The Affordable Care Act (ACA) is failing. Without regard for consequences, the law expanded government insurance programs and imposed considerable federal authority over US health care via new mandates, regulations and taxes. Insurance premiums skyrocketed even as deductibles rose; consumer choices of insurance on state marketplaces have rapidly vanished; and for those with ACA coverage, doctor and hospital choices have narrowed dramatically. Meanwhile, consolidation across the health care sector has accelerated at a record pace, portending further harm to consumers, including higher prices of medical care.
Almost inexplicably, even more top-down control — single-payer health care, a system in which the government provides nationalized health insurance, sets all fees for medical care and pays those fees to doctors and hospitals — has found new support from the left. And this despite its decades of documented failures in other countries to provide timely, quality medical care, and in the face of similar problems in our own single-payer Veterans Affairs system.
Clearly, this moment cries out for the truth about single-payer health care — conclusions from historical evidence and data.
Single-payer health care is proven to be consistently plagued by these characteristics:
Massive waiting lists and dangerous delays for medical appointments
In those countries with the longest experience of single-payer government insurance, published data demonstrates massive waiting lists and unconscionable delays that are unheard of in the United States. In England alone, approximately 3.9 million patients are on NHS waiting lists; over 362,000 patients waited longer than 18 weeks for hospital treatment in March 2017, an increase of almost 64,000 on the previous year; and 95,252 have been waiting more than six months for treatment — all after already waiting for and receiving initial diagnosis and referral.
In Canada’s single-payer system, the 2016 median wait for a referral from a general practitioner appointment to the specialist appointment was 9.4 weeks; when added to the median wait of 10.6 weeks from specialist to first treatment, the median wait after seeing a doctor to start treatment was 20 weeks, or about 4.5 months.
Ironically, US media outrage was widespread when pre-ACA 2009 data showed that time-to-appointment for Americans averaged 20.5 days for five common specialties. That selective reporting failed to note that those waits were for healthy check-ups in almost all cases, by definition the lowest medical priority. Even for simple physical exams and purely elective, routine appointments, US wait times before ACA were shorter than for seriously ill patients in countries with nationalized, single-payer insurance.
Life-threatening delays for treatment, even for patients requiring urgent cancer treatment or critical brain surgery
Those same insured patients in single-payer systems are dying while waiting for the most critical care, including those referred by doctors for “urgent treatment” for already diagnosed cancer (almost 19% wait more than two months) and brain surgery (17% wait more than four months). In Canada’s single-payer system, the median wait for neurosurgery after already seeing the doctor was a shocking 46.9 weeks — about 10 months. And in Canada, if you needed life-changing orthopedic surgery, like hip or knee replacement, you would wait a startling 38 weeks — about the same time it takes from fertilization to a full-term human life.
Delayed availability of life-saving drugs
Americans enjoy the world’s quickest access to the newest prescription drugs, in stark contrast to patients in single-payer systems. In Joshua Cohen’s 2006 study of patient access to 71 drugs, between 1999 and 2005 the UK government’s guidelines board, NICE, had been slower than the United States to authorize 64 of these. Before the ACA, the United States was by far the most frequent country where new cancer drugs were first launched — by a factor of at least four — compared to any country studied in the previous decade, including Germany, Japan, Switzerland, France, Canada, Italy and the UK, according to the Annals of Oncology in 2007.
In a 2011 Health Affairs study, of 35 new cancer drugs submitted from 2000-2011, the US Food and Drug Administration (FDA) had approved 32 while the European Medicines Agency (EMA) approved only 26. Median time to approval in the United States was about half of that in Europe. All 23 drugs approved by both were available to US patients first. Even in the most recent data, two-thirds of the novel drugs approved in 2015 (29 of 45, 64%) were approved in the United States before any other country. And yet, only months ago, NHS in England introduced a new “Budget Impact Test” to cap drug prices, a measure that is specifically designed to further restrict drug access even though the delays will break their own NHS Constitution pledges to its citizens.
Worse availability of screening tests
Despite what some might suppose about a likely strength of a government-centralized system, the facts show that single-payer systems cannot even outperform our system in something as scheduled and routine as cancer screening tests. Confirming numerous prior OECD studies, a Health Affairs study reported in 2009, before any Affordable Care Act screening requirements, that the United States had superior screening rates to all 10 European countries with nationalized systems for all cancers. Likewise, the single payer system of Canada fails to deliver screening tests for the most common cancers as broadly as the US system, including PAP smears and colonoscopies. And Americans are more likely to be screened younger for cancer than in Europe, when the expected benefit is greatest. Not surprisingly, US patients have had less advanced disease at diagnosis than in Europe for almost all cancers.
Significantly worse outcomes from serious diseases
It might be said that the bottom line about a health care system is the data on outcomes from treatable illnesses. To no one’s surprise, the consequences of delayed access to medications, diagnosis and treatment are significantly worse outcomes from virtually all serious diseases, including cancer, heart disease, stroke, high blood pressure and diabetes compared to Americans.
And while some studies have noted that Canadians and Germans, for example, have longer life expectancies and lower infant mortality rates than Americans do, they are misleading. Those statistics are extremely coarse and depend on a wide array of complex inputs having little to do with health care, including differences in lifestyle (smoking, obesity, hygiene, safe sex), population heterogeneity, environmental conditions, incidence of suicide and homicide and even differences in what counts as a live birth.
The truth is that the UK, Canada and other European countries for decades have used wait lists for surgery, diagnostic procedures and doctor appointments specifically as a means of rationing care. And long waits for needed care are not simply inconvenient. Research (for example, here) has consistently shown that waiting for medical care has serious consequences, including pain and suffering, worse medical outcomes and significant costs to individuals in foregone wages and to the overall economy. In contrast to countries with single-payer health systems, it is broadly acknowledged that “waiting lists are not a feature in the United States” for medical care, as stated by Dr. Sharon Wilcox in her study comparing strategies to measure and reduce this important failure of centralized health systems.
What has been the response to the public outcry about unacceptable waits for care in single-payer systems? First, a growing list of European governments have issued dozens of “guarantees” with intentionally lax targets, and even those targets continue to be missed. Second, many single-payer systems now funnel taxpayer money to private care to solve their systems’ inadequacies, just as we now do in our own Veteran Affairs system, and even use taxpayer money for care in other countries.
Instead of judging health system reforms by the number of people classified as “insured,” reforms should focus on making excellent medical care more broadly available and affordable without restricting its use or creating obstacles to future innovation. Reducing the cost of medical care requires creating conditions long proven to bring down prices while improving quality: increasing the supply of medical care, stimulating competition among providers and incentivizing empowered consumers to consider price.
Single-payer systems in countries with decades of experience have been proven in numerous peer-reviewed scientific journals to be inferior to the US system in terms of both access and quality. Americans enjoy superior access to health care — whether defined by access to screening; wait-times for diagnosis, treatment, or specialists; timeliness of surgery; or availability of technology and drugs. As those countries turn to privatization to solve their systems’ failures, progressives here illogically pursue that failed model.
And make no mistake about it — America’s most vulnerable, the poor, as well as the middle class, will undoubtedly suffer the most if the system turns to single-payer health care, because they will be unable to circumvent that system.