Health care, like all finite commodities, must be rationed. The only real choice involves the mechanism by which that rationing is carried out. It can be based on market forces or it can be based on the whims of some priviledged elite. An article in yesterday’s Telegraph suggests that the former might be more compassionate than the latter:

Smokers, heavy drinkers, the obese and the elderly should be barred from receiving some operations, according to doctors, with most saying the health service cannot afford to provide free care to everyone.

In a survey of 870 family and hospital physicians,  a majority said that the NHS should not provide free care to everyone. There was, however, some diversity of opinion concerning which patients should be thrown overboard:

One in three said that elderly patients should not be given free treatment if it were unlikely to do them good for long. Half thought that smokers should be denied a heart bypass, while a quarter believed that the obese should be denied hip replacements.

My bet is that the mothers, wives, and children of these same docs would somehow manage to get special dispensations, regardless of their age or lifestyle choices. It is also probable that people with political or financial pull would somehow be treated.

This is a big problem with government-run health care. Regardless of what you call it, any system that tries to outsmart the market ends up rationing care based on the whims of people who don’t face the consequences of their own decisions.

Is this what we want in our country?

Cheap, government-subsidized health insurance is popular. Who woulda thunk it? Apparently not the geniuses who govern the state of Massachusetts. The Boston Globe reports the following:

Spending on the state’s landmark health insurance initiative would rise by more than $400 million next year … The biggest driver of the cost increase is projected growth in the number of people signing up for state-subsidized insurance, which now far exceeds earlier estimates.

That’s right. The state’s “leaders” created strong financial incentives to sign up, and then were apparently surprised that a lot of people responded:

Officials had projected that about 140,000 would enroll in the new state-financed insurance plan … But by the end of last month, 169,000 people had signed up …  and the state is now estimating enrollment will reach 225,000 by June 2009.

This does not, however, mean that Massachusetts has reached its ostensible goal of ”universal coverage.” Ignoring the possibilty that they may be fined, a large percentage of the Bay State’s uninsured population have chosen to remain uninsured. 

And it is probable that, like a similarly misguided program in Maine, “Commonwealth Care” is causing significant crowd-out of private coverage. In other words, it is highly likely that many of the people signing up were probably already insured.

And who do you suppose is going to pay the bill for all this idiocy?

State and federal taxpayers are expected to bear nearly all of the additional cost.

Did you notice the phrase “and federal taxpayers”? It’s not enough that the taxpayers of Massachusetts have to finance this mess. Those of us with better sense than to live in that state will have to pony up our money as well.

Why am I paying for an unsuccessful program that I don’t support concocted by politicians I never had a chance to vote against?  

Many single-payer advocates got the vapors when Rudy Giuliani quipped,  ”If we ever got Hillarycare in this country, Canadians will have nowhere to go for health care.” Well, this Globe & Mail article suggests he was on to something:

More than 150 critically ill Canadians – many with life-threatening cerebral hemorrhages – have been rushed to the United States since the spring of 2006 because they could not obtain intensive-care beds here.

But not before they endured purgatorial delays in the ER:

Before patients with bleeding in or outside the brain have been whisked through U.S. operating-room doors, some have languished for as long as eight hours in Canadian emergency wards while health-care workers scrambled to locate care.

And these delays took their toll on the patients:

“There have been very serious health-care problems that have arisen in neurosurgical patients because of the lack of ability to attain timely transport to expert neurosurgical centres in Ontario,” said R. Loch Macdonald, chief of the division of neurosurgery at St. Michael’s Hospital in Toronto.

But surely this is a new problem that Canada’s health care bureaucracy will move quickly to remedy? Nope.

[Provincial] governments were warned of a shortage of neurosurgical services five years ago. In August, 2003, a report co-authored by Chris Wallace, head of the division of neurosurgery at Toronto Western Hospital, said that “increasingly, the resources are not available to handle neurosurgical emergencies.”

Ontario has the worst situation. So here’s the response of Alan Hudson, the head of that province’s waiting-time strategy:

He immediately struck a panel to study it. “The solution to fix this is within sight,” said Dr. Hudson, a former neurosurgeon and hospital president. “What it requires is some organization.”

Man, what a hero! Superman and Green Lantern, to paraphrase a lyric from the ancient past, got nothin’ on him. I’m sure Ontario’s neuro patients take great comfort in the knowledge that such people are on the case.

Wait a minute! Canada has a single-payer system. They call it “Medicare.” Isn’t that the kind of system that’s supposed fix all our health care woes down here below the 49th parallel?

So, why would the lucky beneficiaries of Canada’s version of Medicare-for-All need to avail themselves of our “evil for-profit” medical system in order to get decent care?

Single-payer zealots Steffie Woolhandler, David Himmelstein, et al, have produced a study confirming the blindingly obvious fact that ER wait times are increasing. From 1997 to 2004, the median wait to see an ER doctor went from 22 minutes to 30 minutes. For heart attack victims, the median wait jumped from 8 to 20 minutes.

None of this will come as the slightest surprise to anyone familiar with the operations of a typical hospital ER. So, why did these people spend so much time and money to tell us what we already know? The answer to that question can be found in their suggested solutions:

Reversing the trend of longer ED waits would likely require multiple reforms. Possible interventions include expanding insurance coverage and access to primary care resources to increase alternatives to ED visits; directing hospital resources to medical need … instead of profitable but unnecessary services.

Doctors Woolhandler and Himmelsrein are founding members of a single-payer advocacy group called Physicians for National Health Program that endorses HR676, the Dennis Kucinich “Medicare for All” bill. So, when they use the word “reform,” they mean a government imposed solution.

Thus, “expanding coverage” means getting rid of private insurance and letting Medicare metastisize throughout the entire health care system. And “directing hospital resources to need” means a federal decree from CMS telling hospitals what kinds of services they are permitted to offer.

The irony here is that increased ER wait times are the direct result of government intervention in the health care market. At the same time CMS began driving primary care physicians out of the market with it price control structure, Congress imposed EMTALA on the nation’s ERs.

So, the ER wait time problem cannot be solved by more government meddling. The solution is to pay primary care doctors enough so that they can afford to treat Medicare and Medicaid patients, remove the state and federal regulations that keep insurance costs so high, and revise EMTALA so that ERs are not inundated with patients seeking free care for non-urgent complaints.

Ron Paul’s primary contribution to the January 5th Republican debate at St. Anselm College was to provide comic relief. Nowhere was that more evident than in his answer to Charlie Gibson’s tendentious question about “why we can’t afford medical insurance for everybody”:

How can we afford a trillion-dollar war and we can’t afford health care? Well, that’s the reason. The resources are going overseas. We’re fighting a trillion- dollar war, and we shouldn’t be doing it. Those resources should be spent back here at home.

This is, as Saddam Hussein might have phrased it, the mother of all false dichotomies. It’s one thing for the nutroots to make wacky statements like this, but this guy is a member of Congress.

Members of the Ron Paul cult imbibe some very powerful Kool-Aid, so the nuttier he gets the more loyal they are.  Fortunately, his association with the “Truthers” and the extremist newsletters reported by TNR will probably destroy his campaign.

Well, the single-payer crowd is gleefully touting the latest Commonwealth Fund study as if it settles the health care debate in their favor. Here’s the chart that has set their hearts aflutter:

Looks bad. But, as is often the case with the Commonwealth Fund, there is less here than meets the eye. The most significant problem with the study is its data source:

For this study, the researchers used data from the World Health Organization on deaths from conditions considered amenable to health care …

Using W.H.O. data to compare these kinds of outcomes is a very dodgy business. Why? Because accuracy in diagnosing and recording causes of death varies wildly from nation to nation. That’s why the W.H.O. issues the following warning:

Comparison of cause of death data over time and across countries should be undertaken with caution … coding underlying causes of death involves some extent of misattribution or miscoding … incorrect or systematic biases in diagnosis, incorrect or incomplete death certificates, misinterpretation of ICD rules for selection of the underlying causes.

The people who produced the “study” were apparently heedless of this warning. They have therefore produced the mother of all apple-to-orange comparisons. That hasn’t given a moment’s pause to the single-payer crowd.

But, then again, facts have never mattered much to the advocates of government-run health care.

In the run-up to the Iowa caucus,  various surrogates for Barack Obama’s political opponents attempted to swiftboat him, ostensibly for his refusal to include an insurance mandate in his health care plan. As I said here, the mandate issue was really just a pretext, but it received a lot of play in the establishment media and the blogosphere.

Thus, the Democratic and independent voters who gave Obama his astounding victory did so in the full knowledge that he is against mandates and that his opponents are very much in favor of forcing people to buy health insurance. This suggests to me that rank-and-file voters are considerably less enthusiastic about mandates than are many “progressive” policy wonks.

And consider this:

Nearly a quarter of Democratic caucus-goers interviewed in the entrance poll were under 30 years old, a jump from 2004. Obama got 57 percent of the vote from the under-30 crowd, compared with just 14 percent for 2004 vice presidential nominee John Edwards and 11 percent for Clinton.

How is this under-30 vote related to the mandate issue? Well, as it happens, it is just these voters who would be ripped off the most by a health insurance mandate. As Betsy McCaughey of the Hudson Institute puts it:

According to the latest Census data, 56% of the uninsured are adults aged 18-34 … mandates would force the young to subsidize the heath tab for the middle-aged generation.

So, is it a concidence that a commanding majority of the young adults who voted in the Democratic caucus voted for the only candidate who won’t make them buy insurance they don’t need? Perhaps, but I think they were telling Clinton and Edwards to take their mandates and shove them.

For Massachusetts residents with the effrontery to disobey their Boston masters in the matter of health insurance, the new year comes with a bite. As the Boston Globe enthusiastically phrases it:

The maximum penalty for those who flout the law and do not buy health insurance would be $912 a year, compared to $219 in 2007.

Notice the wording of the above sentence. If a Bay State citizen insists on exercising his autonomy as a free man in the free market, he’s a scofflaw. The Globe also wheels out that tired canard about automobile insurance:

This approach makes buying health insurance a responsibility of all residents, similar to the way drivers are required to purchase auto insurance.

As I explain here, this is a false analogy. There is no universal mandate requiring everyone to buy car insurance, and the market for auto insurance is (mostly) free of the kind government-induced distortions that make health insurance so expensive.

Most ironic of all, this travesty was signed into law by a man who represents himself as a believer in the free markets. Because he is now hoping to get the votes of conservatives and Libertarians, Mitt Romney has downplayed the role of mandates in his proposals for national health care reform. But, as Peter Chowka points out, they will probably materialize again if he is elected:

It is reasonable to assume that, if he is elected and keeps his promise to insure everyone in the U.S. “within four years,” mandates would be required.

With a guy like Romney in the White House, who needs Hillary?