to impose universal coverage, they will find that citizens will be left with neither care nor quality.

---

The writers thank Merrill Mathews, Jr., Ph.D., for contributing to this commentary.