Promise me anything

Sally Pipes is president of the Pacific Research Institute and the author of False Premise, False Promise: The Disastrous Reality of Medicare for All (Encounter). I interviewed her on Feb. 6, just after that book came out, and just before COVID-19 hit the headlines. Her analysis makes me realize that we have not only a political problem but a cultural problem affecting both supply of doctors and demand for their time.

After Hillarycare crashed and burned in the 1990s, why didn’t Republicans from 2003 to 2006, when they controlled both the White House and Congress, do anything regarding healthcare? That is a million-dollar question. If they had come up with a good solution focusing on competition and choice, empowering doctors and hospitals, doctors and patients, I don’t think we’d be in this mess today.

Not enough poor constituents in Republican congressional districts? Most people in the Senate and House and in state legislatures find it confusing and complicated. They don’t want to get into the weeds about preexisting conditions and all that. The way to deal with that problem is for the federal government to give significant funding to create high-risk pools so those people can get affordable coverage and continuous coverage.

Both political parties and most Americans agree that our current system is very messy. Do we need to go one way or the other, toward competition or toward socialism? The Democrats’ public option idea is a stepping-stone approach to single-payer: Government would price its premiums for coverage lower than the private sector could, and therefore would crowd out private coverage. But the American people don’t understand what it means to have the government fully take over their healthcare. They should look at the Department of Veterans Affairs, an example of a true single-payer system. Long waits, rationed care, and lack of access in many cases to the latest treatments.

Beyond the political problem, do we also have a looming supply-side problem, since more than 40 percent of physicians say they’re burned out and want out? When Obamacare came into being almost 10 years ago now, it pushed mandates and regulations on doctors, including electronic health record requirements. It’s become very burdensome. My own OB-GYN retired at the end of January: just couldn’t take it anymore. My husband’s doctor retired last year, saying that with all the paperwork he couldn’t focus on the patients.

But lots of doctors support “Medicare for All.” Why? Many think it would be easier with only one entity paying them—but those who think the government would pay up quickly and efficiently, for whatever procedures they do, should think again. If we get single-payer, more doctors will retire. They’d be paid Medicare rates that are 40 percent below what they get paid for treating private patients today. The best and brightest of the country have traditionally gone into medicine, but that flow would disappear under a single-­payer system.

The United Kingdom right now has a shortage of 100,000 doctors, nurses, and healthcare workers. They’re not paid well, they have to work very long hours, they’re all exhausted.

Why? Aren’t some people dedicated to helping others, even if they make less money? Yes, there are. But the United Kingdom right now has a shortage of 100,000 doctors, nurses, and healthcare workers. They’re not paid well, they have to work very long hours, they’re all exhausted. In the U.S., many doctors, male and female, have shut down their private or small group practices and gone to hospitals because they don’t want the paperwork and they don’t want to work long hours.

Will physicians who want regular hours and a salary be excited about more competition in the health marketplace? Well, no. You’re seeing that a lot among millennials. They’re pie in the sky. Many have not been out in the working world. They want government to provide all these entitlement programs, but they don’t realize that government doesn’t have any money. The taxpayers have the money, and taxpayers have to fund it. If the government totally took over the healthcare system, tax increases would be large, and we’d see rationed care and long waits.

Let’s turn to the demand side. A lot of anti-poverty programs worked, to a certain extent, when only those who really needed them signed up. Even if they were eligible, they didn’t want to sign up unless they actually needed the money. But after my father died, my mother in Florida was lonely, and her entertainment was going to different doctors, which worked for her on Medicare and a supplemental insurance plan. When we moved her to Texas where we live, she didn’t demand as many doctor visits. Your mother’s case is quite common—and particularly in Canada where, because it’s supposedly free, people who are lonely, people with mental issues, are always booking appointments. A doctor in Canada is seeing around 65 patients a day. That’s exhausting. One of my best friends retired from medicine at 40 because, he said, he couldn’t see 65 patients a day, couldn’t do a proper exam, couldn’t get the tests that are needed. That means people with serious conditions have a long wait time.

Are any doctors coming up with creative ways to solve that problem? In the U.K. today, under the National Health Service, the average doctor is seeing 70 patients a day. They’re now talking about setting up group appointments, with 15 people with similar conditions getting together for one appointment with a doctor. Can you imagine how that would go over in this country?

How can copay requirements help? A copay is always a good thing, because, when people have some skin in the game, they’re careful how they spend their money, how often they go to the doctor.

What else should we learn from government-run programs? Americans in Florida have relatives in Cuba who can’t get aspirin, Kleenex, all these things. It’s a terrible system, and care has to be rationed. My own mother died in Canada in Vancouver from metastasized colon cancer. When she thought she had a problem and went to her primary care doctor, she had an X-ray. He said, You don’t have colon cancer. I told her, You don’t detect colon cancer with an X-ray, you need a colonoscopy. When she went back to her doctor, he said, “I’m sorry, but there are too many younger people with issues and so you can’t have a colonoscopy.” Six months later she had lost 30 pounds and was hemorrhaging, so she went to the hospital in an ambulance. She got her colonoscopy, but died two weeks later from metastasized colon cancer. You can ration care, but it harms patients.

I’m sorry about what happened to your mom. Are Canadians sometimes too polite and patient? Some 608,000 Canadians last year came to the U.S. and paid out of pocket for MRIs, CT scans, heart stents, and hip replacements. When you’re in pain or you think you have a serious illness, you don’t want to be on a long waiting list.

Right. When I did some reporting in Cuba, a doctor told me that hospital policy was BYOX, bring your own X-ray film, if you hope to get an X-ray. Yes.

We often hear that Canada has free healthcare and people are happy. In addition to long waits and rationed care, it’s not free. The average Canadian family today pays $13,311 dollars a year in hidden taxes for a healthcare system that denies them care.

So should healthcare be a right? And if so, what quantity and quality? All the Democratic presidential candidates in a debate put up their hands when asked, Do you think healthcare is a right? But isn’t a right to food more important, since, if you can’t have food, you won’t live to see the doctor? In the U.K. patients are only eligible for certain procedures if they lose weight or quit smoking. If healthcare is a right, does government have the right to say you can’t get top-notch care: You only have a right to equal care? Will the government have the ability to ban people from paying for better care—which is the way it is in Canada? If healthcare is a right, there will be an unlimited demand for healthcare, and the supply just won’t be there.