The Freeway to Surfdom; J. Orient, M.D.

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 de stroying the insurance and medical system that we already have. Remember what happened in 1965. Be fore Medicare was enacted. The majority of senior citizens had insurance. After Medi care, they just had Medicare. Their private insurance policies were all torn up. At first, that seemed okay, or even won derful. Everybody seemed to be getting more for less, or even for free. Now, Medi care 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 Dr. Orient practices private medicine in Tucson. She is also Executive Director ofthe Association of American Physicians and Surgeons.

and hamlet and then stopped repairing the bridges. When we build a freeway, we don't nec essarily destroy all the other roads. In Brit ain and Germany, private medicine is al lowed to coexist with nationalized medicine. But in Canada, it isn't. If you're a Canadian and want something the government isn't willingto pay for, or you want it now instead of three years from now, you have to go to the V nited 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 Con gressmen, but those won't provide Ameri can-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 V.S. if you be long 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 435 436 THE FREEMAN • NOVEMBER 1993 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. Hos pital 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. (Unti!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 fa vorite model for wouldbe reformers resemble the Canadian system in that pa tients 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.