In a speech on November 13, 2002, in what many considered a precursor to his presidential campaign, Former Vice-President Al Gore announced his support for a single-payer "nationalized" health care system, citing the need to provide care to nearly forty million currently uninsured Americans as his motivation [1]. While Mr. Gore has since withdrawn from the presidential running, the idea still remains very much on the minds of Washington politicians and Americans in general.

I desired to approach this topic with an open mindedness, but after reading about the socialized health care systems present in Canada and Europe, it soon became clear to me that these systems were not something I could support. All of these systems have their various nuances, and it would not be possible for me to deal with every aspect of every one in an article of this size. Thus I have chosen to focus my analysis on one system, Britain's National Health Service (NHS), for the sake of clarity and coherence.

But before I begin my discussion of the NHS, I would like to respond to a common argument often used during debates of this nature. The nationalized health care systems of Britain, France, and Canada, among others, are frequently compared with the US system, and this comparison is used to conclude that socialized systems are superior to free-market systems. I agree that the US Health care system has its flaws, but in truth, it cannot be considered a model of "free-market" health care. Approximately 45% percent of the money spent on health care in the US is for government programs or hospitals-17% Medicare, 15% Medicaid, 12% Dept. of Defense and VA-and 6% of money is spent on the construction of new hospitals and clinics. This leaves less than half of the money spent on US health care-49% to be exact-for private insurance or out of pocket payment [2]. Thus, the comparison of socialized health care systems with the supposed "free-market" system of the US is not valid. Furthermore, my other contention with this argument is that at some point one must judge a system on an absolute scale as opposed to a relative scale. This is what I intend to accomplish through making a comprehensive comparison of the pros and cons present within the NHS.

The NHS was created in 1948 and promised free health care to every citizen of Britain. While initially successful, the system has now come under financial troubles and has begun to reveal the inherent flaws in a rationing-based system. The first flaw that one would expect to see is overuse of the service, a free commodity, until it becomes completely exhausted. In economics, this is known as the "free-rider" problem and is exactly what has taken place in Britain. The NHS has essentially put a monetary cap on the services it will provide, which they believed would satisfy all the health care needs of all UK citizens. But because the NHS did not take into consideration the increase in demand due to the seemingly limitless, and free, supply of health care services, many patients are finding themselves without the treatment they need. While the situation becomes more complex when one takes into consideration the growing and aging population and increasing costs for more recent technology and medical advances, theses problems are nonetheless related to the initial assumption that all health care costs could be contained and presented to the public as free. To compensate for this flaw in the system, the NHS was forced to establish a waiting list. According to a NY Times article on April 18, 1999, the number of sick people on the waiting list was 1.12 million [3]. Since then the number has risen to nearly 1.5 million people. That is approximately 6% of the British population, a number equal to the US's current unemployment rate.

But even worse, those on the waiting list are not able to receive the care they need in time. Every year, twenty-five thousand cancer patients on the NHS waiting list die unnecessarily [4]. The NY Times reports that these are "[cancer patients] who would most likely have survived if they lived in countries with better standards of treatment, like France, Germany, or the US" [5]. The World Health Organization has recently called the NHS a deliverer of "third world cancer care" [6]. Furthermore, according to the BBC, five hundred patients die from heart disease while on the NHS waiting list [7]. These are patients that should get their "operations as soon as the heart condition is diagnosed," but are forced to wait because of limited resources [8].

This free-rider behavior is not unique to Britain, and I believe these behavioral trends would continue if a socialized health care system was implemented in the US. A recent study reported on July 20, 2002 in the NY Times reveals this same prediction. In a system where treatment in free, John E. Wennenberg of the Dartmouth Medical School, states that "if there are twice as many doctors, then patients will come for twice as many visits" [9]. A study comparing the costs and benefits of Medicare, a governmentally funded health care program targeted towards citizens sixty-five and older, in the cities of Miami, FL, and Minneapolis, MN, revealed that essentially health care supply drives health care demand. Miami, which possesses a high abundance of specialists and doctors, treated patients at fifty thousand dollars more per patient over a lifetime than did Minneapolis, which possesses many less specialists and doctors. As the article revealed, "[patients] had more than six times as many visits to medical specialists as those in Minneapolis, spent twice as much time in the hospital and were admitted to intensive care units more than twice as often"[10]. But all this additional health care had no discernible impact on patients' health. What it did show is that when health care is free (Medicare), people will exhaust the available resources despite whether or not it has any benefit on their health.

In addition to the free-rider problem, socialized health care creates other behavioral problems. When citizens know that they possess free access to health care, they may not feel the need to be as responsible for their health. Preventive care is something that is critical in saving costs and is the best way people can limit the effects of the disease, but the presence of the health care 'safety net' removes the incentive to make use of preventive care. As Sarah Lyall of the NY Times points out, "many Britons never visit the doctor until their symptoms become alarming" [11]. Often when they do arrive for a check-up, their disease has already progressed to a serious, yet preventable, state.

Because of waiting lists and overuse, the NHS is trying to meet growing needs with waning resources. This has stopped the NHS from being able to invest in cutting-edge treatments and has thus created a technology lapse. A prime example is prescription drugs. According to the BBC, drugs may soon cost the NHS "a price that it will struggle to afford, no matter how much extra cash is pumped into the system" [12]. A survey published by the National (UK) Schizophrenia Fellowship found that nearly half of health authorities in the UK cannot afford modern anti-psychotic drug treatments for schizophrenics [13]. Instead, thousands of patients are being given older, less effective drugs, which have serious side effects. Multiple sclerosis patients cannot receive Beta Interferon from the NHS, even though it has been shown to have a dramatic effect on a potentially crippling disease. What is the NHS's excuse? Stephen Thorton, chief executive of the NHS confederation, says "[health authorities] have to take some critically difficult decisions, weighing up on balance whether to invest in a drug like [Beta Interferon], or whether to invest in other new procedures and interventions in other parts of the health service" [14].

Mr. Thorton's words could not more perfectly elucidate the problems with a rationing based system. Money that is allocated for certain uses is often used up for problems that suddenly arise, forcing the NHS to remain in a state of perpetual catch up rather than one of progress. Information technology is another prime example. According to the BBC Online, Britain Health Secretary Alan Milburn has admitted, "the NHS's information technology is fragmented and piecemeal" [15]. As he told the author of the article, "it is clear that money earmarked for IT in the past has been siphoned off for other projects and as a result the NHS is falling behind when it should be steaming ahead." Information technology is rapidly infusing all areas of medical technology and thus makes these statements significant. But just how bad is it? It is so bad that hospitals can't carry out simple procedures like e-mail. Hospitals will instead print out letters, post them, and then have them scanned back into the system to finally be attached to the patient's computerized file. Some employees spend "virtually all day scanning letter from hospitals, insurance companies and other practices into the computer" [16]. This is all money that could be saved and put towards better use.

While the system clearly has its effects on patient care, doctors and nurses also suffer. According to Sir Donald Irvine, the president of the General Medical Council - the doctors' own regulatory body - morale among doctors in the NHS is at an all time low [17]. As he states himself "I cannot remember a time when so many doctors have felt so angry, undervalued, and disillusioned" [18]. He cites doctors' inability to perform the type of care they feel is best for their patients coupled with low salaries as the major contributors to low morale. Doctors also receive the brunt end of public and government criticism despite having literally no control over the situation. How are doctors supposed to provide a high quality of care under these circumstances, and even if they could, why would a system want to continuing placing them under these stresses?

The situation for nurses is even worse. According to the BBC "eight out of ten nurses have considered leaving their jobs because of either low morale or poor pay" [19]. Recent studies have shown that one-third of nurses have taken on a second job in order to make extra money. Of the nurses that considered leaving their job, 87% cited feeling undervalued [20].

With the situation becoming worse and worse for doctors and nurses, the number of students applying to medical school has also significantly dropped. According to the Universities and Colleges Admissions Service (UCAS), for every two medical school seats that exist there are only three applicants interested in filling these seats while just six years ago, the ratio was five to two [21]. This is a 40% decrease in medical student admissions and clearly does not speak well for the future of the profession.

Looking at the data I have shown I feel that I can safely assert that reform is needed. The NHS is in financial crisis, which needs to be remedied quickly and efficiently. But before I continue, I would like you to consider an idea by Nobel Laureate in Economics Milton Friedman. He wrote: "If economic power is joined to political power, concentration seems almost inevitable. On the other hand, if economic power is kept in separate hands from political power, it can serve as a check and counter to political power" [22].

This statement sums up precisely why the NHS, or any socialized health care system, will continue to have difficulties. The population is growing and getting older, technology will continue to be expensive and demand will continue to increase. The inadequacies have already been exposed, but now in addition to that, reforming the system is even more difficult. Remember the twenty-five thousand cancer patients that die annually? According to Karol Sikora, the former chief of the World Health Organization's cancer program, Britain needs about double the number of cancer specialists [23]. To reach European levels, "Britain would have to spend hundreds of millions of dollars to hire, train, and support new cancer doctors" [24]. But because the economic power is joined with the political power, this becomes difficult to accomplish. Tony Blair recently promised that the NHS would bring up its health spending to European levels by 2006. But the promise soon became an "aspiration" once treasury officials calculated that such a feat would cost an extra twelve billion pounds a year, money that would come out of roads and schools. As Friedman so accurately pointed out, serious reforms of this manner become almost impossible because the money needed to fix things will always be linked to another social program as long as the system is run by the state. PM Blair was able to make some twenty-one billion pounds available to the NHS already, "but much of that money is being taken up by steep salary increases for workers" [25].

From the analysis of the NHS, we can see that socialized systems that ration health care are full of problems. They promote overuse with inadequate supply, discourage self-responsibility by providing a 'safety net,' limit technology growth, place doctors and nurses under incredible pressures, and are very difficult to reform. For these many reasons, I believe that implementing a socialized health care program in the US is not the answer to our health care problems and would eventually make the situation worse.

Vishal is a fourth-year pre-medical student majoring in Bioengineering.