The Waiting Is The Hardest Part

(Thomas Eakins, The Gross Clinic, 1875)

A common objection to single-payer health care systems is the supposedly lengthy amount of time patients wait to get an appointment. Actually, this depends on the reason for the appointment.

Medical care divides into three tiers: primary, secondary, and tertiary. In America, primary care refers to the family doctor, pediatrician, or gynecologist who meet most medical needs. In most other wealthy countries, primary care begins and ends with the family doctor, and indeed some do not offer pediatric care as we understand it. Secondary care refers to hospitalization and outpatient services involving surgery or another significant intervention such as chemotherapy. Tertiary care involves a rare condition requiring a highly specialized intervention.

When a country makes a decision to offer universal access to health care to citizens, residents, and visitors regardless of their income, policy implementation inevitably focuses on the health of the overall population as opposed to marketing health care to individuals. Population-based health policy leads to an emphasis on preventive care both at the public health level and at the provider level. At the provider level, that means getting people into the system before problems develop, which in turn means emphasizing primary care over secondary and tertiary care. Primary care is also less expensive than secondary care, so the more that health needs can be met at that level, the lower the overall bill to taxpayers and the more affordable the system becomes.

In practice, then, countries that offer universal coverage -- i.e., all wealthy nations except for the United States -- have a high ratio of primary care physicians to secondary care doctors. And while this can result in a wait for treatment of nonacute conditions, well-off citizens in these countries can generally purchase supplemental insurance for reducing waits or buy into a national program. And note the distinction: Longer waits for nonacute secondary care are a function of policies that follow from universal coverage, not a supposed single-payer health care government bureaucracy or lack of supply created by a disincentive to become a physician. (Single-payer countries have no more or less doctors than any other developed nation.)

So, there is a tradeoff: In a universal health care system, individual patients with nonacute conditions either wait longer for treatment or purchase a place in line in exchange for universal coverage, cheaper health care, a longer life expectancy, and wide array of services for the population as a whole.

Is it a tradeoff worth making?...