• The demonization of wait times

    I’ve spent a lot of time this last week talking about wait times. In fact, I’ve been talking about them for years. But I was thinking last night that I’ve fallen into a trap. In debating the existence of, or lack of, wait times, I have failed to put them in proper perspective.

    Wait times aren’t like cancer. We know what causes wait times; we know how to fix them. You spend more money.

    The wait times that Canada might experience are not caused by its being a single payer system. I can’t tell you how may times I’ve been confronted by an angry opponent of health care reform who lectures me on how much less time it takes to get a hip replaced or a cataract repaired in the US than in Canada. But do you know who gets most of the hip replacement and cataract repairs? The elderly.

    Do you know who pays for care for the elderly in the United States?  Medicare.

    Do you know what Medicare is?  A single-payer system.

    So our single-payer system manages not to have the wait times issue theirs does. There must be some other reason for the wait times. There is, of course. It’s this:

    Canada isn’t some dictatorship. They aren’t oppressed. In 1966, the democratically elected government enacted their single-payer health care system (also known as Medicare). Since then, as a country, they have made a conscious decision to hold down costs. One of the ways they do that is by limiting supply, mostly for elective things, which can create wait times. Their outcomes are otherwise comparable to ours.

    Please understand, the wait times could be overcome. They could spend more. They don’t want to. We can choose to dislike wait times in principle, but they are a byproduct of Canada’s choice to be fiscally conservative.  They chose this. In a rational world, those who are concerned about health care costs and what they mean to the economy might respect that course of action. But instead, we attack.

    What disturbs me is that we, in this country, panic about our extreme health care costs and the deficit, while simultaneously attacking other systems for the means by which they control those things. You can hate the high costs or you can hate the wait times for some things, but it’s sort of irrational to think you can have neither.

    UPDATE: Edited for clarity.

    • Do you happen to know what wait times in the VA are? I’d be interested to know. My guess is that they’re low because society is willing to pay for veterans’ healthcare — and when you spend more, you wait less, even in a pure model of socialized medicine like the VA.

    • The health care crisis is a crisis of expectations. Patients expect instant care and access to “everything” at little to no cost (buffered by insurance and other programs). Industry including insurers ( and their stock holders) expect double digit yearly profit increases. Doctors expect incomes consistent with their expectations.

      Where are the brakes?

      • You just explained Capitalism. You should read up on it. It’s the best system for lifting people out of poverty in the world.

    • A small quibble… my sense is that Canadian wait times are in part due to mistakes in allocating physicians, and they could be shortened without increasing cost. But overall, a very sensible post.

    • Thanks for exploring this subject, Aaron. There’s another option you should consider.

      In a market-oriented system, if you increase the supply of physicians and hospitals, wait times go down, and costs go down because of price competition. Unfortunately, we deliberately constrain the supply of both with Congressional action.

      • @Avik – Costs go down? I think you mean prices. Costs likely go up (P x Q).

      • Avik brings up a good point but it’s broader than he asserts. Avik’s point, wait times can go down by increasing the supply of physicians, isn’t limited to a purely laissez-faire system. In France wait times for visits to general practitioners is substantially less than in the U.S.. Aaron has also presented evidence that France has substantially more GPs per capita than the U.S. Additionally, there’s plenty of anecdotal evidence in the health literature and in French policy debates that they have an oversupply of doctors. My personal experience is that you can get a same day appointment with most GPs and pretty certainly an appointment by the next day. Doctors also alternate so that some are open early in the morning and some are open the evening. As a result of the oversupply, they are able to pay doctors substantially less than in the U.S. per act (it’s a fee for service system in the clinic setting) and in overall compensation (this holds in PPP terms, nominal exchange rate terms and in terms of their place in the income distribution).

        I’d suggest we need more doctors in the US. Note that PPACA, as amended by the HCERA (“health reform”) increases Medicare compensation for teaching institutions to pay for greater medical education. To address concerns of doctors finding new procedures, the payer “la securite sociale” also retrospectively reviews providers billings to search for irregularities or particularly high claims.

    • Past experience has shown, more doctors=more utilization and more costs. Health care is not TV’s or computers.

    • Paul, but it’s unclear whether the increased utilization is due to lower time costs of waiting or induced demand because of more docs.

    • “In a market-oriented system, if you increase the supply of physicians and hospitals, wait times go down, and costs go down because of price competition. ”

      Not what we see with private insurance. We docs just find more work to do.


    • steve, the current private insurance system is not very market-oriented. Very little in the current system is market-oriented.

    • Your OECD link is broken, please update

    • It’s also worth noting, as the Dartmouth Atlas says, that:

      “rates of knee replacement, hip replacement, and back surgery all vary remarkably [across the US], reflecting the fact that there is far less consensus among physicians about *when* to do these procedures, who needs them, and how effective they are in addressing the problems they are intended to solve.” (my emphasis)