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Goodman on single payer

With the current focus on "equity" and "disadvantage," even in the midst of a pandemic, one might yearn for the simplicity of a government run system. Surely if health care were free at the point of delivery, paid for by taxes, all the inequities of health care would disappear, no? (Sure we might all get ...

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With the current focus on "equity" and "disadvantage," even in the midst of a pandemic, one might yearn for the simplicity of a government run system. Surely if health care were free at the point of delivery, paid for by taxes, all the inequities of health care would disappear, no? (Sure we might all get bad health care, but we'd all get the same health care, no?) 

No. John Goodman has a nice Forbes article explaining why and giving the evidence from UK and Canada. Bottom line: Nothing is free. Everything is rationed. If it is not rationed by price, it is rationed by political access or personal connections. Markets are the great leveler, as anyone can get money but it's hard to get friends and connections. 

When Britain founded the National Health Service

It was often said "health care is a right." Aneurin Bevan, father of the NHS, declared, “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."

30 years after the NHS began the Working Group on Inequalities in Health investigated and  

The Black Report found little evidence that the creation of the NHS had equalized health care access or health care outcomes at all. Here are the words of Patrick Jenkin, secretary of state for social services, in his introduction to the report: 

“It will come as a disappointment to many that over long periods since the inception of the NHS there is generally little sign of health inequalities in Britain actually diminishing, and in some cases they may be increasing. ..”

.. 30 years after Britain had nationalized its health care system and replaced private care with public care, it appears that inequalities in access to health care and health care outcomes were not any different than if the NHS had never been established at all!

The Black report concluded

the Group has reached the view that the causes of health inequalities are so deep rooted that only a major and wide-ranging programme of public expenditure is capable of altering the pattern

They don't mean public expenditure on health. They mean redistribution and public expenditure to eliminate economic and social inequality that leads to health inequality even when it is provided free and supported by taxes! That was 1980. 

About two decades later, ..a second study, .. was conducted. The findings? Not only had inequalities not diminished since the publication of the Black Report, they appeared to actually have gotten worse. 

In Canada, studies find that the wealthy and powerful have significantly greater access to medical specialists than less-well-connected poor people. High-profile patients enjoy more frequent services, shorter waiting times and greater choice of specialists. Moreover, among the non-elderly white population, low-income Canadians are 22% more likely to be in poor health than their U.S. counterparts.

How does inequity persist if it's given away free by the government? Goodman: 

But of greater interest is to understand why inequalities persist in systems nominally dedicated to their removal.

...In Britain, health care access and health care outcomes are known to vary radically by postcode... In general, the hospitals with the largest budgets, the most modern equipment and the best doctors are located in the areas of the country where the highest-income Britons live. And that’s not an accident. Where hospital funds are spent is just as much a political decision as any other decision government makes. 

Rich people know how to get the government to locate a hospital in their area, and how to put up a fuss if it's not. That's the whole point of "privilege!" 

Second, higher-income Britons and Canadians are more likely to have a social relationship with their doctors. In both countries there are long waiting lists for hospital procedures. The patient who has dinner with her doctor at a country club is more likely to be able to jump the queue than a carpenter, bricklayer or other tradesman. ...

...higher-income, better-educated people are almost always more successful at navigating bureaucratic systems. The British NHS is not like Walmart, which continuously monitors its sales in order to make sure it always has in stock whatever its customers want, when they want it. It’s more like a Department of Motor Vehicles, where the lives of employees are improved if the customers get tired of waiting and go home. Rationing by waiting is as much an obstacle to care as rationing by price. It seems that the talents and skills that allow people to earn high incomes in the economic marketplace are similar to the talents and skills that are useful in successfully circumventing bureaucratically managed waiting lines.

Bottom line: Decades of experience with non-price rationing of health care in countries with cultures very similar to our own provides a ton of evidence that the poor, racial minorities and other marginalized groups rarely make it to the front of the waiting lines.

If I were cynical I might suggest this explains the puzzle that ultra-wealthy coastal elites want single payer most, and actual people experiencing low incomes are less enthused. The latter have more experience with the actual operation of government services. The former all know a great doctor. 

I had occasion to look up per capita GDP by the way. Canada: $46,194. UK $42,330. US: $65,297. The whole package, whatever it is, does not look that appetizing, no matter how much you like hockey, rugby, and cricket. 

John H. Cochrane
In real life I'm a Senior Fellow of the Hoover Institution at Stanford. I was formerly a professor at the University of Chicago Booth School of Business. I'm also an adjunct scholar of the Cato Institute. I'm not really grumpy by the way!

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