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Lives at Risk: Single-Payer National Health Insurance Around the World

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LIVES AT RISK is a must read for anyone interested in reforming the U.S. health care system. Goodman, Musgrave, and Herrick, stern critics of the existing system, warn against looking to Canada, the U.K., and other single-payer systems for solutions. ..... Opponents of single-payer insurance will find their views strongly validated by the mountains of carefully documented evidence in LIVES AT RISK. At the same time, open-minded proponents will learn the weaknesses in what they advocate; the book will lead some to rethink their support, and others to work harder in honing their arguments. Either way, the single-payer proponent who reads this book will become a smarter advocate of whatever views he holds afterwards. ..... LIVES AT RISK calmly, carefully catalogs and eviscerates widely held beliefs about the virtues of single-payer schemes. The authors methodically reveal how claims diverge from reality. The evidence in LIVES AT RISK paints a sharp contrast between the current American system (which the authors wish to change) and the single-payer systems abroad. Single-payer systems solemnly pledge that all citizens have a right to health care, whereas America does not. Yet by measure after measure, it is America that provides more complete, more egalitarian, more high-quality health care than do single-payer systems. Single-payer proponents argue that Canada, Britain, and others deliver health care more cheaply, more efficiently, and more equitably, but in LIVES AT RISK these lofty claims dissolve beneath the data. Again, a reasoned proponent of single-payer insurance can dispute the data presented, but he will have to work harder to do so, and that will enrich the public debate we need. ..... Goodman, Musgrave, and Herrick are not merely bomb-throwers who demolish single-payer insurance and then retire to the drawing room. Having addressed the failings they see in single-payer systems, they then turn toward the task of reforming the American system. They propose specific ways to harness the desires and intelligence of consumers to create a better system in the U.S. Once again, whether or not the reader buys the authors' proposals, he or she will leave the book with a far greater understanding of the task ahead.

There is little disagreement among stakeholders in the U.S. health care system--patients, insurers, physicians, policy analysts, and the like--that America's health care system must change to adjust to the twenty-first century. But what to do?

Some observers advocate a return to the fee-for-service health care arrangement that prevailed in the 1950s. Others want to move in the opposite direction, toward the government-run health care bureaucracies common in other developed countries.

Advocates of the latter approach, known as universal or single-payer health insurance, are a minority in the U.S. health policy debate--but they are vocal and well-funded. In Lives at Risk, John Goodman, Gerald Musgrave, and Devon Herrick urge that we disregard pleas for such a drastic change in our approach to health care until we carefully consider whether such a system--failing in every country where it currently exists--could possibly be effective and efficient for the U.S.

Goodman is founder and president of the Dallas, Texas-based National Center for Policy Analysis (NCPA); Musgrave and Herrick are NCPA senior fellows. In Lives at Risk, they examine in microscopic detail the many flaws in the structure of single-payer health insurance, and they provide evidence that single-payer social policy is not in the best interest of consumers.

They explain, for example, how universal health insurance systems encourage over-consumption by patients, and how such over-consumption always leads to financial crises and broken promises of universal access and quality care. "One of the cardinal beliefs of advocates of single-payer health insurance is that health care should be free at the point of consumption, regardless of willingness or ability to pay," they write. Not surprisingly, such "free" medical care is over-utilized--to the point where demand exceeds the system's ability to sustain supply.

Promise Clashes with Reality

Goodman and his coauthors reveal how the promise of "health care for all" under a single-payer system clashes with reality. "The promise of national health insurance," they explain, "is that government will make health care available on the basis of need rather than the ability to pay." But in reality, single-payer systems tend to overspend on primary care for the healthy, while denying more expensive specialist care to those with serious medical problems.

The evidence creates a sharp contrast between the U.S. health care system and single-payer systems abroad. Although single-payer advocates claim their approach delivers health care more efficiently, more equitably, and at lower cost than our system, those claims crack open under the weight of the data.

According to Lives at Risk, wherever national health care is the only option, rationing by waiting is the norm. Rationing decisions are made by local health care bureaucrats, who are responsible only for spending, not healing.

Lives at Risk should be required reading for academics and policymakers of all opinions on health policy reform--and also for the medical community, consumers, advocates of single-payer insurance, and journalists who report on the issue. Newt Gingrich, former speaker of the U.S. House of Representatives, suggests in an editorial review, "This book will be an eye-opener for anyone who thinks a government-run system is the solution for our healthcare problem."

Information Age Requires New Approach

Dr. Robert Hamilton, a retired general and vascular surgeon living in Alton, Illinois, sees Lives at Risk from a physician's point of view. "Although this book is a brilliant exposition of the grand-scale effects of single payer health care financing and the economics of health care delivery, the implications for individual physicians and their patients are enormous," he noted

"Systemic inefficiencies, which interfere with timely, appropriate diagnosis and treatment of the individual patient, are dangerous and frustrating for physicians and patients alike in a system dominated by a government health care bureaucracy."

Hamilton suggests, "The way out of our professional doldrums is not through greater control of our profession by outside forces, but by making the patient-physician relationship the driving force. This book will restore optimism to those physicians whose frustration with imposed systems has nearly led them to give up on their noble profession."

Goodman, Musgrave, and Herrick do not just make a hard-boiled assessment of single-payer systems and then run for cover. They also turn their attention to the U.S. health care system. Instead of the usual worn-out generalities and obsolete assumptions, they point to specific problems and lay out specific ways to harness the intelligence of consumers and the power of the free market to improve health care in the U.S.

"The modern era has inherited two models of health insurance: the fee-for-service model and the HMO model. Neither is appropriate for the Information Age," they write. "Both models assume that (1) the amount of sickness is limited and largely outside the control of the insured, (2) methods of treating illness are limited and well-defined, and (3) because of patient ignorance and asymmetry of information, treatment decisions will always be filtered by physicians, based on their own knowledge and experience or clinical practice guidelines."

Regardless of whether the reader agrees with the authors' conclusions, Lives at Risk helps us understand how different policy approaches might lead to two very different outcomes for the U.S. health care system: complete meltdown under single-payer health care, or transformation into a system driven by consumer demand instead of health care bureaucrats and political expediency.


Conrad F. Meier (meier@heartland.org) is senior fellow in health policy at The Heartland Institute and Editor Emeritus Health Care News

Goodman and associates provide a valuable alternative look inside the single-payer, national, universal access health systems of Europe and Canada. This book is long overdue.

I teach a college class in comparative health systems that contrasts the U.S. health system with those of other nations and I use this book as an alternative text. I warn students that it is a polemic; Goodman is on a mission. But since the great mass of academic texts are written by professors in love with Europe and in contempt of the U.S. failure to insure 43 million citizens, this book is a welcome splash of cold water in the face.

The problem is that neither Europe nor the U.S. have solved moral hazard. As long as government, or our tax-subsidized employer, is pre-paying our healthcare, and we can leave your wallet at home and demand all the tests and treatments we are allowed, we are in trouble. It is a big Las Vegas buffet and we are all high-rollers pigging out and over-eating because the tab is on the house.

The result will be disaster in Europe as the aging population increases its demands on a limited supply of younger workers. The disaster in the U.S., with Social Security and Medicare/Medicaid already on track to consume the entire federal budget, is well publicized.

Goodman solution is a revamped Health Savings Account (HSAs) that make each of us responsible.

Whether agree that HSAs are the answer, or prefer some other approach, read this book. Racing to establish universal entitlement is a recipe for univeral disaster.

John Goodman et.al. have provided an impressive and accurate explanation of the failures of government dominated health care as seen from the data from those western countries which have adopted this model. They also present an outline of perhaps the only viable alternative. Succinctly written, the book should be read by every professional in the trenches and certainly every policy-maker.

W. G. Irwin,M.D.

Many people in the U.S. extol the benefits of a single-payer health care system even though they've never lived through such a system. Lives At Risk examines these alleged benefits and reports how they actually play out in countries where such a system is already in place, primarily in England, Canada, France, and similar countries with cultures and standards of living that make for a relevant comparison to the U.S.

The book refers to 20 alleged benefits (a pretty complete set) as myths and debunks them. For example Myth #3 is that in a single-payer system care is allocated according to need, not wealth. The book exposes the truth -- it turns out that the poor get much worse health care than the wealthy in these countries. I don't know how many times I've heard Americans demand that "health care is a right", implying that a single-payer system would recognize such a right. That's Myth #1. It turns out that real single-payer countries don't consider health care a right. It's just something they give out to appeal to voters. If they allocated funding for 80 heart surgeries and you're #81, tough luck, they don't owe you a heart surgery they say.

So on for a total of 20 myths, though some are minor variations of others. Their treatment of each myth is backed up with pages of references to studies and all sorts of data. The rest of the book discusses why things are this way, and gives the authors' proposed solution which is kind of a takeoff on health savings accounts.

The Good:

Systematically looks at individual belief's about health care (ex: Costs, Access, etc) and then attempts to contrast popular belief's with cold hard facts. This makes it simple to simply skip to a section that interests you. Moreover, for its breadth, it is a very fast read. Some of the stronger arguments deal with lack of rural access to care, the myth that preventative care will save money, or that a nationalized health system will save money in general (etc...)

While the chapter on preventative care is particularly good, the best parts of this book are surprisingly those with the fewest hard data and the most simple logic. For example - the insight that "We could potentially spend our ENTIRE gross domestic product on health care in USEFUL ways" - seems to escape 99% of those currently debating health care. From this argument one can take the real dilemma of health care to its logical conclusion - you have to, in some way, limit care. This can only be done by a) administrative decisions or b) market forces.

Thus, the author's make strong arguments for what lies behind those two forces - i.e. what drives administrative decision making and what types of market forces are responsible for determining costs. In the final chapters of the book, the Author's take their own views, using the latter argument, to discuss health savings accounts - their historical use and how they could be used more effectively. This section is the real gem.

The Bad:

Well, for starters, the sub-title doesn't really mesh with the overall content. They spend a majority of their arguments on the British NHS which, from what I can tell, is among the worst nationalized health care systems in the developed world. This is too bad as I can see opponents of the author's view writing the work off entirely for not talking more about France or Japan - "Well true that would be bad, but if we implemented it here it would be more like the healthcare systems in Japan, France..." etc etc... In that regard, it neither fully dispels all the myths nor arms those in agreement with the author's with enough data.

Overall:

The strengths easily outweigh the weakness', and there is enough validity in their arguments to make this worthwhile to just about anyone interested in the current debates. It is too bad the focus seemed to fall on the weaker NHS like systems and not the stronger - for this reason it will too quickly be written off as biased by many.

This book is a very informative book. It breaks things down for the average person to understand, but still gives plenty of statistics and facts to make it relevant to anyone.
I challenge anyone to read this book with an open mind and still believe in national health care.

To all the right-wingers who have already reviewed this book, and loved it, I would say that this book merely preaches to the choir. It is written by economists from the Heritage Foundation, a right-wing think tank. This is NOT a non-partisan treatment of healthcare. Almost every paragraph has errors within it. This is mere propaganda. So if you want propaganda, to be told what you already want to believe, then by all means buy the book (or just save your money and watch some more FOX "News").
But if you are non-partisan (this reader is a Republican but who cannot abide the lies written in "Lives at Risk" as he is also a pharmacist with over 25 years experience in healthcare), something these economists certainly cannot say, and one who generally wishes to enter into a dialog on the relative merits of improving our current messy, expensive, low quality "system" then by all means skip this book. I am developing a longer critique of the book, with more extensive treatments of the lies and factual inaccuracies within, and will post that later to my web site, [...]
A much better book on the subject is Hijacked! by John Geyman, MD. Hijacked: The Road to Single Payer in the Aftermath of Stolen Health Care Reform
[...]

I spent a few months reading various writings on health care systems and trying to clean up the trash heap that is all Wikipedia articles on the topic. I thought I had a good grip on what was going on around the world. I was wrong.

Lives at Risk presents a crystal clear picture of the health care industry in the US, UK, and Canada. It exposes the economic and political factors that have caused decreasing performance and increasing costs in all three countries. Finally, Lives at Risk makes a recommendation for a way to do things better.

This book lays it all out in short, easy chapters supported by copious references for those who want to know more.

Mr Goodman points out some important facts about the uninsured in America, as well as the lies which are pushed by the leftist and the media. He intimately describes the socialized medicine systems throughout the world and compares those systems with America's healthcare system. A well-researched, compelling book! This is a MUST READ for anyone who thinks that Government controlled, single-payer "free" healthcare is what America Needs!!