A new scare tactic of opponents to healthcare reform is to claim that it must lead to cruel and arbitrary health care rationing and long dangerous waiting lists for surgical procedures. The opponents of reform are wrong.

In fact, no high income European country has a policy of rationing care, at least in terms of denying care to certain classes of people or for certain diseases as a policy. There is the kind of rationing that occurs with any health insurance system, which occurs when the health policy benefit package is defined. But that kind of rationing occurs in the US all the time, but probably in a more opaque and capricious way than where there is public input into the benefit design. Wherever supplemental private insurance policies exist, some of that kind of rationing can be avoided by buying additional insurance on the private market for supplemental insurance.

Related to waiting times, is the scare tactic of claiming that reform will produce waiting lists. If there is no overt rationing, then demand for procedures and surgeries in excess of capacity constraints can be rationed in a different way by making people wait for elective procedures. The scare tactic is to claim that any kind of health care reform will lead to waiting lists for procedures that are covered by the basic comprehensive health insurance package. But that is not true. First, it is not even relevant if people can buy supplemental private insurance which they can use to get quicker service.

Some countries do have significant waiting times for elective procedures. The longest waiting times have been in Sweden, and the UK. Other countries with significant waiting time have been Australia, Canada, Denmark, Finland, Norway, and Netherlands.

However, many countries do not have waiting times: Austria, Belgium, France, Japan, Luxembourg, Switzerland. A small minority of patients in Germany may experience short waiting time. All of these countries have universal coverage and much lower costs than the US.

What is the difference between the two groups? How do some countries provide universal coverage at lower cost with no significant waiting time for elective procedures? The secret is simple: adequate capacity. Countries with no waiting times have more acute care hospital beds or outpatient surgery capacity, and they have more physicians and surgeons qualified to do the sorts of surgeries needed than countries with waiting lists. They also have payment schemes that reimburse those doctors by the number of procedure performed (this does not have to be fee-for-service, it could be blended salary, incentive pay plans for performing procedures over and above their other pay).

It is very doubtful that the US would move to salaries for doctors, so the US will probably keep an incentive scheme compatible with no or short waiting lists.

However the US has an only average or lower ratio of doctors to the population compared to other high income countries. The US also has the lowest ratio of hospital beds to the population of any high income country except for Sweden, which has waiting times. But the US also has the shortest average hospital stays. On the other hand, there is probably an overcapacity in ambulatory surgery clinics in the US, So, there is reason for concern, but it could also be that a combination of greater efficiency in acute hospital care and substitution to outpatient surgery, where possible, can make up the difference.

But, the bottom line is that there is no reason that universal coverage and lower cost must result in arbitrary rationing or long, inconvenient, or dangerous, waiting time for elective surgery. It is a myth.

It is true that additional capacity and cost control measures will be needed, but these are planned for in the current healthcare reform proposals.

It is often overlooked that the US does ration care and impose waiting times compared to other high income countries, but the forms are different. The US imposes rationing on the front end for people seeking primary care and in emergencies. Waiting times in emergency rooms are very long. A lower proportion of people in the US who need to see a doctor can make a same day appointment than in Australia, Germany, the Netherlands, New Zealand, or the UK. The proportion is only lower in Canada. A larger proportion of people in the US have to wait six days or more to see a doctor than in all these countries except for Canada. So, perversely, the waiting list is when a person first seeks care. People have fewer alternatives to the emergency room after hours or on weekends than all these countries except Canada. And surveys suggest that people wait less time for elective surgery in Germany than the US.

The US policy of waiting times may extend to emergencies. A recent survey found that by several measures, the time from first symptom for heart attack and first treatment is longer in the than England and Australia. For example, for 25% of the AMI admissions in the US 15 hours or more elapsed between the first onset of symptoms and treatment, compared to 8.7 hours for England and 6.4 hours for Australia.

The US can have universal coverage and lower costs without rationing or waiting lists. The US healthcare system has more waiting for primary care (and some serious emergent care) than several other high income countries now. The US can avoid waiting lists for procedures by expanding additional capacity and reducing costs of care, both of which are part of current reform proposals.

Sources

OECD Health Data 2007
http://www.oecd.org/document/16/0,3343,en_2649_37407_2085200_1_1_1_37407,00.html

International Health Policy Surveys (2007) The Commonwealth Fund. URL:
http://www.commonwealthfund.org/surveys/surveys_list.htm?attrib_id=15318

Luigi Siciliani and Jeremy Hurst. Explaining Waiting-Time Variations for Elective Surgery Across OECD Countries. 2004 OECD Economic Studies No. 38, 2004/1.

Kathleen Dracup, Debra Moser, Sharon McKinley et al. An International Perspective on the Time to Treatment for Acute Myocardial Infarction. Journal of Nursing Scholarship, 2003; 35:4, 317-323.