Depends on What the Meaning of “Universal” Is

Ezra Klein thinks some countries have achieved universal health coverage. Ramesh Ponnuru demurs: “If you can’t get an operation because your country’s national health insurance system has you on a long waiting list, in what sense have you enjoyed ‘universal coverage’?” Klein replies by defining away the problem: “waiting for an elective procedure – no country I know of has waiting lists for emergency procedures – that you then receive doesn’t contravene the terms of health coverage at all.” Jonathan Cohn adds: “some countries with universal coverage don’t seem to have waiting lists at all,” notably France and Germany. Who’s right?

The evidence seems to lean toward Ponnuru’s position. A few items:

  1. Canada’s Supreme Court wrote in a case last year: “The evidence shows that, in the case of certain surgical procedures, the delays that are the necessary result of waiting lists increase the patient’s risk of mortality or the risk that his or her injuries will become irreparable. The evidence also shows that many patients on non-urgent waiting lists are in pain and cannot fully enjoy any real quality of life.” So the issue isn’t just about elective or unnecessary medical care, or just about mortality risk. (Next Monday, the Cato Institute will release a study by the doctor who litigated that case.)
  2. In a 2004 poll conducted by the Stockholm Network, residents of France and Germany expressed the least dissatisfaction with treatment delays (out of eight European nations surveyed). Nonetheless, the French and Germans who were dissatisfied with their health care system’s waiting times outnumbered those who were satisfied (50 percent and 55 percent dissatisfied, respectively). So there may be a problem in those countries, even if the authorities do not measure it. (Perhaps we could approach the uninsured the way that France and Germany approach waiting times, and just stop counting them.)
  3. There are indications that people who actually get sick in the U.S. fare better than in nations with “universal” coverage. Women who get breast cancer in Germany are slightly more likely to die of it than breast cancer victims in the U.S. (31 percent vs. 25 percent). For prostate cancer, you are twice as likely to die of it in Germany as in the U.S. (44 percent vs. 19 percent). More such data can be found here and here. If that’s the case, the appeal of “universal” coverage fades.

Can we achieve “universal” coverage? If we could, would it be better than what we have? If it would, would it be worth the cost of a tax burden like that of France? These are open questions, and they are for proponents of universal coverage to answer.

As they try to answer that question, I recommend Crisis of Abundance, a short Cato Institute book by econo-blogger Arnold Kling.