The Freeway to Serfdom

Universal access will destroy our existing insurance and medical system.


Dr. Orient practices private medicine in Tucson. She is also Executive Director of the Association of American Physicians and Surgeons.

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 a 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 first is this: Do we want to tear up the main business district of town?

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 okay, or even wonderful. Everybody seemed to be getting more for less, or even for free. Now, Medicare is bankrupt, and we’re just beginning to see the effects of government rationing. It’s as if we built an Interstate into every town and 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 a 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 Congressmen, 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 U.S. if you belong to a “managed-care” plan). But you can only get on the freeway from the on-ramp. There is no tollgate or stoplight—but the traffic might be backed up for miles and moving imperceptibly.

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.

(Until recently, this concern did not apply to dog owners. They could buy a CT scan for their dog, but not for themselves.)

American “managed-care” plans—a favorite 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 that nobody pays.

Even if we abolish payment at the time of service, medical care must still be paid for. The only choice is to pay in advance or to pay later. With government programs, we often borrow money and commit our great-grandchildren to pay.

Another problem with the freeway is that you can only go 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 are able to afford for themselves.

The roadblocks are at the exits that lead to the hospital. The global budgeters “contain costs”—ration health care—by denying those things that you do need insurance to pay for: heart surgery, radiation treatments for cancer, hip replacements, things like that. Out of “compassion,” reformers may open another exit: the one that leads to the cemetery. Do you think it’s accidental that euthanasia and “universal access” are on the agenda at the same time? When government gets involved in providing health care, health care must be rationed.

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


November 1993

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December 2014

Unfortunately, educating people about phenomena that are counterintuitive, not-so-easy to remember, and suggest our individual lack of human control (for starters) can seem like an uphill battle in the war of ideas. So we sally forth into a kind of wilderness, an economic fairyland. We are myth busters in a world where people crave myths more than reality. Why do they so readily embrace untruth? Primarily because the immediate costs of doing so are so low and the psychic benefits are so high.
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