Volume 56, No. 3 March 2000

PAYER FAILURE

Throughout the U.S., corporate socialism (managed care) is failing. More than 130 of California's 350 independent practice associations have declared bankruptcy, and 90% of physicians' groups are on the brink of insolvency. About 54% of physicians in the Denver area have changed addresses in the past year as practices fold. Harvard Pilgrim, the largest HMO in Massachusetts, is in receivership after losing more than $170 million in 1999 and abandoning its Rhode Island business.

Physicians in troubled plans may find a major source of revenue cut off, while they may be contractually obligated to care for the plan's patients-without charge-for months.

Proposed "patients' rights" legislation such as the Norwood- Dingell bill (see p. S1) will increase costs and decrease the number of subscribers to pay the costs. Passage of such "right to sue" legislation is likely to induce one-third of employers to drop health insurance benefits, according to a survey by Hewitt Associates (BNA's HCPR 2/7/00).

Such events are "clearing the field for socialized medicine," explains AAPS Past President Bud Goltry, M.D.

Hardly anyone advocates "socialized medicine" by name, but "single payer" has many prominent spokesmen, such as Arnold Relman, M.D., former editor of the New England Journal of Medicine. Speaking at a January meeting sponsored by the Volusia Academy of Medicine and the Volusia County Medical Society, Dr. Relman cited three examples of single payers: Britain, Canada, and U.S. Medicare. One advantage, he stated, was physician autonomy: British and Canadian doctors are "free to do what they want with the resources provided." U.S. Medicare, which "is not socialized at all," exerts "virtually no control over the practice of medicine."

Other advantages, in Dr. Relman's view, are administrative efficiency and equitable distribution of resources. Moreover, the single payer "exerts considerable influence on quality" and is able to "make providers more accountable." He acknowledges the danger of top-down bureaucratic control, but "the U.S. experience with Medicare is reassuring." In an exchange with AAPS Executive Director Jane Orient, M.D., he conceded that Canada does have shortages and queues, but "the only problem with the Canadian system is that they don't spend enough money on health care."

Calgary radiologist Martin Levant, M.D., disagrees: "Canada throws plenty of money at the problem-it goes right down a black hole." Canadian federal, provincial, and local governments have accumulated $850 billion in direct debt, and $3.5 trillion in unfunded liabilities ($1.3 trillion due to medicare), or more than $100,000 for every Canadian.

Worse than the shortage of funds is the shortage of personnel. Physicians are graying along with the population and are not being replaced. A dangerous shortage of pathologists could result in 1,500 misdiagnoses per year. Canada needs at least 500 more now; about 10 started training this year. The average age of certified pathologists is over 50. Since 1994, physicians with training in another specialty have been forbidden to enter pathology programs. Radiologists are also in critically short supply, as is the equipment they use. Moreover, "full service doctors are on the verge of extinction" (Medical Post 12/7/99). Not a single family doctor in a southern Ontario city would accept a new patient.

With the advent of medicare, provinces believed that too many doctors would drive up costs by making it easier for patients to get treatment. According to Hugh Scott, director of the McGill University Health Centre, Quebec's medical system has been "completely disabled" by governmental quotas on the number of prospective doctors and nurses accepted into universities (Gazette, 1/10/00).

Queues are no longer just an inconvenience for patients awaiting elective surgery, as to relieve disabling pain. (In 1998, 212,990 Canadians were on surgical wait lists, up 13% from 1997, see www.fraserinstitue.ca). The Calgary Regional Medical Staff Association advises physicians to shield themselves from legal liability by having patients with potentially life- threatening conditions sign a waiver form if they choose to remain on the wait list instead of leaving the country to get immediate service. Elderly patients with heart conditions may be kept on a trolley in a drafty hallway for more than 40 hours awaiting emergency treatment.

Meanwhile, a white van advertising "Emergency Medicine 24 Hours," equipped with an x-ray machine and dark room, is parked in the driveway of Dr. Jacques Chaoulli of Quebec. It is illegal for him to use the van, or to provide any private medical services in a hospital (CMAJ 11/16/99).

Doctrinaire socialists are bitterly resisting any liberalization of laws against private medicine, including the very modest proposal of Alberta Premier Ralph Klein to allow private facilities to perform surgical procedures such as joint replacements that require an overnight stay, at the government- controlled fee. (The private sector may only provide services such as abortions that do not require an overnight stay.)

Any such relief valve would "diminish the political will to improve public services," according to Federal Health Minister Allan Rock (Calgary Herald 10/30/99).

The dominance of the single payer apparently needs to be complete in order to accomplish its magical effects.

As the competing microcosms of collective prepayment for comprehensive "health maintenance" are collapsing when their liabilities come due, will Americans turn to the payer that is (like the Soviet Empire) too big to fail?

The risk is not just a huge mortgage on our economic future, but the integrity of the profession and the lives of many patients, as experience shows (see pp. 2, S1, and S2).

Single Payer Myths and Facts

Better Health. The lowest survival rate in the West for most types of cancer is seen in Britain. Disability-free life expectancy for female Canadians had fallen to 63.8 years in 1991 from 66.1 years in 1978, according to the Organization for Economic Cooperation and Development (Wall St J 1/28/00).

Emphasis on Prevention. Only 30% of at-risk British patients were immunized against influenza this season, and only three hospitals immunized their staffs (Sunday Telegraph 1/16/00).

Physician Autonomy. The British government has plans to send "deficient" doctors to "boot camp" for retraining, among other measures. "If these changes are introduced, we're going to spend all of our lives being inspected," stated Dr. David Pickersgill, Chairman of the BMA's Medico-Legal Committee (AM News, 2/14/00). Canadian family physicians also complain of increasingly onerous demands by hospitals for more CME hours and more inspectors (Medical Post 12/7/99).

Low-Cost Administration, Efficient Resource Allocation. "The failure to collect information is one reason for medicare's famously low administrative costs," writes David Frum. Even such basic facts as average waiting times are known only through the work of private organizations such as the Fraser Institute; "the government does not collect the data." Efficiency is comparable to that of the Trans-Siberian Railway: "Costs are hidden, investment in new technology is avoided, unionized unskilled...workers are overpaid, [and] skilled workers are underpaid" (National Post 11/27/99). Labor costs absorb 80% of the budget in Canadian hospitals, compared with 55% in the U.S. (Wall St J 1/28/00). The OECD ranks Canada in the bottom third of 29 countries for the availability of medical technology though it is fifth in national health expenditures.

Patients Are Protected Against High Costs. British patients are re-mortgaging their homes to avoid months of pain or death on the waiting list (Sunday Telegraph 1/16/00). Canadians spend $1 billion per year on medical services in the U.S. (Medical Post 1/4/00). Within Canada, 30% of health expenses (including semi-private and private hospital beds, private nurses, prescription drugs, and physiotherapy) are privately paid.

Overwhelming Popular Support. "Horror stories [anecdotes] from the United States keep Canadians in a trance despite the rest of the world's discovery that central planning does not work," writes Dr. Thomas Marshall, an ER physician in Sudbury, Ontario (Globe and Mail 1/25/00). However, the political situation is changing. A 1998 poll by the Harvard School of Public Health and the Commonwealth Fund showed that 56% of Canadians believe fundamental changes are needed, and 23% say medicare needs to be completely rebuilt. A 1999 poll conducted by Pollara showed that 74% of respondents support user fees, outlawed since 1984 (NY Times 1/16/00).

Equitable Access. In Ontario, each $10,000 increase in median income was associated with a 10% reduction in the risk of death within one year of a myocardial infarction. Socioeconomic status also had a pronounced effect on access to specialized cardiovascular services (N Engl J Med 1999;341:1359-67). Unequal access could explain why Canadians with incomes under $25,000 per year are stronger supporters of user fees than those with incomes over $75,000, who are better able to circumvent the system.

Universal Coverage. Because of requirements to pay premiums or to register, a fair number of people (4.2% in British Columbia) are not covered. The B.C. Medical Assn reports that as many as 4,000 patients every day are refused funding for legitimate medical expenses (Fraser Institute, 1/29/00).

AMA Rejects CPT Resolution

The following resolution, introduced by Chester Danehower, M.D., of Peoria, IL, who is a member of the AAPS Board of Directors, was rejected at the recent meeting of the AMA House of Delegates:

WHEREAS: Our AMA recently determined that it was unethical for physicians to make a "profit" on products that they sell in their offices; and

WHEREAS: Our AMA is the ethical standard bearer for the medical profession; and

WHEREAS: Our AMA should lead by example;

Therefore be it RESOLVED that our AMA provide CPT code books, CPT-related products, and CPT-related services to the physicians of this country without "profit" to the AMA; and be it further RESOLVED that our AMA provide a financial statement to the AMA House of Delegates at each annual meeting regarding all CPT activity.

AAPS-PAC Report

In the last election cycle, our biggest success was to help elect Rep. Mark Green (R-WI). So far this cycle, the PAC has contributed to the House campaign of Jim Rogan of California and the Senate campaign of Murray Sabrin in New Jersey. Criteria: agreement with AAPS principles; need for money; and chance to win. Let us know of worthy candidates.

Declaration of Arbroath

Robert Webster, M.D., of Jasper, GA, writes: Robert Bruce of Scotland, mentally almost defeated, once sat in a cave wondering what to do next against England, an apparently unbeatable foe. He noticed a spider that was constantly slipping when trying to reach the roof of the cave. It never gave up and eventually reached its goal. That lifted Bruce's spirits, and he led his men into a winning battle. There followed the Declaration of Arbroath, a statement that has come down through the centuries, even to the American War of Independence: "For as long as one hundred of us shall remain alive we shall never in any wise submit to the rule of the English, for it is not for glory alone that we fight, for riches or for honors, but for freedom, which no good man loses but with his life."

If It Isn't Nailed Down...

Without prior preparation, few organizations can continue to operate after a search warrant is executed, according to Medicare Compliance Alert 1/10/00. Patient charts, software, hard drives, back-up tapes, financial records, insurance claims, your Rolodex, tax returns, training certificates, appointment books, manuals, passwords, peripherals needed to access electronically stored data, bank statements, pass books, safe deposit box keys-all this and more may be seized.

As a result of such a search in August, 1999, chiropractor Brian Watkins was put out of business although no charges have yet been brought against him. He has sued the state of Pennsylvania. However, it is all but impossible to recover damages, and there is zero chance if the target is found guilty of anything on the basis of something seized in the search.

Keep an off-site back-up of critical data.

Another point to remember: You will be deemed to know the content of any compliance policies or Medicare materials that may be seized. They serve as evidence that you had access to information needed to follow the rules.

Penalties for False Claims Increased

Pursuant to the 1996 Debt Collection Improvement Act that requires agencies to adjust penalties for inflation, the Dept. of Justice has increased penalties for civil violations of the False Claims Act by 10%, the maximum allowable amount. Penalties now range from $5,500 to $11,000 per claim.

"For those...who believe the penalties are excessive and extortionate, their concerns should increase," stated attorney John T. Boese (BNA's Health Care Fraud Report 1/26/00).

Colorado Keeps Mandatory Hepatitis B Vaccine

In Colorado, the Board of Health is required by law to follow the recommendations of the Advisory Committee on Immunization Practices (ACIP) of the U.S. Public Health Service. However, the legislature explicitly retains the power to delete or rescind the rules. Representative Shawn Mitchell introduced a bill to repeal the mandate to immunize infants and school-aged children against hepatitis B.

"The children of Colorado are more likely to be harmed than helped by this vaccine," stated Philip Incao, M.D., a Denver family physician and AAPS member. Also testifying in favor of the bill were Jane Orient, M.D.; Bonnie Dunbar, Ph.D.; Barbara Loe Fisher of the National Vaccine Information Center; and persons injured by the vaccine.

After four hours of testimony, legislators killed the bill on an 9 to 4 vote, noting that Colorado parents may opt out of the vaccine even without declaring an objection to all vaccines. Most parents are apparently unaware of the option.

Warnings on Rotavirus Vaccine

In June, 1999, rotavirus vaccine was "recommended" and on its way to becoming a mandate. In July, it was withdrawn because of reports of intussusception. By the end of 1999, 99 reports had been submitted to the Vaccine Adverse Events Reporting System (VAERS). Documents recovered in response to a Freedom of Information Act (FOIA) request by AAPS included the following comments:

"Given the occurrence of intussusception among recipients of rotavirus vaccine (1) in the Shanghai trial; (2) in prelicensure trials of rotavirus vaccine in the U.S.; and (3) post-licensure as reported to VAERS, we are quite concerned" (Melinda Wharton to Walt Orenstein, 5/27/99).

"I talked to Peggy Rennels. She...said that she had TOLD Peter Paradiso she thought there was something there pre- licensure. She also said that she gave a talk at Emory (!) and that someone had come up to her and said that they had had a case of intussusception...." (M Wharton, 5/28/99).

"The intent was not to be dismissive (we are quite concerned about this, and think that the reported cases are the `tip of the iceberg') but I guess that got lost. Originally it was `substantially' higher but that got changed to `somewhat' which I know doesn't say much" (Melinda Wharton, 6/21/99).

"I talked to Dr. Richard Ricketts, Chief of Pediatric Surgery at Emory....What struck him about the cases was that they were `too young' (in his experience, intussusception is very unusual among those <6 months of age) and the high proportion that needed surgical correction (at Emory, only [about] 25% go to surgery)....

"In your abundant spare time..., maybe you and Walt and Jose can decide what `n' is for getting the ACIP on the phone ...to reconsider the recommendation for this vaccine. You don't have to tell me what it is, but I would appreciate it if someone was talking about it" (Melinda Wharton, 6/22/99).

"I was going over this with Mike Blum on the phone (safety guy with Wyeth Lederle) and realized that person-time is wrong..., so I think that it is even worse than it looks here....This also doesn't take into account the one-week- following-a-dose issue" (Melinda Wharton, 6/23/99).

"I guess I am ok with the bending over backwards tone of the [MMWR] article, but we are getting close to the line of discomfort for me. There is going to be something here and we quickly are going to get clobbered" (M Wharton, 6/24/99).

"VAERS data are alarming...and...are consistent with an incidence markedly in excess to that expected by chance alone....Even if ACIP supports the current plan of action (continuing the vaccine while we collect more data), I'm not sure what will happen if we get another 50 reports to VAERS next week, after this hits the press" (M Wharton, 6/23/99).

"In order to include the case reported to VAERS, they are having to look at admission diagnoses because for some reason intussusception was not included among the DISCHARGE diagnoses....So much for completeness of ascertainment by review of discharge data, and for VAERS being `biased' by the active surveillance project-the influence seems to be going in the other direction....NCK [Northern California Kaiser] found ANOTHER non- ascertained case by reviewing the barium enemas done on infants, that didn't show up from EITHER discharge or admission codes." (Melinda Wharton, 6/30/99).

"[I]f the vaccine does this 1 in 10,000 doses (our current guess) then the deaths due to intussusception will be of the same magnitude as the deaths due to rotavirus vaccine" (Larry Schonberger, 7/21/99).

"A fatal case was reported this morning; a 5-month-old previously healthy child received rotavirus, DTaP, IPV and Hib/Hep B vaccines on Feb 18, 1999. On Feb 23, the child was seen in the emergency room and diagnosed with gastroenteritis. The following day she developed bloody diarrhea....She died while awaiting helicopter transport....At autopsy, the child was found to have an 8 cm intussusception with necrosis and septic shock" (M Wharton, 7/22/99).

[Additional information is posted at www.aapsonline.org.]

Members' Page

Penmanship and Other Schemes. Emergency physicians are being hit with demands for refunds because Medicare clerks "can't read their handwriting." If the clerk can't read the writing, then whatever the physician did for the patient didn't really happen, and if it didn't happen, the physician is not entitled to any payment. Never mind that documentation in compliance with Medicare regulations is not the first priority in an emergency room. Other demands don't matter because patients don't matter to the Medicare bureaucracy. The most important thing is that government can no longer afford the entitlement it has granted to a growing segment of the population. An increase in taxes or premiums or a decrease in benefits will not be tolerated; the only thing left is to pay physicians less and less for their skill, training, and labor. The penmanship scheme, the "covered but included in" scheme, and other ploys effectively create a class of physician slaves who are forced to provide services for no pay at all.
Lawrence R. Huntoon, M.D., Ph.D., Jamestown, NY

The Biggest Monopolist. Problems arise with monopolies if there are artificial barriers to entry. If barriers are low, competitors will arise if a business provides poor service or charges too much. Government, of course, has the highest possible barriers to entry, through force of law. No wonder it doesn't do anything right.
Greg Scandlen, Alexandria, VA

Insurance Mandates. "We mandate car insurance, don't we?" is one rationale for individual mandates for medical insurance. This is not a good analogy. Auto insurance mandates - generally for liability coverage-protect innocent third parties who may be injured, not the driver or his car. There are still a lot of uninsured motorists. [And what happens to the uninsurable? Losing a driver's license is one thing....]
Gerry Smedinghoff, Wheaton, IL

Social Justice. We learned from the New York Times about an elderly woman who has trouble paying for her prescriptions. She can no longer afford to travel worldwide as in her younger days. There we have it. She made a personal choice to travel instead of saving for her old age. Now taxpayers who save all their lives are expected to pay for her prescriptions-in other words, to subsidize her earlier world travel.
Craig Cantoni, Scottsdale, AZ

The Danger of External Review. So-called patients' rights legislation such as Dingell-Norwood presume ever-greater federal intrusion into medical care. It will fail in the claimed objectives and increase pressures to federalize medicine and medical financing....Granting open-ended determination authority to "expert" medical review panels outside of and without consideration of contract terms permits all manner of mischief, [which] could illegally restrain trade, eliminate unwanted competition, reduce innovative clinical treatments, etc. The greatest danger of such panels will be a tendency to rewrite extant health insurance contracts while not bearing professional, personal, or financial accountability for their decisions and actions.
Stephen Barchet, M.D., Issaquah, WA

Learn from British Error. From a letter to Rep. Chris Cox: Retention of §203 of HR 2990, the Medical Savings Account expansion [in the "Patients' Bill of Rights] will save top-quality medical care in America. As an ex-Brit, let me tell you that single-payer insurance is a hellhole that even the Socialist Blair has recognized as a dead loss for quality medicine!
Christopher Lyon, M.D., Ph.D., Newport Beach, CA

The Road to Tyranny. HCFA justifies its actions against me [see AAPS News Jan. 2000 and WorldNetDaily 1/27/2000] by claiming a potential threat to patients, although millions of patients are treated safely in facilities like mine. As economist Murray Rothbard commented regarding the snares of picayune regulations: "Once we bring in threats to person and property that are vague and future, i.e. are not overt and immediate, then all manner of tyranny becomes excusable."
Robert Gervais, M.D., Mesa, AZ

Privacy. In my 14 years as a urological oncologist, I have seen a continued erosion of patient privacy. Now a clerk or bureaucrat at HCFA can request, through the professional peer review organization, copies of sensitive information about my patients, without the patient's permission. I am not allowed to tell the patient that his records have been requested, nor am I privy to the reason for the request....Though I'm just a simple country doctor, it appears to me that this closely resembles the state of affairs in Cuba or in the East Germany of the 1980s.
Stephen Reznicek, M.D., Cadillac, MI

Discounts. A surgeon sent a patient away for trying to negotiate a discount from the $1200 fee. A family physician asked how much Aetna US Healthcare would pay. "Oh, those creeps only pay $200!" The family physician asked why the surgeon would accept $200, months late, from an insurer and yet turn away a patient who wanted to pay more than $200 in cash immediately. "You know, I never thought of it that way." What do doctors fear? Colleagues stealing the $200 patient?
Alieta Eck, M.D., Somerset, NJ

Legislative Alert

and More Government

Bill Clinton characterized his own State of the Union proposals for health care as "the biggest expansion since the enactment of Medicare." He called for a 10-year, $110 billion program to expand access, focused on enrolling folks in the Children s Health Insurance program (CHIP): the government program for the kids has become an engine to enroll the parents too. With a $1.9 billion "outreach" program, Clinton has also called for the expansion of Medicaid coverage for 19 and 20 year olds. And another $5.5 billion would be earmarked to add another 400,000 more uninsured children into CHIP.

For those who don t get it, the game plan is to squeeze the private sector from the bottom by moving Medicaid eligibility up the age and income scale. But then, of course, Clinton proposes to squeeze the private sector from the top down, through an expansion of Medicare eligibility down the age scale, capturing the folks between 55 and 65 with a 25% tax credit to buy into Medicare. No tax credit would be permitted, of course, to buy into a private insurance plan.

Members of Congress are expected to ignore the Clinton proposals, hoping against hope that somehow they will just go away. They won t. Perhaps it will dawn on the national legislature that most of what is wrong with American medicine is rooted in bad, very bad, government policies, particularly tax policies, which distort the market, undercut efficiency, and frustrate consumer choice and competition. Meanwhile, each and every measure designed to compensate for these distortions, in the form of mandates and regulations, only accelerates the loss of patients' control over the most important decisions of their personal lives.

Patients' Rights

Congressional leaders are saying that they want to put a "patients' bill of rights" on Clinton's desk by April. Polls show that Americans-and most doctors-favor new legal rights to sue health insurance companies. And politicians are scrambling to be on the "right side" of the managed-care issue. But on the big picture, there is little doubt about either the ultimate end or the intervening means. Few in Washington with two brain cells to rub together think for one New York minute that the most aggressive left-wing Congressional champions of the patients bill of rights-opening up unprecedented lawsuits and imposing volumes of new regulations on private insurance -want to make the private health insurance system "work better." No way. They want to kill it.

The proposed "rights" are just a form of lethal injection. The strategy is clear. Under the guise of protecting private-sector patients from the abuses of employer- based HMOs, enact a comprehensive federal regulatory system over all private health insurance, including traditional fee-for- service medical plans (that s what the House version does, by the way). You thought regulation of health insurance was a state matter? Silly little principled you. Then, make sure that you create a new system of contract law under which third parties who are not signatories to the contract have a right to sue under the terms of the contract that they didn t sign. (If that sounds positively weird, as a matter of law, you re onto something.) Then, assure that employees are not signatories to contracts for health insurance; that would allow a level of personal control over the terms, conditions, and benefits of private health insurance that neither the Administration nor its allies in Congress would ever tolerate. Then, make sure that coverage disputes in private plans are transformed into matters of tort litigation. This will guarantee a vast reservoir of future business for aggressive attorneys. Get set for a wave of litigation unlike anything ever imagined in the medical malpractice arena. Of course, insurance companies and employers will have to incorporate the financial projections of their potential legal costs into their premiums, which will go up. Then, broadcast to the entire world that it is not your Congressional intent to promote suits against private employers, notwithstanding that an employer is the principal in the employer-based contract arrangement and the health insurance company is an agent. (As good trial lawyers know, that "congressional intent" stuff is fodder for hayseeds, something for barristers to twist and turn. No self respecting Big Boys of the Bar, slaking their everlasting thirst for the Big Bucks of personal injury and such, think much of the men and women of Congress to know their own mind about such matters, let alone read the fine print of the bills they pass. When it comes to getting at the real meaning of the law-and the most lucrative interpretation thereof- they and their friends up in high places on the Bench know how to mine the precious kernels of legal truth. The patients' rights legislation must have millions of them.)

Doubt this? Notice the last Medicare ruling on private contracting in United Seniors Association et al v. Shalala (1999): private contracting is OK so long as the medical service contracted for is officially deemed unnecessary, with the qualification, of course, that it is not "unwarranted" as well. Separate the warranted and unnecessary from the necessary and the unwarranted, just like the wheat from the chaff. Why that profound truth had been buried deep in the Medicare Law all along-it's just that we policy rubes, like the rest of the mere mortals, never had the insight to comprehend it.

The combination of massive federal regulation and new and unprecedented opportunities for creative litigation will drive health insurance premiums sky high. According to the Lewin Group, every 1% increase in health insurance premiums causes about 300,000 persons to lose coverage nationally. The number of uninsured among America s working population will increase over and above the record levels it has already reached. Congressional leftists will make speeches about how the private sector system isn t working. And, fighting back crocodile tears, they will throw up their hands and tell us that they tried, really tried, to make the private sector work, and there s nothing left to do but set up a cradle-to-grave system of national health insurance. (Please remember that Congressman John Dingell (D-MI) of the Norwood-Dingell bill has long been a champion of national health insurance.) If we could just get everybody covered, we would not only have high quality but low cost. Sounds like Paradise.

The Ghost of Medicare Future?

By the way, how are things going in those islands of Single Payer Paradise? Consider the latest from Great Britain, an island nation of 58 million souls, which spends between 6 and 7% of its national economy on health care. The British National Health Service (NHS), created in 1948 by the Prime Minister Clement Atlee s Labour Government, has got to be the Granddaddy of national health insurance.

In 1997, an estimated 1.3 million Britons were waiting for hospital beds. Campaigning on a program to reform the NHS, the Blair Government blamed the previous Conservative ministry for the problems of the NHS, and said that it was going to reduce the embarrassing waiting lines. Instead, the waiting lines have increased by 100,000 since 1997, and the Independent Health Association of Great Britain estimates that there are also at least 465,000 British citizens waiting to get on the waiting list. British newspapers, from the grey and sober broadsheets like the Times of London and the London Daily Telegraph to Britain s more raucous tabloids have been carrying ugly headlines about declining quality, lack of care for very ill patients, and even people dying of substandard medical care in British hospitals.

For British senior citizens, a trip to hospital can be deadly business. According to Dr. Adrian Treloar, a consultant and senior lecturer in geriatrics at Greenwich Hospital and King s and St. Thomas's medical schools in London, senior citizens are victims of "involuntary euthanasia" in the British government s hospitals. "There are severe pressures on beds and in order to relieve this there may be a tendency to limit care inappropriately where you feel doubtful about the outcome. Are the elderly being served properly? No. They are not getting what they deserve and I think they are being sold short. I think that is becoming clearer and clearer. If old people start to resist early discharge they are seen as an encumbrance" (London Telegraph, 12/6/99).

According to the London Telegraph account, British police are investigating 60 cases involving British senior citizens who died after allegedly being deprived of food and water by government s hospital staff. Curiously, the British have in place a "complaints procedure"-we colonials would call it a grievance and appeals process-to handle such matters. In bureaucratic systems, as physicians who wrestle with Medicare and Medicaid know very well, there is a strong emphasis on the government s precious process. But the families of senior citizens in Britain appear to be rejecting The Process and going straight to Scotland Yard. More interestingly, an organization called "SOS NHS Patients in Danger," are taking the cases of 50 patients who have died at the hands of the NHS to the European Court of Human Rights. Another group, Age Concern England, according to a December 6th edition of CNN, charges that "ageism" is "apparent at all levels of the health service from primary care through to major teaching hospitals."

Naturally, British authorities have become very defensive about the performance of the world s most famous single-payer system. Sir John Grimely Evans, Professor of Clinical Gerontology at Oxford University, has been writing to the NHS to be forthright on the question of age discrimination in the NHS. Says Sir John, according to the Telegraph, "There is secrecy. Our difficulty is getting our hands on the relevant information."

The growing crisis in the NHS is highlighted in a recent report published by the Institute for Economic Affairs, a prominent London-based think tank, which reveals that Britain has one of the worst survival rates in the developed world for patients with serious illnesses like heart disease and cancer. According to a remarkable January 26th column in The Wall Street Journal by Steven Pollard, a columnist for the London Express, the World Health Organization estimates that there are 25,000 unnecessary deaths a year in Britain because of "a denial of cancer care." Moreover, other sources confirm that Britain not only has fewer doctors per patient, but there are also shortages of drugs and medical equipment. According to the January 14th report from Reuters News Agency, Prime Minister Tony Blair s Health Secretary Alan Milburn conceded that there were "inequalities" in the NHS, but that the British government was determined to correct them. The Blair Government is pledge to spend an additional $33 billion over the next 20 years. Lord Winston, a Labour Member of the House of Lords, described by Reuters as a "fertility expert," has broken with the government on this issue and has gone so far as to say that the British government is being "deceitful" about its "reforms of the NHS." He noted that the funding level for Britain s health care system was "not as good as Poland s." That s cost control for you.

What an excellent lesson for the next generation of America s senior citizens. Despite popular perception, neither Medicare nor the NHS is free. Nor does it offer any genuine security: Funding is decided, not on the basis of medical decisions, but political ones. What the government can give, the government can take away. As HCFA Administrator Nancy Ann Min- DeParle stated: "We feel we need to pay adequately for services but that no one is entitled to a certain level" (Scripps Howard News Service 12/14/99).

The single payer is slow to change. As Health Secretary Alan Milburn told the BBC, according to the Reuters report, "Nobody pretends that we can turn around the National Health Service overnight. What we ve consistently said is that to turn it around and to give the country an NHS that is fit for the 21st Century will take ten years." Ten years. Of course, the lesson is that a system based on central planning and price controls is always slow to change; in fact, rapid change is unsuitable to bureaucratic systems, which do not and cannot quickly adapt to changing conditions in the same fashion as private firms in a highly competitive market.

This is yet another great lesson for the next generation of America s senior citizens: The language of lethargy and inflexibility is what they can and must expect out of HCFA, the American single payer. It is worth noting that Senator Orrin Hatch (R-UT) felt compelled to introduce legislation that would force Medicare to expedite its process for approving new treatments for America s senior citizens, noting that Medicare patients have to wait months and even years for the most innovative treatments to be approved by the Medicare program. (Hatch noted, for example, that HCFA took four and a half years to approve the use of coronary stents.)

In Britain, the situation is actually worse than merely the government s behavior and its defensiveness. British medical professionals are becoming accomplices in this tragedy. As the Telegraph reports, British Medical Association guidelines say that British doctors should be permitted to withdraw nutrition and hydration by tube for stroke victims and "the confused elderly," even when the patient is "not terminally ill." According to Dr. Treloar, "The only safeguard is that you get a colleague to say it's a good idea, which is about as flimsy as you can get. If the medical profession is going to move, as they have done, to a position where they accept the deliberate withdrawal of food and fluid from patients, then it's very difficult for patients to trust the doctors."

As Holmes would say, "Elementary, my dear Watson."

Robert Moffit is a prominent Washington health policy analyst and Director of Domestic Policy at the Heritage Foundation.