The Waiting Game

Is there rationing by waiting under government-provided health care? Of course there is.

  • In Britain, where the government has been measuring these things for years, up to one million people are waiting to enter British hospitals; and the waiting lists are an issue in every election.
  • In Canada, where the Fraser Institute keeps the best records, people are waiting for 771,000 procedures; and the Canadian Supreme Court, after declaring such waits a violation of basic human rights, ruled that residents of Quebec can buy private care when they are denied prompt service from the government.

However, in the documentary “SiCKO,” Michael (if-you-disagree-with-me-you-must-be-on-the-drug-industry-payroll) Moore claimed there was no serious waiting problem in Canada. On CNN and his Web site, he claims there is more waiting in the United States. Source of that claim? The Commonwealth Fund. Paul (if-you-disagree-with-me-you-must-be-evil) Krugman has now joined the fray, making the same claim in the New York Times. He too cites the Commonwealth Fund.

Since our friends at Commonwealth are serious researchers, it must not be pleasant for them to see their work used as cannon fodder by people who are basically in the business of character assassination. But in a way, they have brought this on themselves. Commonwealth has no economic theory of waiting. They also have no political theory of waiting. The term economists use for testing without theory is “junk in, junk out.” At Commonwealth, they don’t test theories. They collect data. But data collection without a theory is almost as bad.

What is a theory of waiting? More than 30 years ago I proposed a theory of how governments ration health care (elements of it are reproduced in Lives at Risk).  Basically, the political incentive is to overprovide to the healthy (who have 80 percent of the votes) and underprovide to the really sick (who have 4 percent of the votes, assuming they can get to the polls and vote at all). This theory is broadly consistent with evidence collected in several Commonwealth surveys:

In Britain and Canada, it is easier to see a physician and there are more visits than in the United States.

  • However, once at the doctor’s office, Americans with real problems get more services and get more attention (almost one in three spend more than 20 minutes with the physician in the United States compared with one in five in Canada and one in 20 in Britain).
  • For more serious care, only 8 percent of patients wait more than four months for surgery in the United States, compared with more than one in three patients in Canada and 41 percent in Britain.

In making international comparisons, however, one must be careful because:

  • We basically pay doctors in the United States the same way Canada pays its doctors; as a result both countries have similar problems: no telephone or email consultations, very few electronic medical records, etc.
  • In the United States, we pay only 13 cents out of pocket every time we spend a dollar on health care (about the same as the average European country!); as a result, we ration our doctors’ time by waiting as well.
  • Almost half of our health care dollars are spent by government; and Medicare, for example, exhibits the same political pressures evident in Britain and Canada – for example, covering inexpensive items and leaving seniors exposed to catastrophic expenses.
  • Anecdotal evidence suggests that many of our Medicaid patients wait as long for specialist care and surgery as Canadians wait.

In comparing our system to others, we are mainly comparing private sector socialism to public sector socialism. For a theory (as opposed to a random accumulation of facts) of how waiting works under our system, see my “What Is Consumer-Directed Health Care?” in Health Affairs at

http://www.ncpa.org/email/hlthaff.25.w540v1.pdf.

Finally, we have a new Michael Moore site: http://sicko.ncpa.org/. At his own site, Michael invites visitors to send him health horror stories – but only about the U.S. system! To add balance, our site has horror stories about Canada, France and Britain (easily obtained from a Google search).

Comments (12)

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  1. University Update - Sicko - The Waiting Game says:

    [...] Transformers Link to Article sicko The Waiting Game » Posted at The John Goodman Health Blog on Monday, July 23, 2007 The Waiting Game Is there rationing by waiting under government-provided health care? Of course there is … from the government. However, in the documentary "SiCKO," Michael (if-you-disagree-with-me-you-must View Entire Article » [...]

  2. Jerry Kerbo says:

    When we talk about our system vs nationalized health care and attempt to compare the longer wait times to access the system in countries such as Britain and Canada; everyone tends to miss explaining why. I think we might start winning some minds over if we can explain why you have to wait in Britain. The uninformed everyday consumer sees no correlation to national health care and having to wait — they probably are just thinking we can do it better — that Britain and Canada just don;t know how to do nationalized health care. If you could include in your messaging why it is that Britain and Canada restrict access, you might make more hay.
    Thanks for listening.

  3. Stephen Gregg says:

    Don’t disagree with you. However, not sure facts and logic will dictate the outcomes. If the “right” does not move to strike a negotiated deal with the “left”, most likely the latter wins, and the nation loses.

  4. Dr. Bob says:

    How true. In the UK shortly after WWII, there were enough folks who not like the National Healht Scheme. There were also physicians who felt the same way. Theses physicians became known as the Harley Street Doctors, which was the street where their offices were located. Concierge medicine in the US is nothing more than a replication of that 1945 model, driven by free market forces. In the UK today, almost all care is delivered by PCPs. Access to specialists is restricted, and only on referral from a PCP. As you correctly state, the delays for surgery are unconscionably long, to the point where the National Health folks are importing surgeons form other EU countries to relieve some of the burdens and delays.

    And why do you think so many Canadian docs are coming to the US? The Canadian health plan runs out of money in November every year, those who can afford private care will preferable come to the US and Canadian courts have now mandated that if delays endanger a patient, they can opt for private insurance.

    The transplant surgery situation is even more frightening, but no more so that in the US. 85% of patients waiting for surgery die waiting. This is not only due to bureaucratic delay, but to the scarcity of organs. If cutting edge medicine is to continue, the entire infrastructure must be in place. Ethical concerns must be addressed which are presently sorely deficient. The discrepancy between recipients based on race or ethnicity is as much a problem (and maybe even more) of the availability of compatible organs as it is to cost concerns, short-changing minorities or intentional denial.

  5. Roger Beauchamp says:

    I think it would be better psychology to state that half of our health care dollars are controlled by the government, meaning citizens earn these dollars and the government takes them by taxation and determines how they are spent. We need to convince citizens that the vast majority have the ability to provide for their own health care needs if government would just permit them to do so.

  6. Anthony Cooper says:

    Mr. Goodman, Regarding "Moore’s polemic hardly a model for health-care reform," an article you authored that appeared in the July 29 Wisconsin State Journal. A great American, President Ronald Regean, once used the term Trust but verify when talking about negotiating with the Russians. I find myself asking the same questions while reading your article. A series of assertions are made.(In Britain about 1 million patients are waiting to admitted to hospitals at any one point in time… doctors in other countries often don’t tell their care is being rationed. Instead they say there is nothing we can do. Yet, no source is provided for this information or description offered as to the context in which such information was acquired. You extoll the virtues of typical private healthcare plans were treatment of less than 4% pf tje enrollees accounts for more than half of medical expenditures. The presumption is that those receiving care are tuly the most in need. Healthcare expenditures concentrated on a small portion of the population will bring about the best results. However, you have to go no further than the recent Tenet Health System case to realize that some runups of medical expenses are of questionable validity. Even when the need and delivery of services is valid, one has to wonder if the treatment was truly effective. Or are avalanches of medical tests and medical and drug treaments meant to mask inefficient and ineffective care? Regards, Tony Cooper

  7. Physicians in Wisconsin

    Once again an awesome post – problem is every time I read your blog more ideas are presented and I just cant keep up with it!!! However don’t for one moment stop!

  8. Evan says:

    I think the solution to the private medical problem is simple, bring back the big unions, re-create the middle class, and make sure the bulk of the population is pulling down good salaries and full time employment instead of pushing the ENTIRE ECONOMY TO PART TIME NO BENEFITS WORK. Then I will pay money out of pocket for health care.

    And just as a personal note, I avoid going to doctors as a habit. I exercise. But I have a bump on my back that I think is non melanoma skin cancer, but i’m not about to drop $150 to get it checked out because i’m just too goddamn poor right now. How many people you think are like me out there who don’t show up in ANY kind of calculation in this country?

  9. Brian says:

    Unfortunatly since I have family in Canada, I know 100% that these facts are highly suspicious. Waiting time for an emergency room? 30 mins or less. Waiting time for doctor visits…. maybe a week tops. This is first hand knowledge, and the inflated scare tactics of republicans is just that- scare tactics. Even foregners are traeted with speed and dignity and there isn’t a worry over whether your insurance, (if your lucky enough to have insurance), will cover your costs because they are automatically handled.

    Also having lived in England and served in the military in England I can also state with 100% confidence that the mis-representation of british health care is also exagerated.

    Even if there were wait times and long lines, some type of health-care is better than no health care at all. Another point that republicans often miss.

    I truly wish that we could solve the health-care problem here in the USA without all the lies and half-truths. The only concievable reasoning for this is because republicans don’t WANT affordable healthcare. They don’t want to interfere with free-market and competition, regardless of the fact that no competition exists in the health-care industry especially the insurance racket.

  10. Steven says:

    I guess that Brian’s family in Canada must be lucky. I live in Canada. I can tell you that if I wait for less than 30 minutes in the emergency room, it’s considered a miracle. To tell you the truth, I would be a bit worried if I became very sick these days. As far as seeing your family doctor in less than a week, it’s possible IF YOU HAVE A FAMILY DOCTOR.

    I know for a fact that certain provinces do better than others. Ontario has the best public health care system in the country. That partly has to do with the fact that this province is paying better salaries and attracting doctors nationwide that might not want to change country.

    Little anecdote: my wife used to be a secretary in a clinic in Montreal. People were able to pay a fee of around $1000 a year for a membership. What this membership did was that it made it possible to jump the queues. Lots of politicians and left leaning actors and actresses took advantage of that. Imagine!! The people promoting the most socialized medicine were jumping the queue. No wonder they liked it so much!!! Every time a member would come in, the staff would discretely place the file on top of the other files in the queue list. You can compare this to what the elite in the USSR did: promote the system they put in place for the general population while secretely favouring themselves. Also, why are so many Canadian politicians getting surgery in the US? The prime minister of Newfoundland went to get surgery in February 2010. Of course, that was courtesy of the taxpayers.

    Anyways… Of course the US system is flawed to but not as much as our system. People can discretely die in waiting list in the name of EQUALITY. We need a truly free market in that field and I know the US system is not a free market although it is mostly privatized. Regulations mess it all up.

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