Lives at Risk

Lives at Risk

infobox Book |
name = Lives at Risk: Single-Payer National Health Insurance Around the World
orig title =
translator =

author = John C. Goodman, Gerald L. Musgrave, Devon M. Herrick
cover_artist =
country = United States
language = English
series =
genre = Health Care Economics
publisher = Rowman & Littlefield Publishers, Inc.
release_date = August 28, 2004
media_type =
pages = 727
isbn = 0742541525
preceded_by = Patient Power
followed_by =

Lives at Risk is an analysis of modern health care systems. It examines the flaws of current health care systems and proposes reforms for the American health care system. In doing so it examines twenty common assumptions about government involvement in health care systems which they argue are myths. The book continues on to discuss the economics and politics behind health care in the United States, and proposes market based reforms. [ [ NCPA: Lives at Risk: Single-Payer National Health Insurance Around the World ] ]


It begins by examining how three fundamental facts about health care systems.

# The potential exists to spend the entire US GDP on health care in useful ways.
# As time goes on, Americans desire to spend more of their income on health care.
# The US has suppressed normal market forces in dealing with 1 and 2.

The authors contend that Americans could potentially spend their entire GDP on medical testing alone. [Lives at Risk page 2] They further explain that as people become older and wealthier, they naturally spend more of their money on health care. [Lives at Risk page 6] They explain how the suppression of normal market forces, in conjunction with the first two facts, has created the problems currently faced with health care in the United States and abroad.

Problems with national systems

The authors examine whether countries other than the United States have been able to solve the problems listed above. [ [ / News / Boston Globe / Opinion / Op-ed / National health insurance: the wrong Rx ] ] Since the stated goals of national health insurance are often to make health care available based on need rather than ability to pay, they state that

# national health care systems lead to rationing in the form of waiting lists
# access to health care is correlated with income under national systems
# too much money is spent on the healthy, while the most critically sick are denied access to specialized care and technology

They claim that this situation is the natural result of putting politicians in charge of health care, as the policies tend to maximize the number of voters serviced rather than achieving the goals of equality. [Lives at Risk page 10]

Trends in national systems

The authors explain that most European countries with a national health care system have introduced market based reforms and relied on the private sector to reduce costs and increase the availability and effectiveness of health care. Some examples include

# the NHS has begun treating patients in private hospitals and contracting with private health care providers
# the Canadian health care system spends over a billion dollars annually on U.S. medical care
# Sweden has introduced reforms to allow more than forty percent of all heal care services to be delivered privately

Goals of the book

The authors state that the goal of the book is to dispel myths about health care as delivered in countries with national health insurance. Further, they desired to explain why the American system is bad, why the nationalized systems are worse, and how to reform the American system without making the same mistake made by many other countries.

Myths about government health care

Right to health care

While health care is not a right in the ordinary sense of the term, many people refer to it as such while calling for government entitlement programs. According to the book, citizens in countries with national health care systems do not have an entitlement to health care. The only country in the world that provides an entitlement to any health care service is the United States, whose citizens are legally entitled to kidney dialysis treatment. Citizens of other countries are not entitled to any particular treatment. While many citizens under national health care systems are allowed to wait in line for services, they are not even entitled to hold a place in line, as other patients may jump the queue.

Equality under national systems

The elderly, minorities, and rural areas are all discriminated against in national systems. National systems do not make care available based on need.

The British National Health Service was championed in 1950s as a way to end inequalities in health care. After thirty years the Black Report found inequality had not changed, and after fifty years the Acheson Report found that it had widened. ["Independent Inquiry into Inequalities in Health" Acheson Report (London Stationery Office, 1998)] Furthermore, health care quality in different parts of Britain varies greatly, with higher quality care being found in the wealthier areas. ["Geographic Variations in Health," UK Office for National Statistics, Decennial Supplement 16, 2001]

Large geographic disparity in health care has been observed in Canada as well, where the amount of money spent on urban patients was many times larger than that spent on rural patients. [Arminee Kazanjian et al., "Fee Practice Medical Expenditures per Capita and Full-Time-Equivalent Physicians in British Columbia, 1993-1994," University of British Columbia, 1995] High profile Canadian patients such as politicians and the wealthy enjoy more frequent services, shorter waiting times, and greater choice in specialists. [Sheryl Dunlop, Peter C. Coyte and Warren McIsaac, "Socio-Economic Status and Utilisation of Physicians' Services: Results from the Canadian National Population Health Survey," "Social Science and Medicine" 51, no. 1 (July 2000): 1-11]

That national health care systems make treatment available on the basis of need rather than ability to pay is also discussed as a myth. While British NHS gives preferential treatment to paying customers, such as foreigners, many Britons opt to pay out of pocket for private services in order to avoid waiting for public health care. [ "NHS Patients Opt for Private Surgery" BBC News, January 15, 2002 ]

Quality of health care

Priorities do not go towards having the greatest impact on health. Outcomes of national systems are of lower quality. Modern technology is less available under national systems. Prescription drugs are less available under national systems.

The authors contend that the United States' high infant mortality and mediocre life expectancy are not indicative of the quality of health care. In the latter case, they note that while Japan has a longer life expectancy, Japanese Americans enjoy the same long life expectancy. Similarly, infant mortality among Asians is low in Asian countries and in the US. ["Infant Mortality Statistics from the 1997 Period: Linked Birth/Infant Death Data Set," "National Vital Statistics Reports 47, no. 23 (July 30, 1999)]

The United States has a better survival rate for prostate cancer and breast cancer than most industrialized countries. [ Gerard F. Anderson and Peter S. Hussey, "Multinational Comparisons of Health Systems Data, 2000," Commonwealth Fund, October 2000.]

The authors point out that access to modern medical technology is better in the United States than in countries with national health care systems. [ Uwe Reinhardt, Peter S. Hussey and Gerard F. Anderson, "Cross-National Comparisons of Health Systems Using OECD Data, 1999," "Health Affairs" 21, no. 3 (May/June 2002): 169-81, Exhibit 5.]

Costs and efficiency

Administrative costs, costs to patients, and unnecessary care go up while efficiency goes down.Citizens under national health care system do not get more preventative care than Americans.The overhead of managed care systems in the US is less than that of national systems.

A national system would not improve America's international competitiveness in industry.

Costs of prescription drugs are comparable in national systems and in the US.

Public opinion

Public opinion of national health care has decreased rapidly since its inception in various countries.


Large organizations such as car manufacturers, cities, or states do not need federal action to implement single payer systems.

Economics and politics of health care

Proposed reforms for the American health care system

The proposal to reform the American health care system is to restructure the social safety net so that it rewards people who take care of their own health care needs while providing disincentives for those who rely on the safety net. The goal is to make it so that the economic impact of a person's choice to take care of themselves or to use the safety net is economically neutral to the rest of society.


The accuracy of some claims in this book are questionable. For example, the book claims that "citizens in countries with national health care systems do not have an entitlement to health care" and that only the U.S. gives an entitlement, but only cites an entitlement to kidney dialysis. In Britain, these rights come from a sub-set of Common law, Administrative law which is enforced by judicial review. For example parliament in the has U.K. has established a National Health Service to provide health care for the population but gives leeway to the NHS to determine what is and is not covered. The NHS establishes rules about how judgements are to be made about giving or denying care. This is tested from time to time in judicial review to create, a body of law without parliament having to legislate on the minutiae of details. This very flexible process confers legal rights to UK residents to a wide range free health care. Similar rights exist in most other countries with common law principles such as Canada and Ireland. Citizens in the U.S. generally only have a right to care if they can pay for it whereas U.K. citizens have a right to get most health care for free.

The article also says "elderly, minorities, and rural areas are all discriminated against in national systems. National systems do not make care available based on need." Again this is a highly questionable interpretation. The Black Report is cited as main evidence. One might be forgiven, having read the conclusions in "Lives at Risk" for thinking that the Black Report had reported that the NHS was fundamentally flawed and discriminatory. But that is not true. The authors essentially compared the situation immediately POST creation of the NHS with the situation 40 or so years later. So it only compares a national health care system at one point in time with the same system at a different point in time. It did not compare the situation immediately before the creation of the NHS with the situation later and did not conclude that public funding of heath care had been a failure. Although changing the rules of health care delivery had meant that health care delivery discrimination had been considerably reduced, it was still demonstrable that the level of improvement seen by disdvantaged groups as a result if the introduction of the NHS had reduced over time. In absolute terms the system post NHS was still better than pre-NHS. Black's recommendations were not to scrap publicly funded health care in favour of some other system, but to recommend that the positive discrimination was needed to ensure certain that minority groups did not lose out. Part of the problem was not that the system discriminates against particular groups but rather that the there are some groups better able to use the system than others. The system was not taking adequate steps to stop this from happening.

See also

* socialized medicine
* single payer
* publicly funded health care
* health care system

External links

* - One analysis which the book is based upon.


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