A sizable, but likely still a minority, of the population seems to think that the federal government should have sole responsibility for the funding and delivery of medical care in the US – ie, a single payer system. Many, if not, most people make up their minds about the provision of both medical care and politics on the basis of emotions rather than analysis. Nevertheless, it is useful to look how a single payer system is working elsewhere.

The National Health Service was established in the United Kingdom shortly after the end of WW II. It provides medical care for at least 90% of the British population. The remaining 10%, the most affluent citizens, pay the taxes that support the system, but go to private practitioners and hospitals for their medical care. To understand how the public and private medical systems in the UK operate go here.

The NHS has been popular since its inception both with patients and doctors. The latter have been very well paid since the beginning of the system. Recently, however, junior physicians (the equivalent of US resident physicians) have threatened to strike over low pay and long hours.

The NHS has struggled with increasing costs for decades as has virtually every medical system in the developed world. A system funded entirely by the government has only two ways to react to increasing costs. It can get more money from the government or limit the services it provides – ie, rationing. The former requires more taxes or diversion of money from other services. The latter means some patients will not get prompt treatment. Either eventuality is hated by the public. In a democracy, the result is flight from reality. All sides of the political spectrum will have their catchwords and slogans. But the basic support of the welfare state, of which medical care is the major component, will not be fixed until after it collapses. No other solution is politically possible. We’d rather have a lot of pain later than a moderate amount now.

Consider the recent response of parts of the NHS to rising costs and the subsequent reaction. The NHS (or a component thereof) will ban overweight patients and those who smoke from elective surgery until they lose weight or stop smoking. The clinical commissioning groups of of East and North Hertfordshire are under financial duress and are seeking to save £68 million during this fiscal year. Whether they can save the whole amount by denying care to those whose behavior they find objectionable is uncertain. But it’s easy to see where they’re headed.

You could expand the list of miscreants who do things that are felt to worsen their health to people with more than 1 or 2 traffic violations or to those who drink too many sugary drinks even if their BMI is less than 30. Thirty is the cutoff that the CCGs find actionable.

Of course the Royal College of Surgeons is outraged as they should be. But the basic problem remains. How to pay for ever increasing portions of medical care that are the inevitable consequence of an aging population and a delivery system that operates outside the border of a free market. Here’s the explanation for this rationing:

The CCGs already delay surgery for up to nine months for those with a high BMI, telling them to lose at least 10 per cent of their weight.

The new rules increase the amount of weight the heaviest patients must lose – and crucially, they mean those who fail to lose weight or give up smoking could wait indefinitely.

The restrictions mean those with a Body Mass Index of 30 or more will be set targets to reduce their weight by 10 per cent over nine months, with those with a BMI over 40 will be told to cut their weight by 15 per cent.

At the end of the nine months, any patient who failed to lose enough weight will have their circumstances “considered by a clinical panel” a spokeswoman said.

Those who have not lost enough weight could be left waiting indefinitely, she confirmed.

The CCG’s executives said they face a shortfall of £550 million by 2021 if they don’t ration care. They didn’t use the word ration. Do I have a solution that would work? Of course not. Once the government gives a benefit that its recipient thinks someone else is paying for, it’s forever – or at least to the death.

Most people think that medical care is a right. How much? Does one have a right to something that someone else is forced to pay for? Life liberty, and the pursuit of happiness do not require additional taxes or an increase in the public debt. But I’m making a losing argument. The best I can offer is – don’t put your faith in politicians. We’re in a medical mess and no one is going to fix it.

A couple of Shakespeare quotations come to mind:
Kill me tomorrow—let me live tonight! Othello Act 5, scene 2
Lord, what fools these mortals be! A Midsummer Night’s Dream Act 3, scene 2