Single-payer supporters portray socialized medicine as a utopia in which everyone gets all the health care he or she needs, free of charge. The facts suggest otherwise. In reality, single-payer systems have a proven track record of denying patients prompt access to treatment, and providing low-quality care.
In Canada, health officials keep costs low by restricting the supply of care, forcing people to wait months for treatment. Even Canada’s highest court has criticized its health system, noting that access to a waiting list does not represent access to care.
In Great Britain, chronic underfunding has created repeated crises in hospitals, as lack of capacity means patients wait for care. Moreover, Britain’s National Health Service (NHS) restricts access to drugs not deemed cost-effective by government bureaucrats, denying British patients life-saving treatments available in other countries.
And who can forget that right here in the United States, our veterans’ health system suffered a scandal in which patients who had survived the battlefield in the service of their country died when they came home—because the government could not provide them prompt access to care? The way Department of Veterans Affairs officials manipulated patient charts to meet government waiting list targets illuminates what a single-payer system would bring to all Americans.
At least in the case of Canada, Britain, and the VA, patients have the option to “go private”—to purchase private insurance, or obtain care at facilities run outside the government system. But if single-payer legislation makes private health insurance in the United States “unlawful,” patients may not even have those other options to obtain prompt care. The end result could resemble The Eagles’ proverbial “Hotel California,” one in which “You can check out any time you like—but you can never leave.”
In 2017, Canada spent less than half the amount the United States did on health care per person: $6,082 versus $12,865.1 Canada spent less on health care than the United States as a percentage of the country’s Gross Domestic Product (GDP), but also had a smaller GDP per person than the United States, giving Canadians less to spend overall.2
Because it spends less money on health care than the United States, the Canadian system results in less care to give. Organization for Economic Cooperation and Development (OECD) statistics demonstrate that, expressed as totals per million inhabitants, Canadians cannot access care as readily as Americans do:
Because Canada’s government limits the care available to maintain lower levels of spending, patients must often wait to access treatment.
Canada’s health system has become defined by a “queuing culture,” in which patients cannot receive care when they need it. The Fraser Institute, a Vancouver-based think tank, has conducted annual surveys of wait times in Canada’s health system. The results from Fraser’s 2018 survey may astonish Americans:
Most Americans would find delays of both this length and magnitude unacceptable. If 2.9% of the population had to wait for access to treatment in a country the size of the United States, that would equate to approximately 9.4 million Americans waiting for access to health care—greater than the populations of Los Angeles, Chicago, and Houston combined.5
Waiting for care has monetary and emotional, to say nothing of physical, costs. The Fraser Institute attempted to quantify the value of these health care queues on the Canadian economy. Their research concluded that waiting lists cost Canadians $2.1 billion in reduced economic output during working hours, and a total of $6.3 billion including their non-working hours.6 Moreover, because this Fraser study only incorporated waiting times after patients saw a specialist, it significantly underestimated the effects of health-care queues on Canadian patients, most of whom must wait months to see a specialist in the first place.
Some individuals might think that, while Canadians must wait for months to receive specialist care, at least Canada provides prompt access to primary care. Think again. A 2016 survey of patients in 11 countries, including the United States, found that Canada also had comparatively poor access to primary care:
Canada’s health-care system provides such poor access to care that between 217,500 and 323,700 patients—nearly 1% of Canada’s population—left the country for care in 2017, choosing to pay out-of-pocket rather than suffer seemingly perpetual waits for “free” treatment.8 With poor access to both specialists and primary care, Canada’s single-payer system provides a grim picture of the future Americans might soon face.
Canada’s health system provides such poor access to care that the nation’s Supreme Court issued a landmark ruling against it. In 2005, the court heard a case in which George Zeliotis, a Canadian who had struggled to receive access to care, and Jacques Chaoulli, a physician rejected for a license to open an independent hospital, challenged the province of Quebec’s ban on private health insurance—the same kind of prohibition included in the House and Senate single-payer bills. The court, noting that “access to a waiting list is not access to care,” struck down Quebec’s ban on private coverage.9
One line in particular from Canada’s Supreme Court should warn single-payer supporters. The court found that
Prohibiting health insurance that would permit ordinary Canadians to access health care, in circumstances where the government is failing to deliver health care in a reasonable manner, thereby increasing the risk of complications and death, interferes with life and security of the person.10
“Interfer[ing] with the life and security of the person” aptly describes the health-care system in Canada, and the restrictions single-payer supporters wish to export to the United States.
Britain’s government-run NHS suffers from many of the same shortcomings. As with the Canadian system, the NHS attempts to contain costs by limiting the available supply of care. Like Canada, the British system also compares poorly to the United State in access to MRI machines, CT scanners, and radiotherapy equipment.11 Britain also provides fewer hospital beds per 1,000 residents (2.58) than the United States does (2.8).12
The past several winters have exposed the NHS’s capacity problems in stark light. Chronic under-funding, coupled with the onset of influenza season, resulted in escalating crises within the NHS—so much so that the first four days of 2018 saw more mentions of the word “NHS” with the words “winter crisis” than for the entire years 2003 through 2009 combined.13 When costs rise due to an aging population and greater use of services, but taxpayer spending fails to keep pace, people must wait longer for services. The percentage of Britons spending more than four hours in the emergency room rose appreciably during the last decade, leading to bottlenecks throughout hospital systems.14
In January 2018, the combination of under-funding and a bad flu season stretched Britain’s NHS to the breaking point. Prime Minister Theresa May ended up offering apologies to British patients for the conditions they faced:
While the canceled operations and overcrowding drove headlines in the moment, a critical analysis found that the problems leading to the “crisis” appeared more structural.16 The Congressional Budget Office’s May 2019 analysis hedged on many specifics regarding single payer, but it made crystal clear that the NHS has suffered from serious shortcomings in recent years. In CBO’s estimation, those flaws came from under-funding caused by the global budget mechanism that the House’s single-payer bill would bring to the United States:
In England, the global budget is allocated to approximately 200 local organizations that are responsible for paying for health care. Since 2010, the global budget in England has grown by about 1 percent annually in real (inflation-adjusted) terms, compared with an average real growth of about 4 percent previously. The relatively slow growth in the global budget since 2010 has created severe financial strains on the health care system. Provider payment rates have been reduced, many providers have incurred financial deficits, and wait times for receiving care have increased.17
With hospitals running at near 95% capacity heading into the peak influenza period in 2018—approximately 10 percentage points above NHS targets—most facilities could barely cope with their regular patient populations and workloads.18 With very little margin for error or “surge capacity,” any problem in the health system, let alone an aggressive strain of the flu, would, and did, stretch the NHS beyond its limits.
Britain’s NHS doesn’t just attempt to save costs by restricting the supply of hospital care provided. It also restricts access to pharmaceutical treatments. The country’s National Institute of Health and Care Excellence has what some might consider an Orwellian acronym, because few find its decisions very NICE. In Britain, the NHS blocks patients from accessing treatments the institute doesn’t deem cost-effective.
Originally founded as the National Institute for Clinical Excellence in 1999, NICE establishes thresholds above which the NHS generally will not cover expensive treatments. It does so by using Quality-Adjusted Life Years (QALYs)—its estimation of the value of a year of life in perfect health. To use a crude example, if a drug extends a life by three months, and one values a year of life at $100,000, the drug would have a QALY of $25,000 ($100,000 times one-fourth of a year). NICE’s more granular analyses also consider the quality of life extended by a particular drug or treatment.
While NICE does not have hard-and-fast rules for drugs’ cost-effectiveness, it scrutinizes drugs with a high cost per QALY:
As a treatment approaches a cost of £20,000 [about $26,000-$27,000 at 2019 exchange rates] per QALY gained over existing best practice, NICE will scrutinize it closely. It will consider how robust the analysis relating to its cost- and clinical-effectiveness is, how innovative the treatment is, and other factors. As the cost rises above £30,000 [about $40,000] per QALY, NICE states that “an increasingly stronger case for supporting the technology as an effective use of NHS resources” is necessary.19
Advocates of this approach believe it helps to force pharmaceutical companies to lower the prices of their drugs, so they will meet NICE’s thresholds. However, some drugs do not meet the thresholds, in which case local NHS trusts often will not cover the therapies.
Stories of the effects of rationing within Britain’s NHS frequently feature in the country’s media. In 2006 one general practitioner, Sarah Jarvis, wrote a firsthand account of her difficulty in caring for her patients, entitled “Sentenced to Death by NICE”:
I was left feeling furious and frustrated after a visit from a patient called Peter. He’d just had a serious heart attack and my job as a GP was to reduce his very high risk of having another. I knew what the latest research told me was the best way, but I had just basically been forbidden to use it by an official email from the Department of Health.20
She went on to explain that, while she initially supported NICE’s creation, the organization had strayed from its original mission, and “served as a brake” on the introduction of new therapies.21 Jarvis recounted how one committee to evaluate a cancer therapy had health economists on its panel to estimate the drug’s costs, but no cancer specialists to gauge its clinical impact.22
Jarvis also noted how NICE initially tried to restrict access to cholesterol-reducing statin drugs for seniors, despite a “wealth of evidence” proving their effectiveness. She wrote that she found it “hard to escape the conclusion that there is a bias against treating elderly people properly simply because…they are an increasing burden on the taxpayer.”23
Despite these flaws in its research process, and the thousands of people denied access to care due to NICE research, some experts consider the organization a “success story” that is “internationally admired and copied.”24 In fact, one British think tank called for the abolition of the Cancer Drugs Fund, created by the Conservative government in 2011 and designed to provide access to costly therapies NICE didn’t deem cost-effective.25 Other health-care analysts want to bring the NICE model of rationing to the United States.
Only a few weeks after President Obama told the New York Times in 2009 that he wanted to consult ethicists for a “difficult democratic conversation” about restricting access to costly treatments, one such ethicist wrote a lengthy essay in the Times supporting the use of cost effectiveness research in the United States.26 The article, entitled “Why We Must Ration Health Care,” said that the QALY “tells us to do what brings about the greatest health benefit,” even though he admitted the approach “may then lead us to give priority to helping others who are not so badly off and whose conditions are less expensive to treat.”27 Ironically enough, however, this ethicist believed that Americans would allow government to ration health care in such a manner only if “the option of private health insurance remains available”—which it would not under the House and Senate single-payer bills.28
The U.S. single-payer bills would bring British-style rationing of health care to the United States, with only minor variations. One section of the House legislation includes the following language regarding cost-effectiveness research:
The use of Quality-Adjusted Life Years, Disability-Adjusted Life Years, or other similar mechanisms that discriminate against people with disabilities is prohibited for use in any value or cost-effectiveness assessments.29
This language, and the bill in general, do not prohibit cost-effectiveness research—quite the contrary, in fact. Other sections of the bill explicitly reference “cost effectiveness” research as one way to determine the value of physician-delivered services and prescription drugs.30 The language described above merely prohibits “mechanisms that discriminate against people with disabilities,” making cost effectiveness research that devalues other groups—for instance, the very young or the very old—perfectly permissible.
Moreover, the Senate bill includes no provision whatsoever blocking the use of QALYs.31 When compared to its companion in the House, such an omission seems particularly noteworthy—an implicit yet deliberate admission that the single-payer system will use cost-effectiveness research to deny access to expensive treatments. As with many elements of government-run health care, this provision will most harm the most vulnerable—those without the means to purchase or access care on their own.
Denying patients costly treatments affects health outcomes, as overseas comparisons demonstrate. For instance, one study examining differences in mortality rates between the United States and other countries found substantially higher colon cancer survival rates for American elderly seniors (those over age 75), in large part because screening did not decline with age in the United States.32 While other countries limit access to screening and treatment for older individuals in ways that raise death rates, the United States’ death rates decline relative to its peers as seniors age, precisely because American seniors maintain access to treatments.
Single-payer supporters often claim that the United States’ poor life expectancy rate compared to other developed countries reflects a poor health system, making the argument for socialized medicine. However, many other factors also affect Americans’ health relative to other countries—for instance, our much more heterogeneous population when compared to smaller European nations.
Moreover, Americans’ higher obesity rates appear to affect death and life expectancy rates, as do higher rates of violent deaths (both homicides and suicides).33 These issues may provide some commentary on American society, but they do not directly speak to the merits of America’s health-care system relative to its peers’.
On that front, the United States has long boasted superior outcomes from cancer treatment—the leading cause of death in developed nations—than its European counterparts. For individuals diagnosed during the years 1995-1999, American patients had an average survival rate of 11.1 years, or nearly 16% greater than the 9.3 years faced by European patients.34 The survival gap between American and European patients has remained constant going back for more than a decade.35
Moreover, while Americans spend more on cancer treatment than Europeans, they also receive more benefits, in the form of longer survival times. From 1983 through 1999, American patients received a net financial benefit—that is, increased survival compared to their European peers, even after accounting for higher spending levels—of $598 billion, or about $43 billion per year.36
Better access to treatment, better survival times, and more benefits to patients—the arguments for the American health system over single payer seem obvious, except to those on the left.
Liberals must also face the flaws exposed in a single-payer system already operating in the United States: The Veterans Health Administration. The waiting times scandal within the VA, which exploded into public view in early 2014, hints at the future the United States could face under a nationwide single-payer system. Veterans who survived battles in far-flung places from Normandy to Vietnam to Iraq could not survive their encounters with a bureaucratic culture that denied patients timely access to care.
Some of the ingredients that precipitated the VA scandal closely resemble the problems seen in other single-payer systems worldwide. For one, under-funding and an aging patient population, a problem magnified in the VA’s case by an explosion of veterans from conflicts in Iraq and Afghanistan while Vietnam and World War II vets grow older and more infirm. Then there’s its bureaucratic culture focused on meeting targets, even if it involves cutting corners to do so, and decades full of warnings that veterans were incurring wait times far longer than those publicly advertised.37
Those factors all culminated in horrific stories like that of Thomas Breen, a 71-year-old Navy veteran. In late September 2013, Breen went to the emergency room at the Phoenix VA hospital with blood in his urine.
Despite his symptoms, his prior history of cancer, and notations on the chart marking his case as “urgent,” Breen was sent home to wait—and wait—for an appointment with a urologist. Despite the urgency of his case, and his family’s regular efforts to get an appointment, not even a VA primary care doctor would see Breen—until he died on November 30, 2013, of Stage IV bladder cancer.38
Breen’s children described his agonizing last days, in which he recognized that the VA system established to help veterans like him had let him down in ways that hastened his death:
At the end is when he suffered. He screamed. He cried. And that’s something I’d never seen him do before, was cry. Never. Never. He cried in the kitchen right here. “Don’t let me die….Why is this happening to me? Why won’t anybody help me?”39
On December 6, 2013, more than two months after Breen’s initial ER visit, his children received a telephone call: The VA finally had an appointment available for their father—who had died a week earlier, thanks in no small part to the agency’s neglect.40
Breen’s case represented a symptom of a larger problem with single-payer systems. As a review ordered by President Obama concluded, the VA had developed a “corrosive culture” that affected morale, one in which VA staffers themselves called the organization’s behavior “unethical” and injurious to patients.41
Scathing as the reviews of the scandal proved, few should find them surprising. When single-payer systems lack adequate funding—and most will lack funding sooner or later because they drive up health spending—the supply of care will not meet available demand, and waiting times will almost inevitably result.
Other government-run health plans also result in poor health outcomes for patients. For instance, the Oregon Health Insurance Experiment revealed poor outcomes for patients on Medicaid.42 The experiment tracked patients randomly selected to enroll in the Medicaid program, and compared their results with a similar set of lower-income patients who remained uninsured.
A series of papers compared the results of the Oregon residents newly enrolled in Medicaid, and they did not speak well of Medicaid’s effects on patients’ health. One paper showed no measurable improvement in patients’ physical health outcomes when compared to individuals who remained uninsured.43
A second paper showed that patients’ use of the emergency room increased by 40% after obtaining Medicaid coverage. That increase in ER usage persisted over several years, suggesting that poor reimbursement levels encourage Medicaid beneficiaries to use the emergency room, rather than a doctor, as a prime source of health care.44
Medicaid beneficiaries have complained about poor access to doctors for years, such that some of them do not consider Medicaid “real insurance.”45 In just a few years, all Americans could face such a situation, with no real options if a single-payer system in the United States, like single-payer systems in other countries, lets them down.
One big difference separates these prior stories with the vision of single-payer health care the Left envisions in the United States. In the examples above, individuals dissatisfied with the government-run plan have options of their own. Thanks in part to the Chaoulli ruling, Canadian patients can purchase private insurance to cover the cost of their care. Indeed, private spending accounts for nearly 30% of all health expenditures in Canada.46
Likewise, patients in Britain can buy supplemental coverage to pay for treatments the NHS will not cover.47 At home, new veterans’ choice legislation, signed into law by President Trump in June 2018, will give them more private options should they face long waits within the VA system.48
But the House and Senate single-payer bills will make private health insurance “unlawful” in the United States, giving patients few if any options if the government-run health plan denies them access to care. Under the legislation, patients could continue pay for treatment entirely out of pocket, but only the richest individuals can afford to fund treatments like cancer drugs, or personalized gene therapies, that easily cost into the hundreds of thousands of dollars per year.
Single-payer supporters may claim that the ban on private health coverage represents an attempt, however ham-handed, to promote “fairness” within the health system. After all, prohibiting private insurance attempts to prevent a two-speed health-care system, in which wealthier individuals can buy their way to the front of the queue.
But even with that prohibition removed, a single-payer system would impose hardships on untold millions of American patients. Eliminating the ban on private insurance would allow some people to opt out of the government system—but certainly not all, or even most. As it is, even with private insurance prohibited, individuals with financial means would still have opportunities to use their financial resources to overcome government-imposed restrictions on access to costly treatments.
To put it simply, the rich will always find ways to obtain access to treatments—whether through private insurance, private care, or both. But the most vulnerable patients, and those of more modest means, will have to take whatever “options” the government-run health plan offers—and experience suggests those options will leave much to be desired.
If single-payer legislation passes, the federal government will have near-total control over your health care. History demonstrates that control will result in government not providing prompt coverage of some patients’ costly treatments. And when government blocks the use of therapies on cost grounds, vulnerable patients will have little ability to access needed care.
This dystopian future awaits American patients under the House and Senate single-payer bills. But other legislative proposals pushed by the Left will also lead to the same bleak outcome of total government control—albeit slightly more slowly.
1 Canadian Institute for Health Information, “How Canada Compares Internationally: A Health Spending Perspective, 2018,” November 20, 2018, https://www.cihi.ca/sites/default/files/document/nhex-2018-international-chartbooken-web.pptx.
2 Ibid.
3 Organization for Economic Cooperation and Development, “OECD Health Statistics,” https://data.oecd.org/healtheqt/hospital-beds.htm.
4 Bacchus Barua, David Jacques, and Antonia Collyer, “Waiting Your Turn: Wait Times for Health Care in Canada, 2018 Report,” Fraser Institute, December 4, 2018, https://www.fraserinstitute.org/sites/default/files/waiting-your-turn-2018.pdf.
5 Edward Berchick, Emily Hood, and Jessica Barnett, “Health Insurance Coverage in the United States: 2017,” Census Bureau Report P60-264, September 2018, https://www.census.gov/content/dam/Census/library/publications/2018/demo/p60-264.pdf, Table 1, Coverage Numbers and Rates by Type of Health Insurance: 2013, 2016, and 2017, p. 4.
6 Bacchus Barua and David Jaques, “The Private Cost of Public Queues for Medically Necessary Care, 2019,” Fraser Institute, March 28, 2019, https://www.fraserinstitute.org/sites/default/files/private-cost-public-queues-medically-necessary-care-2019.pdf.
7 Canadian Institute for Health Information, “How Canada Compares: Results from the Commonwealth Fund’s 2016 National Health Policy Survey of Adults in 11 Countries,” February 16, 2017, https://www.cihi.ca/sites/default/files/document/commonwealth-fund-2016-chartbook-en-web-rev.pptx.
8 Colin Craig, “Policy Brief: The Flight of the Sick,” Second Street, March 2019, https://www.secondstreet.org/wp-content/uploads/2019/03/Policy-Brief-Flight-ofthe-Sick.pdf.
9 Chaoulli v. Quebec, 2005 SCC 35.
10 Ibid.
11 Organization for Economic Cooperation and Development, “OECD Health Statistics.” Data for mammography equipment were unavailable for the United Kingdom.
12 Ibid.
13 Harry Carr, “Why Is There Always a Winter Crisis in the NHS?” Sky News, January 4, 2018, https://news.sky.com/story/why-is-there-always-a-winter-crisis-inthe-nhs-11195502.
14 Ibid.
15 Sophie Borland, Claire Duffin, and James Tozer, “Winter Crisis Cripples the NHS: 55,000 Operations Are Postponed, Patients Are to Be Put on Mixed Wards, and Senior Doctors Will Man Doors at A&E Wards to Turn Away Non-Urgent Cases,” Daily Mail, January 3, 2018, https://www.dailymail.co.uk/news/article-5229733/Thousands-NHS-operations-cancelled-winter.html#ixzz537tRpXfJ; Benjamin Kentish, “NHS Winter Crisis: Theresa May Apologizes to Patients for Thousands of Cancelled Operations,” Independent (UK), January 4, 2018, https://www.independent.co.uk/news/uk/politics/theresa-may-nhs-crisis-winter-apology-patients-cancelled-operations-latest-updates-a8141591.html.
16 Siva Anandaciva, “A&E Performance Reaches a New Low,” The King’s Fund, January 12, 2018, https://www.kingsfund.org.uk/blog/2018/01/ae-performance-reaches-new-low.
17 Section 611 of H.R. 1384, the Medicare for All Act of 2019; Congressional Budget Office, “Key Design Components and Considerations for Establishing a Single Payer Health Care System,” May 1, 2019, https://www.cbo.gov/system/files/2019-05/55150-singlepayer.pdf, p. 26.
18 Anandaciva, “A&E Performance Reaches a New Low.”
19 Nigel Edwards, Helen Crump, and Mark Dayan, “Rationing in the NHS,” Nuffield Trust Policy Brief #2, February 2015, https://www.nuffieldtrust.org.uk/files/2017-01/rationing-in-the-nhs-web-final.pdf, p. 8.
20 Sarah Jarvis, “Sentenced to Death by NICE,” Daily Mail, November 27, 2006, https://www.dailymail.co.uk/health/article-419083/Sentenced-death-NICE.html.
21 Ibid.
22 Ibid.
23 Ibid.
24 Edwards, Crump, and Dayan, “Rationing in the NHS,” pp. 8-9.
25 Ibid., p. 10.
26 David Leonhardt, “After the Great Recession,” The New York Times April 28, 2009, https://www.nytimes.com/2009/05/03/magazine/03Obama-t.html.
27 Peter Singer, “Why We Must Ration Health Care,” New York Times, July 15, 2009, https://www.nytimes.com/2009/07/19/magazine/19healthcare-t.html.
28 Ibid.
29 Section 501(b)(2) of H.R. 1384.
30 Sections 612(d) and 616(1)(A) of H.R. 1384.
31 Compare Sections 501(b)(2) and 612(d) of H.R. 1384 with Sections 501(b)(2) and 611 of S. 1129, the Medicare for All Act of 2019.
32 Jessica Ho and Samuel Preston, “U.S. Mortality in an International Context: Age Variations,” Population and Development Review 2010, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140845/.
33 Ibid.
34 Tomas Philipson, et al., “An Analysis of Whether Higher Health Care Spending in the United States versus Europe Is ‘Worth It’ in the Case of Cancer,” Health Affairs, April 2012, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2011.1298.
35 Ibid.
36 Ibid.
37 United States Government Accountability Office, “Veterans Health Care: VA Needs Better Data on Extent and Causes of Wait Times,” Report GAO/HEHS-00-90, May 2000, https://www.gao.gov/assets/240/230347.pdf.
38 Scott Bronstein and Drew Griffin, “A Fatal Wait: Veterans Anguish and Die on a VA Hospital’s Secret List,” CNN, April 23, 2014, https://www.cnn.com/2014/04/23/health/veterans-dying-health-care-delays/.
39 Ibid.
40 Ibid.
41 Jim Kuhnhenn, “VA Review Finds ‘Significant and Chronic’ Failures,” NBC News, June 27, 2014, https://www.nbcnews.com/news/us-news/veterans-affairs-review-finds-significant-chronic-failures-n143151.
42 More information available at http://www.nber.org/oregon/.
43 Katherine Baicker, et al., “The Oregon Experiment: Effects of Medicaid on Clinical Outcomes,” New England Journal of Medicine, May 2, 2013, https://www.nejm.org/doi/full/10.1056/NEJMsa1212321.
44 Amy Finkelstein, et al., “Effect of Medicaid Coverage on ED Use: Further Evidence from Oregon’s Experiment,” New England Journal of Medicine, October 20, 2016, http://www.nejm.org/doi/full/10.1056/NEJMp1609533.
45 Vanessa Fuhrmans, “Note to Medicaid Patients: The Doctor Won’t See You,” Wall Street Journal, July 19, 2007, https://www.wsj.com/articles/SB118480165648770935.
46 Sara Allin and David Rudoler, “The Canadian Health Care System,” in Elias Mossialos, et al., eds., International Profiles of Health Care Systems, Commonwealth Fund, May 2017, https://www.commonwealthfund.org/sites/default/files/documents/___media_files_
publications_fund_report_2017_may_mossialos_intl_profiles_v5.pdf, p. 21.
47 Quoted in Ruth Thorlby and Sandeepa Arora, “The English Health Care System,” in Mossialos, et al., eds., International Profiles, p. 49.
48 VA MISSION Act, P.L. 115-182.