Tucson Blvd. Suite 9
Tucson, AZ 85716-3450
Phone: (800) 635-1196
Hotline: (800) 419-4777
of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto
Volume 56, No. 3 March 2000
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
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
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
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
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
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
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
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
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
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
"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
"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
"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.]
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
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
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
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
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 AlertThe State of The Union: Missed
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
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
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
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
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