Health: 'Universal' Access Means Limited Access

February 28, 1993|By JANE M. ORIENT

Wouldn't it be wonderful to have all the medical care you needed or wanted, without ever worrying about the bill?

And wouldn't it be wonderful to drive to work every day without ever paying a toll or stopping at the red light?

The second question usually provokes much more critical thought than the first. Before people vote the money to build a freeway through their downtown, a lot of inconvenient objections are raised.

The idea of "comprehensive health care reform" to "assure universal access" should stimulate the same thought process. To build such a system, you start by destroying the insurance and medical system that we already have.

Remember what happened in 1965. Before Medicare was enacted, the majority of senior citizens had insurance. After Medicare, they just had Medicare. Their private insurance policies were all torn up.

At first, that seemed OK -- or even wonderful. Everybody seemed to be getting more for less, or for free. Now, Medicare is bankrupt, and we're just starting to see the effects of government rationing. It's as if we built an interstate highway into every hamlet and then stopped repairing the bridges.

When we build a freeway, we don't necessarily destroy all the other roads. In Britain and Germany, private medicine is allowed to coexist with nationalized medicine.

But in Canada, it isn't. If you're Canadian and want something the government isn't willing to pay for, or you want it now instead of three years from now, you have to go to the United States.

A lot of proponents of "universal access" want to close the private escape hatch. They want no other roads -- just the freeway. Of course, there may be some back alleys or secret tunnels or special facilities for congressman, but those won't provide American-class medical care to ordinary folk.

Some think we don't need other roads if we have a freeway. But remember what a freeway is: a controlled access road.

That's what "universal" access means, too. Sure you have the right to get on the freeway, just as you have the right to medical care in Canada (or the right to comprehensive care in the United States if you belong to a "managed-care" plan). But you can get on the freeway only from the on-ramp. There is no tollgate or

stoplight -- but the traffic might be backed up for miles and moving at a rate that is barely more than 0 miles per hour. (Have you ever been on the Santa Ana Freeway when everybody's trying to get to Disneyland?)

In Canada, you don't have to pay to get medical care. In fact, you are not allowed to pay. Once the global budget is reached in Canada, that's it. The on-ramps are closed. It doesn't matter if you have money. Hospital beds are empty for lack of money to pay nurses, and CT scanners sit idle all night for lack of money to pay a technician. But if some people are allowed to pay, Canadians fear that some people might get better care than others.

American "managed care" plans -- a fa- vorite model for would-be reformers -- resemble the Canadian system in that patients don't have to pay at the time of service. (At least, they don't have to pay very much.) But they do have to go through the gatekeeper, who keeps a sharp eye on the budget.

Unlike the people in toll booths on the New Jersey Turnpike, managed-care gatekeepers don't collect the toll. But that doesn't mean nobody pays.

Even if we abolish payment at the time of service, medical care must still be paid for. The choices are to pay in advance, or to pay later. With government programs, we often borrow money and commit our great-grandchildren to pay. If we had a system like Canada's, we'd probably also have a national debt like Canada's (the equivalent of $6 trillion).

Another problem with the freeway is that you can go only where the freeway goes. If there's a roadblock at your exit, you can't take that exit.

Countries that promise "universal access" are pretty good at paying for well-baby checks and vaccines and doctor visits for the common cold. Those are exactly the things most people should be able to afford for themselves.

The roadblocks are at the exits that lead to the hospital. The

global budgeters "contain costs" (put the lid on spending) by denying those things that you do need insurance to pay for: heart surgery, radiation treatments for cancer, hip replacements, things like that.

Many communities are pretty good at voting down freeways. They should vote this one down, too.

There's a word for universal access to high-quality medical care at an affordable cost, all courtesy of the IRS and other government agencies: It is a fantasy.

If you want to see reality, don't look at Disneyland. Look at the Santa Ana Freeway.

Jane Orient practices private medicine in Tucson. She is also executive director of the Association of American Physicians and Surgeons.

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