If You Are Against state-inflicted public health insurance, financed by a compulsory levy, it is enough in many quarters to mark you down as a moral monster. By implication it is assumed that your "negativism" means that you want poor people to suffer. But does a compulsory national health program, "free" to everybody out of taxes, actually result in a healthier society?
Since many foreign nations, from England and Germany in Europe to New Zealand in the Antipodes, have had ten, twenty, and even thirty years of experience with their own versions of compulsory "medicare," there should be a definitive answer to this question. Helmut Schoeck, a professor of sociology at Emory University in Georgia, has pinned down a vast number of pertinent facts in his symposium, Financing Medical Care: An Appraisal of Foreign Programs (Caxton, 348 pages, $5.50). The testimony of Dr. Schoeck’s many experts is that it is the general tendency of "government medicine" to inflate the cost of medical service without adding anything of value to the general level of health. It may seem like the humanitarian thing to do to make medical service a "free good," like parks or streets or the water from the public drinking fountain at the corner. But actually everybody loses under most public health programs.
The Value of Nothing
The reason, if we look at the experience of England, France, Germany, Sweden, Austria, and New Zealand, is that people do not value what they presume they are getting for nothing. What results from public medicine is a big over consumption of trivialities, with doctors at their wits’ end to find time to spend on serious matters.
Speaking of compulsory medical "insurance" in Germany, Werner Schollgen remarks that personally "costless" access to doctors and medical supplies "encourages the waste of huge amounts of money and medical resources on minute and imaginary ailments. Consequently, it cannot really, in the long run, help individuals with prolonged and catastrophic illnesses."
Looking at the British experience, Colm Brogan discovers that the National Health Service which came out of the Beveridge plan "celebrated its tenth birthday without having built one single hospital throughout the length and breadth of Britain." English girls, says surgeon Reginald S. Murley, decline to take up nursing because of the inadequacy of the hospitals under the compulsory health program. The deficiency is "somewhat concealed by the number of girls from Ireland and the Continent who come to Britain to nurse."
In Germany, "free" medical treatment is accepted with contempt by many people who, after taking the pills they get for "nothing," turn right around and spend their own personal funds on the most arrant type of quack. In Sweden, which adopted a compulsory health service in the nineteen fifties, Alfred Zanker tells us that "the captive beneficiaries of compulsory health insurance… demand medical benefits far beyond what their specific contributions pay for." The general attitude is "I had to pay my share, now it is the state’s turn to render any service I can think of." "Over-treatment" and "multiple treatment" follow. With state "medicare" piled on top of other compulsory welfare expenditures in Sweden, "tax evasion has become a matter of economic survival." The population is not noticeably healthier. And freedom from "material" cares has not made the Swedes any happier. "Sober statistics show that social ills have continued in the era of an ever more perfect welfare state. The crime rate, especially among the younger generation, has reached frightening proportions. Widespread alcoholism has not been curtailed. The divorce rate has reached new heights, and despite generous state subsidies… the birth rate in Sweden has fallen back to its low level of the 1930′s."
No Way to Fix Responsibility
This sort of quotation might be multiplied many times over from Dr. Schoeck’s book. The reason for the degeneration of medicine when governments try to match free patients with "panel" doctors, or dictate arbitrary "fee schedules," or otherwise interfere with the market pricing of medical service, is that there is no accompanying way of instilling responsibility in either patient or physician.
As economist Dennis S. Lees says, the humanitarian cry for "adequacy" comes to mean anything we want it to mean. There is no way of deciding between the competing claims of "adequate" medicine and "adequate" public housing and "adequate" nationalized train service if marginal utility ideas are excluded. "We do not know," says Mr. Lees, "nor is anything built into the machinery of the public sector to tell us, whether production is optimal or not." Yet in a world of scarce goods—and medicine is still a scarce good—there must be some way of deciding where optimal as against "adequate" resources are to go. "Men and materials employed to build hospitals cannot at the same time be used to build schools and factories… Firms producing medical supplies cannot at the same time be producing export goods."
When doctors and hospitals and medical supply companies price their services, there is an automatic check on their indiscriminate use, and money is left for education and factory building. Hardhearted? Well, if it were left at just that, it would be hardhearted. But doctors, from time immemorial, have not attempted to wring big fees from those who come to them asking for charitable care. The price system, which can provide for "optimal" discrimination, is compatible with voluntary relinquishment of time, energy, and pills to the occasional patient who cannot pay for what he receives.
Some Hopeful Signs
In America, there is a tired feeling in many quarters that compulsory "medicare" is part of the inevitable "wave of the future." But "it ain’t necessarily so." In both Switzerland and Australia, the voters have firmly rejected the demands of the socialists that medicine be made a compulsory "free good" financed by taxes or social security levies. The Swiss, in 1958, had 1,109 separate voluntary insurance plans recognized by the federal government, with a membership totaling 4,011,925. "Between 80 and 90 per cent of the Swiss people are members of such associations," says Marcel Grossmann. The federal government in Switzerland does give some subsidy help to voluntary plans which meet formal requirements as nonprofit mutual companies, but that is all. The insured have free choice of physicians, and the doctors set their own price on their services. The Swiss are certainly as healthy as the Swedes or the English, and they are not afflicted with skyrocketing medical costs. Moreover, the traveler in Switzerland notes practically none of the social ills that afflict welfarist Sweden.
In Australia, where the Labor Party ruled at the end of World War II, there was an assumption that the people would vote a National Health Service Act on the order of the British legislation. But, miraculously as it must seem to us, the Australian Liberal Party beat back the Laborite demand for a comprehensive compulsory system for supplying doctor’s services, drugs, hospitalization, and dental benefits.
When a Liberal government assumed office in 1949, a physician, Sir Earle Page, was appointed Minister of Health. Sir Earle helped put the Commonwealth government behind a subsidy of voluntary insurance societies which left the Australian equivalents of our own Blue Cross and Blue Shield to take care of their own members. Nobody in Australia is compelled to protect himself by insurance against the "hazards of living and dying," but the country is pretty well blanketed by the voluntary system.
The Australian Health Plan, says Sir Earle, "has started to pay for itself in shorter illnesses, less sickness, shorter hospitalization, with a consequent turnover of hospital beds and a saving of millions of hours of working time." And because there is no central administrative expense, "the government’s paper work in connection with the Plan is carried on in Canberra, the national capital, by no more than fifteen or twenty people. Everything else is handled—and well handled—by the insurance societies themselves, each of them dealing with its own subscribers."
One Control Leads to Others
One fear expressed by Dr. Schoeck and some of the contributors to his symposium is that when governments undertake to provide comprehensive state plans for compulsory medical insurance, the mounting costs will lead to regimented preventive medicine. Dr. Schoeck raises by inference the Orwellian specter of compulsory setting up exercises, compulsory fat-free diets, compulsory rationing of cigarettes and alcoholic beverages, and other such interferences with the ancient idea that a man’s home is his castle, including the type of table he may care to set in the castle’s dining room. The logical authoritarian answer to high compulsory medical costs is an equally compulsory enforcement of "preventive" health standards. Well, if compulsion is to be the universal wave of the future, why not? So, one-two-three-four, bend that back.
Libertarians who would prefer to leave the promotion of any and all medical benefits to private hands will not fail to note that the coercive "wave of the future" has swept over "voluntary" Switzerland and Australia to some extent: both countries tax their citizens to provide relatively small amounts of subsidy money for bestowal on selected private medical insurance societies. But if one must choose between types of public health coercion, the Swiss and Australian systems are certainly greatly to be preferred to the British, German, Austrian, or Swedish variety. At least, the patient and the doctor are left free to find each other in
Switzerland and Australia, on terms that are mutually agreeable. At least there is a competition between societies to serve their members. As for the U.S., it has the grand opportunity to remain with the Swiss and the Australians on the side of relative medical voluntarism. Dr. Schoeck’s book illuminates a score of pitfalls and outlines at least one or two ways to relative sanity. One can hope for it a wide reading before the country makes its final choice between common sense and going off the deep end.
What Is True Benevolence?
There is increasing evidence that more and more of our physically fit citizens are enjoying their position as voluntary victims of the welfare state. Through their own thoughts and efforts they are becoming unfit, unwilling, or unable to take care of themselves. Nations grow strong through the strength of their citizens. The citizen’s strength is gained by struggling, mentally and physically, to meet difficulties and overcome obstacles. Let us grow under the attitude developed by the exchange of service instead of withering under the attitude of entitlement through outright gifts at the hand of a so-called benevolent government.
Ralph E. Lyne, Taylor, Michigan