Monday, September 22, 2008

Single-Payer Health Care: Immoral and Deadly

[The following is a mirror of the original post at PatientPower. ]

The following letter on the dangers and immorality of single-payer health care was co-authored by Brian Schwartz, Ph.D. and Paul Hsieh, M.D. in response to an article in the April 2008 issue of Annals of Surgery supporting such a policy (Sarpel U, Vladeck B, Divino C, et al. Fact and Fiction: Debunking Myths in the US Healthcare System. Ann Surg 2008; 247(4):563-569; available at Medscape here, registration required [free]).

The journal describes itself as "the world's most highly referenced surgery journal, provides the international medical community with information on significant contributions to the advancement of surgical science and practice."

The Editorial Board rejected it. The reviewer stated:

This is a very biased and vitriolic letter. There certainly is a broad range of opinion as to the best system of health care for the United States and open discussion is to be encouraged. However, to call a single payer system, that serves much of the Western world with equal or better results than we achieve in the United States, “immoral” and “deadly” is inappropriate and serves no purpose. Prior to consideration for publication, this letter needs to be toned down several notches.

The reviewer apparently believed that it was out of bounds to question either the morality of single-payer health care or the alleged fact that it yielded "equal or better results" than the American system. Of course, these were the very points that we believed needed to be challenged and discussed in an open fashion.

Also, as shown here, while the journal was "happy to evaluate a revised version of this manuscript," the reviewer provided minimal guidance on appropriate revisions, and our request for more constructive feedback was ignored.

We submitted a revised version, which the reviewer found "not acceptable for publication in the Annals of Surgery." We'd like to let readers decide for themselves. Here is the complete text of the revised version:

Single-Payer Health Care: Immoral and Hazardous to Patients' Health

In "Fact and Fiction: Debunking Myths in the US Healthcare System"[1], Sarpel et al presume "an obligation to provide healthcare to those who need it." This faulty moral premise underlies all forms of socialized medicine (including the single-payer system they advocate) and should be rejected by Americans as immoral and antithetical to core American values.

The only moral and proper role of government is to protect individual rights of its citizens. But health care is a need, not a right. A right is a freedom of action one possesses, such as the right to free speech. Rights are not automatic claims on goods and services produced by others -- that is just state-sanctioned robbery. If a man is hungry, he doesn't have the right to take a can of soup from his neighbor's pantry. A man's rights imposes only the negative obligation on others to not violate those rights, not a positive obligation on others to provide for all his needs.[2]

Whenever a government attempts to guarantee any service (such as health care) as a "right," it must also control it. This can only be done by violating citizens' actual rights. Under a government-run single-payer system, bureaucrats ultimately decide who receives what care and when, not doctors and patients. Doctors must work under the government's terms and for the government's prices. The inevitable result is a system like Canada's, which harms both patients and doctors through its infamous waiting lists and rationing.

Canadian patients routinely suffer and die while waiting for their "free" health care. According to the Vancouver-based Fraser Institute, "Canadian doctors say patients wait almost twice as long for treatment than is clinically reasonable, ...almost 18 weeks between the time they see their family physician and the time they receive treatment from a specialist."[3] A Canadian woman with a newly-diagnosed breast cancer might wait several months before she receives the appropriate surgery and chemotherapy.[4] The Canadian Medical Association noted, "Protracted treatment delays increase mortality and morbidity rates. [In a 12-month period in Ontario], 71 patients died while waiting for CABG [and] 121 were removed from the list permanently because they had become medically unfit for surgery."[5] The Supreme Court of Canada summarizes these injustices: "[W]aiting lists for health care services have resulted in deaths, have increased the length of time that patients have to be in pain and have impaired patients' ability to enjoy any real quality of life."[6]

The Canadian single-payer system takes its toll on doctors as well. According to the New York Times, significant numbers of frustrated neurosurgeons have left Canada for the US (a net loss of 49 out of a total of 241 in the entire country over a six year period). The surgeons' primary complaint was not money but rather a government bureaucracy which "increasingly rations service because of various technological and personnel shortages," making it impossible for them to practice according to their best medical conscience.[7]

American health care has genuine problems, but they were not caused by the free market but rather from decades of government interference in the free market, as documented in an article co-authored by one of us (PSH).[8] For example, politicians should not dictate whether consumers buy insurance on their own, through a membership group, or through their employer. But, as Sarpel et al acknowledge, the tax-exempt status of employer-sponsored insurance does just that. It locks employees to their jobs, shields insurance companies from competition, and encourages excess insurance coverage which gives patients little incentive to be cost-conscious consumers.[9]

Instead of worsening the current government-caused problems by imposing more futile controls, politicians should adopt free-market reforms that respect individual rights. At the federal level, legislators should eliminate the employer tax break and lower tax rates commensurately. A second-best solution would be to extend the tax exemption to all medical insurance and expenses. Health Savings Accounts are a step in this direction, but should be eligible to everyone regardless of their insurance plan. Such "Large HSAs" would allow consumers to buy medical care and insurance with tax-free earnings.[9]

State-level reforms to make insurance affordable include eliminating mandatory insurance benefits, community rating, and guaranteed issue. Largely because of such controls, the average price of individual and family insurance in the five most expensive states is three times the price in the five least expensive states.[10] Repealing laws that forbid purchasing health insurance across state lines would make health insurance available to millions who currently cannot afford it, while respecting individual rights.[11]

The free market has done a magnificent job in providing Americans with all other necessities of life, such as food, shelter, and clothing, and can do the same for health care if freed from government interference. Patients trust their physicians with their health and their lives. Physicians must not betray that trust by turning them over to the tender mercies of a single-payer socialized medical system that, as we contend, would be both deadly and immoral. They should instead demand free-market reforms.



1. Sarpel U, Vladeck B, Divino C, et al. Fact and Fiction: Debunking Myths in the US Healthcare System. Ann Surg 2008; 247(4):563-569. (Available at Medscape here, registration required [free])

2. Peikoff L, revised by Zinser L. Health Care Is Not a Right, Denver: Freedom and Individual Rights in Medicine; 2007.

3. Skinner B, Rovere M, California Dreaming: The Fantasy of a Canadian-Style Health Insurance Monopoly in the United States. Fraser Institute Digital Publications, Fraser Institute, May 2007: 1–4.

4. Saint-Jacques N, Younis T, Dewar R, et al. Wait times for breast cancer care. Br J Cancer 2007; 96:162-168.

5. Davies R. Waiting Lists for Health Care, a Necessary Evil?. Can Med Assoc J 1999; 160(10): 1469–1470.

Steinbrook R. Private Health Care in Canada. N Engl J Med 2006; 354:1661-1664.

7. Krauss C. Windsor Journal; Doctors Eying the U.S.: Canada Is Sick About It, New York Times. October 27, 2003.

8. Zinser L, Hsieh P. Moral Health Care Vs. "Universal Health Care''. The Objective Standard. Winter 2007-2008; 2(4):9-41.

9. Cannon M. Large Health Savings Accounts: A Step toward Tax Neutrality for Health Care, Forum for Health Economics & Policy 2008; 11(2) Article 3.

10. America's Health Insurance Plans. Individual Health Insurance 2006-2007: A Comprehensive Survey of Premiums, Availability, and Benefits. December 2007.

11. ...And Escape From New Jersey, Wall Street Journal. May 29, 2008. A16.