The Conservative Case for National Health Insurance--got me banned at RedState.

In 2006, I posted the following on RedState, and got banned from that site. I thought about it because of teacherbill’s diary here today, regarding hell freezing over. I reproduce my ancient diary below, as submitted then; links may have broken.

The Conservative Case for National Health Insurance

“There is a tide in the affairs of men, which, taken at the flood, leads on to fortune. Omitted, all their lives are spent in shallows and in miseries.” (Shakespeare, Julius Caesar)

Abstract: Conservatism is now presented with a golden opportunity. American medicine is the best in the world, but our current system of financing medical care creates rents and economic deadweights, and reduces liberty—all antithetical to conservative principles. National health insurance (NHI) will eliminate these rents and deadweights, increase liberty, improve health, and promote economic prosperity. NHI will make our superb medical care system available to all Americans for less money than we currently pay to provide health care for a fraction of our citizens. NHI would affect only the financing of medical care, not the practice of medicine. National health insurance is consonant with conservative principles and values.

I believe that American conservatives, including the Republican Party, are now presented with a momentous opportunity cleverly masquerading as a menace. This perceived menace is a tidal event of Shakespearean proportions. Republicans can ride this tide on to fortune, or they can impotently attempt to sweep it back and spend subsequent decades in shallows and in miseries.

In this essay, I shall argue that conservative principles, values, and interests support national health insurance (NHI), and that conservatives and the GOP should adopt health care reform that includes national health insurance.

Just to be clear what I am proposing for National Health Insurance: That the United States’ Federal Government be a single-payer, covering basic health care services for all United States citizens. I am proposing, essentially, ‘Medicare for all’ US citizens, reimbursing physicians, hospitals, and other providers, for all covered services, the scope of such services to be determined by an independent board (similar to the membership of the Federal Reserve board, made up of recognized health authorities, independent of politics), based upon the best available evidence for cost-effective medicine. Reimbursement rates would likewise be set by this board based on historic reimbursement patterns, but always with an eye to supporting evidence-based, cost-effective medicine as it inevitably evolves. Insurance companies would have no role in covering these services, but would be free to sell supplemental policies to cover (for example) cosmetic plastic surgery, alternative medical therapies, and so on. Physicians and other providers would be free to opt in or opt out of the system during some annual ‘open season’ but could not select whether to accept or decline payment otherwise. Any given physician might provide both covered and uncovered services, though: for example, a plastic surgeon would be able to bill NHI for repair of facial injuries from an automobile accident, but not for a facelift. My proposed NHI is the socialization of the costs of medical care, the inflated costs of which we already bear. It is not the ‘socialized medicine’ bugaboo of regimented, employed, physicians. In fact, it expands freedom of choice for physicians and for currently insured and uninsured alike.

The conservative rationale for this proposal:

National Health Insurance:

Promotes liberty of patients and physicians alike.

45 million Americans do not have access to care by a physician of their choice. NHI addresses this. Many more millions who currently have health insurance are limited to specific providers and groups of providers, and are similarly limited in their liberty. Many physicians’ liberty is currently limited by economic considerations—these individual physicians may be limited by contracts with insurers, or by the need to restrict the numbers of charity cases they see.

Promotes economic activity.

Many current employees are tied to their employers by health insurance that they cannot afford to relinquish, particularly if they have a sick child or spouse. Freeing them to pursue better employment would improve economic activity.

Reduces the ‘free rider’ problem.

An undetermined number of Americans elect to forgo health insurance, ‘betting’ that they are healthy, and lucky, enough not to need major health care while they are ‘bare.’ When they do get sick, to the extent they cannot afford health care, they depend on some form of charity care. And, all too often, they face bankruptcy.

Promotes equity.

The flip side of the free-rider problem is the problem of who pays for care of the medically indigent. Most physicians provide significant free care, though this percentage is dwindling. Hospitals provide free care, as well, but the burden is not equally shared among hospitals. There seems to be no more justification for society’s expectation that the burden for charity medical care should fall upon the medical sector that it would be reasonable to ask farmers to be solely responsible for feeding the hungry, the construction industry to house the homeless, or the garment industry to clothe the naked. To the extent that some sort of social contract exists, it is among society at large.

Promotes fairness now, and anticipates the future.

Currently, health insurance companies try very hard to select low-risk patients: the problem of ‘cherry picking.’ They like to insure healthy workers, and when they pursue the senior market, they might, for instance, send their reps to square dances or set up booths at senior athletic events. They do not spend an inordinate amount of time soliciting new clients at nursing homes. They get more sophisticated in their cherry-picking all the time, but the real threat looming on the horizon is genetic profiling. As soon as this is available, they will be able to ‘insure’ the nearly risk-free, and leave adverse selection to the public domain. The way to avoid this problem is to have all U.S. citizens in one risk pool: NHI.

Promotes economic efficiency.

Currently, the private health insurance sector consumes approximately 20-25% of its revenues in overhead and profits. Medicare’s administrative burden is 4%. The Canadian system consumes just about 1% in administrative overhead. (I believe that Canadians are not four times as smart as Americans; I believe that the extra administrative burden in our own Medicare is due to our contracting out to private, for-profit contractors those functions better done in-house. And the Medicare D fiasco will carry a 12% administrative overhead and pay perhaps double what it should for drugs—but this is a discussion for another venue). To the extend the government has encouraged the health care industry/insurance industry liaison, it has established what economists term rents—and this overhead is an economic dead weight costing the U.S. economy. It takes more people to administer Blue Cross/Blue Shield of Massachusetts that it does to administer the entire health care system of Canada. Before Canada implemented their national health program, their health costs were the same fraction of GDP as in the U.S. After they implemented their program, Canada’s cost remained stabilized at 9% while U.S. costs have increased to 15% of our GDP—but Canada’s health outcomes have improved absolutely and have improved relative to the U.S.! Meanwhile, “The United States wastes more on health care bureaucracy than it would cost to provide health care to all its uninsured.” (Himmelstein, Woolhandler and Wolfe, ‘Health care system in 2003: the cost to the nation, the states, and the District of Columbia, with state-specific estimates of potential savings’ (http://www.pnhp.org/news/IJHS_State_Paper.pdf))

Reduces medical malpractice claims, lawsuits, and (possibly) premiums.

Currently, of judgments and settlements in medical malpractice cases, most of the award is for the expense of medical care. To the extent such care is provided by NHI, there would be no reason to ask (or justification for awarding) for these damages. In any given case of medical liability, if there is no claim for the expense of medical care, there is a lower probability of any lawsuit being filed at all. We can anticipate fewer lawsuits, lower settlements, less clogging of courts, lower expenses to run our courts. Whether physicians would see lower premiums is a matter of conjecture, since premiums that they pay bear almost no relation to the loss-experience of the carriers themselves.

Can be a good deal for most physicians and hospitals.

Currently, physicians typically employ several staff for billing, and hospitals have large billing departments. Cost savings drop to the bottom line. In addition, if medical liability claim reduction is reflected in rates, more income flows to physicians. How much income will increase or decrease will largely be a function of allowable charges, set by the board I propose. I would expect the board to attempt to be income-neutral, but that is conjecture. I would note that if administrative overhead is reduced from 20% to 4% (or even 1%!), and the current piece of the medical economic pie that physicians get is 11%, physician income could more than double from that savings alone—not that I expect it to happen.

Increases the wealth of the nation.

Effective medical care makes us richer. Life and health have economic value, or we wouldn’t spend so much to try to preserve both. Providing efficient, effective care to people who don’t get it now will make them richer, and, since they are part of our society, as citizens, consumers, and workers, we will be more prosperous as well. This is especially true in areas like vaccinations, which return exponentially on investment. NHI improved health outcomes in Canada and other nations, and will do the same in the U.S.

Improves international competitiveness.

General Motors builds cars in Canada for about $800 less than in the U.S., because of decreased medical costs there. (Meanwhile, Wal-Mart spends money teaching its employees how to file for Medicaid….) Instituting NHI would reduce the direct burden on corporations that currently pay for their employees’ health care, and would eliminate the legacy costs to corporations that are currently being crushed under such costs.

Reduces other costs to society.

Many costs of our inefficient system will be reduced by NHI:

Less defensive medicine

Auto insurance: decreased auto insurance rates as companies experience lower loss rates

Decreased costs to our courts.

Less advertising by attorneys.

Less front-loaded charges by companies trying to hedge against unpredictable rises in health care costs.

Unburden legacy costs to corporations.

Promotes families.

Health care is a major concern of families. Illness is a major contributor personal bankruptcy. Medical care of children is often a relatively low priority of society (or pediatrician incomes would not be at the low end of the medical-income spectrum), but has potentially high impact for families and for the economy as a whole.

Is a once-in-a-generation opportunity for conservatives and the GOP.

National Health Insurance is the right thing to do, for the reasons I have enumerated. If the GOP seizes this opportunity, it can claim credit for NHI for generations, and it can shape the structure of NHI as it will not be able to do so effectively if it is a Democratic plan. I’m not suggesting that the GOP do it because it’s expedient to do so—such an argument would be, in my view, immoral, and most un-conservative. But when the right thing to do is also in the interest of the Right, then the Right ought to take this tide at the flood.

Winners and Losers

In any major societal change, there are winners and losers. I anticipate:

Losers:

Health insurance industry will be a big-time loser. Billions gone. Execs on the street, looking for honest work.

Thousands of people now working in the offices, file rooms, and clerical pools of insurance companies and in the billing departments of hospitals and physicians offices will be out of work, too. Their industry-specific skill sets will no longer be needed, and that is most unfortunate. But their employment was part of the economic dead weight I cited.

Medical liability companies. With lower risk of suits, rates will eventually have to come down, ditto their income. Expect a long delay.

Healthcare administrators will have a hard time, too.

PPOs and any organization that makes money by shifting risk to individual physicians.

Trial attorneys and their staffs will suffer horribly.

Drug companies. With NHI, current Medicare D must become more manageable, rationalized, and drugs put out to bid.

Advertising industry.

Lobbyists and political consultants to the healthcare industry (but they’ll get a nice short-term bump in the run-up to NHI.)

Slow politicians.

Winners:

America. Almost every U.S. citizen, long-term, despite the disruption.

U.S. Public Health departments as they concentrate on public health rather than indigent care.

Physicians, I believe. But the devil is in the details of fee schedules. Most likely better job satisfaction for physicians, too, as they will not be spending eight hours per week dealing with insurance companies.

Politicians and parties who shape NHI.

Notes and further explication:

Funding:

I would propose a flat tax of about 8% on all individual and corporate income to pay for NHI. I arrive at this figure because we currently spend 15% of our GDP on health care this country, and my NHI would not cover most alternative care or cosmetic surgery or some other services (see below) and so on. The precise amount would be determined by the board I propose, based upon best medical evidence. This is not an increased cost to society, but a reduction in cost, as the economic dead weight of insurers, liability insurance, and other losses is eliminated.

Some individuals (especially high-income individuals like Bill Gates) will be worse off. Some corporations (those who are not paying much for medical care, such as Wal-Mart) will be worse off. Most individuals and many corporations (like General Motors) will be better off.

Services not covered:

My own preference would be to not cover elective abortion services and in-vitro fertilization. As discussed, my NHI would not include cosmetic surgery, but it would (for instance) cover repair of cleft-lip/cleft palate, and correction of scars from traumatic injuries, or medically necessary blepharoplasty. It ought to cover preventive dental care that the board finds medically cost effective (for example, if periodontal disease causes coronary artery disease, treatment might be covered). Services not covered would also include such things as bone marrow transplantation for breast cancer, until, and unless such therapies are proven effective. This would eliminate the kinds of political and court battles that this specific issue engendered. Of course, research would be needed to determine what treatments are effective, and NHI must fund well-designed research protocols.

Why not Romney-care?

The Romney plan is well-considered, but I believe it inadequate. It leaves in place many of the deficiencies of the present system, including almost all of the economic dead weight I have discussed.

What about Canada and other nations?

Before NHI, Canada had a higher infant mortality rate and a lower life expectancy than did the United States. Now Canada is superior to the U.S.in both measures—and has the highest patient satisfaction of any nation.

Every nation in the industrialized West spends less, gets more, and has higher satisfaction rates with its system than does the U.S. There are a lot of reasons for the disparities—economic, racial, data-gathering, and so on. And each of these nations has done NHI differently. When we design NHI, we need to look at the successes and failures of each system. We would not, in my opinion, ever want to design a quasi-British National Health Service.

Aren’t all those data you cite flawed?

Yes. To some degree, the data used to compare health outcomes among nations are all flawed.

Infant mortality data are among the most hotly contested. Perinatal mortality is associated with many factors—race, socioeconomic status, diet, alcohol and illicit drug use, violence, maternal height, health insurance status, and a host of other associations. Some nations tend not to report as live-born those infants born with very low birth weight. In some places, infants who are born exceedingly small (as Isaac Newton reportedly was) are laid aside, expected to die, and are often uncounted, whereas in the U.S., they are more often treated with heroic measures. And some nations do not count foreign nationals’ infants, but do count their own infants born on foreign soil; so it’s all very messy. On the other hand, the currently uninsured in the U.S. get less prenatal care than do the insured, and lack of prenatal care is a predictor of pre-term delivery, small-for-gestational-age birth-weight, and perinatal mortality. I don’t know anyone who asserts that if data were uniformly gathered, that the U.S. would suddenly have the best perinatal outcomes in the world—and if anyone so asserts, I’d love to see the data underlying that claim. Given the Canadian experience of improved infant mortality after NHI, anyone who values life might consider NHI worth a try here.

Longevity and age-specific mortality data are also often cited as indices of healthcare status. Critics fairly observe that mortality is a function of complex inputs, and that wealth, proper diet, exercise, clean air and pure water, hygiene, sewage treatment, vector control, violence reduction, and so on have been bigger contributors to our dramatic improvement in longevity—and our improved vigor at every age—that we have seen over the last two centuries. But vaccination, antibiotics, anesthesia, surgery, roentgenography, and the host of technical medical advances have helped, and I don’t know anyone who thinks we’d do nearly as well without them, or would dispense with them just to see how much they really do contribute.

Patient satisfaction is another controversial area, since the U.S. lags. Maybe our European friends have been brainwashed into thinking they have it pretty good. Maybe Canadians are such nice people that they wouldn't complain, and that’s why they have the highest patient satisfaction in the world. Maybe Americans are just whiney.

Oh, yeah. One more data set. Two generations of American soldiers marched off to European wars. One of the things they remarked—as did several additional generations of American tourists—is how short all those Europeans were. Well guess what? European kids are now taller than are American kids. Maybe it’s the metric system.

So it’s just a competition? Us against the rest of the industrialized West with regard to statistics?

Not so much. Suppose you live in a nice neighborhood, call it IndusWest. It’s the nicest neighborhood, the best in the world, used to have nasty brawls, but that’s all over now. You own a shiny car, and you’re proud of it. Your neighbors all have shiny cars, too. But your neighbors tell you they paid about half, maybe two-thirds what you paid. And they say they get better mileage. You rationalize: Franky is a liar. Gerhardt drives with a foot like a feather. Tommy doesn’t even take care of his sick, elderly parents, how much can you trust him? But your next-door neighbor used to have a car just like yours, traded his in, and is the happiest guy in the world now. Do you continue to rationalize, or do you check out the dealerships that your neighbors bought from?

Are you saying our car—I mean, our medical care—is the worst in the world?

Far from it. American medical care—the doctors and nurses, biomedical researchers and engineers, the entire medical team, and their hospitals and technologies—are at the apex of an ascending arrow of human progress. I was proud to be a tiny part of that team for my entire professional life. I am so proud of its accomplishments that I want our best care to be available to every American.

There are flaws in all those other national medical systems I cited. If you have a myocardial infarction in England, your treatment is likely to be both delayed and suboptimal relative to the care you’d get in the U.S. (But our friends the Brits are working on this problem). And if you are old and need dialysis like Tommy’s parents (above), you are out of luck (with which problem the Brits do not appear to want to deal). I think the British system is the one I’d least like us to emulate—and it seems to me to be the one with the most central planning and the most governmental meddling. Remember, my NHI is merely a payment mechanism for covered services.

Look, if I get sick, I want to be in America. (As I write this, I’m in the woods in the Yukon, and if they take me to Whitehorse for treatment, O.K.) But the point is, I have health insurance (TRICARE, as it turns out) in America. Too many of our fellow citizens do not have health insurance, and it is at great cost to all of us.

If medical care is free, won’t people use too much of it?

Some have argued that health care is what economists call a normal good, in that the wealthier one is, the more one buys of it. But health care is not a good in itself—no one goes out and buys an appendectomy because he has a little extra change in his pocket, or because his neighbor has such a shiny new scar that everyone just must have a new scar, too. Health care is only of instrumental value because it extends our lives, relieves pain, restores us to function, improves our eyesight or our psyches, and so on.

But, to the extent that an artificial reduction in cost leads to over-use, it is already true that our current tax policy induces excess demand, especially by those in higher tax brackets.

And our medically uninsured currently use too little medical care, if outcome data are to be believed. About 45 million Americans lack any health care insurance at any given moment, as many as 80 million lack health care insurance in any given year, and the number is growing. A simple lack of health insurance is associated with a 25% increase in mortality; being a diabetic is safer than not having health insurance. Admittedly, the relationship is not strictly causal: getting sick in America regularly means losing your health coverage (c.f. the definition of irony).

Some writers have suggested that the way out of our healthcare financing crisis is to make this a pure free-market system. Just let each person/consumer/patient pay for each item on the medical smorgasbord without any third party paying for it, and the person/consumer/patient will make a rational economic decision just as he does for an automobile or television purchase. I have no doubt that this draconian measure would lower the total bill for medical care, but it would increase dramatically the cost of inadequate and delayed care. Imagine, for example the cost of educating this patient: a forty-year-old man with acute chest pain. You might need to convince him it’s a myocardial infarction (teach him to read EKGs) and explain why/how thrombolytic therapy works, and why you want to give him drugs that are going to cost him thousands of dollars—all while his myocardium is dying by the minute.

The rational decision-making needs to be done by cool, educated minds. They can decide how much is too much, or too little medical care for society to pay for. Individuals still will have the power to choose to buy more, from their own pockets.

Isn’t believing in NHI like believing in a free lunch?

There is no free lunch. We are already paying more than we would pay for NHI—we’re just not getting it! Some people have argued that, ‘Well, everybody in America gets medical care, they just have to go to the ER and get the best medical care in the world.’ But we all pay for that care: doctors pay in charity services, hospitals pay in write-offs, insurance companies pay in higher charges, governments collect more in taxes or run higher deficits. As it is right now, we are paying for lunch, with a side of sirloin. We get the bologna sandwich, and the steak goes to the insurance companies, drug companies, and all the others who will be losers under NHI.

(What’s in that bologna sandwich? Once again: We spend far more on health care than any other society, often twice as much as other industrialized nations, and lag behind these other societies in measures of life expectancy and infant mortality. As many writers have noted, these other societies are more homogenous than our own, or count live births differently, or a multitude of other explanations or excuses. What seems to lack in all of these rebuttals is that other societies are more diverse than we are, and yet have better health outcomes (Canada, for example, is more diverse), and that, within our own country, the most diverse state (Hawaii) has the highest life-expectancy, and ranks among the highest in other positive health care outcomes as well. The counter-argument to my examples would be to say that the diversity I cite is a diversity that includes fewer individuals of African ancestry, and these individuals have much lower life expectancy and other indicators of health than do whites, Hispanics, and Asians. I agree; and in the next breath, I would point out that these same African-Americans have less health insurance, and I’d point out the “crossover phenomenon”: for example, a black woman in the US has a lower life expectancy than a white woman until about age seventy—at which point, five years or so after Medicare has kicked in, she has a greater life expectancy than does a white woman.)

What about care that’s not strictly cost-effective? And what does cost-effective mean, anyway?

These are tough questions, and I don’t have complete answers. I would give heavy weight to the value of life, not just the measurable economic value of that human life. So I’d cover dialysis for the aged, optimal care for quadriplegics, lifelong care for the hopelessly insane. These would be societal decisions, of course.

What about health savings accounts?

HSAs are a great program for people who are rich and healthy and smart enough to game the system to their own advantage, with a tax subsidy, to boot. HSAs are not an insurance system that creates a national risk pool that I have argued is needed. A tax subsidy that encourages people to game the system at the expense of the rest of us is not consonant with any conservatism that I can understand.

What about incentives to reduce unnecessary use under NHI?

There needs to be a mechanism to reduce unnecessary use. For some behaviors—for example, an anxious mother who brings her children in for every cold and sniffle, education is appropriate, and an NHI data system would be ideal for identifying such behaviors. To the extent it was necessary, effective, and safe, I would not object to deductibles and co-pays that demonstrably reduce unnecessary visits for such things as ordinary colds (for example), as long as there is some mechanism to insure that we have not erected barriers to early diagnosis of bacterial meningitis (for example). And, I’d want to be sure that the administrative burden for these deductibles and co-pays was not out of proportion to the cost-savings from decreased utilization. Again, these would be matters for my NHI Board to deal with.

What about waste on drugs as in current Medicare D?

My NHI would have drug coverage, with Board-determined co-pays/deductibles, and no ‘doughnut hole.’ Covered drugs would be bid out, preventing a repeat of the Medicare D debacle. (Savings from current Medicare D would make up for a lot of cost in NHI.) ?

Would NHI really create wealth?

I think so. Health certainly creates wealth. And we have evidence that a great proportion of current medical care does improve health. It wasn’t always that way, of course. It was only some time less than a century ago, it seems, when an average patient seeing an average physician had less than 50-50 chance of benefiting from the encounter; however, we are long past that point, and health care is a great benefit to society. It ought to be funded, especially in areas that clearly create wealth—e.g., childhood vaccinations, maternal health care.

Would NHI make my life easier?

Do you add up your medical expenses and insurance costs at tax time? Do you write checks for care and then have to get reimbursed by your insurance company? Do they often deny coverage until you appeal? How many times did you have to appeal?

Are you a physician? Do you like dealing with lots of different insurance companies. (Seattle area physicians have 755 insurance plans to deal with). Spending an average of eight hours a week dealing with insurance companies who make money by collecting premiums and denying benefits? Getting pre-authorization for necessary procedures? Filing for payment a dozen times? How do you like the incomes of insurance execs?

Won’t this NHI create a pool of private information that is vulnerable to abuse?

Yes. But the information already exists in many different databases, at all the insurers you already have, and Medicare and other agencies you might deal with anyway. I think it’s likely to be better protected by a single NHI agency, but this electronic genie is out of the bottle. And besides, one of the chief reasons you might want your medical information private is your medical insurability. With NHI, that’s a lot less of an issue, right?

Are there any advantages to this pool of information?

Huge benefits to researchers who are looking at best practices, health outcomes, the sorts of information that can lead for longer, healthier lives for us and our kids.

Aren’t you advocating Socialized Medicine?

Yes. I advocate socializing the cost of effective and necessary health care in the U.S.A.—but I am not advocating socializing the practice of medicine; the practice of medicine would look like it does today, except that doctors will not spend the average of 8 hours per week dealing with insurance companies, all patients will be able to afford care, the administrative burden on hospitals will virtually vanish, and the economic dead weight of the insurance companies will be lifted. We are already, as a society, paying for the cost of medical care: through taxes, insurance plans, charity care, and so on. We are also paying a huge administrative burden, and we are paying another huge burden in opportunity costs by not assuring the best health care for all Americans. I want to make the payment system simple, explicit, fair, and efficient. We already socialize most of the cost of medicine (60% of medical care in this country is currently paid for in taxes), and we already socialize the costs of defense, fire protection, coinage, highways, and so on.

What resources and references can you provide?

(The best way, I think, would be, for you to do your own search on MEDLINE and/or Google Scholar. Google (not Scholar) will get you lots of chaff. Here are the resources I looked at, and I looked at a painful amount of the chaff, too.)

Lasser KE, Himmelstein DU, Woolhandler S. Access to Care, Health Status, and Health Disparities in the United States and Canada: Results of a Cross-National Population-Based Survey, American Journal of Public Health, July 2006, Vol. 96, No. 7

Woolhandler S, Himmelstein DU. The deteriorating administrative efficiency of US health care. N Engl J Med. 1991;324:1253-1258.

Himmelstein DU, Lewontin JP, Woolhandler S. Who administers? Who cares? Medical administrative and clinical employment in the United States and Canada. Am J Public Health. 1996;86:172-178.

Woolhandler S, Himmelstein DU. Costs of care and administration at for-profit and other hospitals in the United States. N Engl J Med. 1997;336:769-774.

Pauly MV, Percy AM. Cost and performance: a comparison of the individual and group health insurance markets. J Health Polit Policy Law. 2000;25:9-26

Heffler S, Levit K, Smith S, et al. Health spending growth up in 1999: faster growth expected in the future. Health Aff (Millwood). 2001;20:193-203.

Remler DK, Gray BM, Newhouse JP. Does managed care mean more hassles for physicians? Inquiry. 2000;37:304-316.

Grumbach K, Bodenheimer T, Woolhandler S, Himmelstein DU. Liberal benefits, conservative spending: the Physicians for a National Health Program proposal. JAMA. 1991;265:2549-2554

US General Accounting Office. Canadian Health Insurance: Lessons for the United States. Washington, DC: US Government Printing Office; 1991. Publication GAO/HRD-91-90.

Sheils J, Hogan P. Cost of tax-exempt health benefits in 1998. Health Aff (Millwood). 1999;18:176-181

Internet Resources, just a click away (informative, fun, links currently working as of 12 August, 2006):

http://content.healthaffairs.org/cgi/content/abstract/21/4/88

http://www.pnhp.org/news/2004/january/national_health_insu.php http://bcn.boulder.co.us/health/healthwatch/canada.html

http://www.healthaffairs.org/: Health Affairs, 25, no. 4 (2006): 969-978

http://www.enterprisehonolulu.com/html/display.cfm?sid=176

http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_20.pdf

http://www.livescience.com/humanbiology/050228_life_expectancy.html

http://www.commondreams.org/news2006/0209-12.htm

http://www.commondreams.org/views02/0525-06.htm

http://www.pnhp.org/news/IJHS_State_Paper.pdf

http://www.press.uchicago.edu/Misc/Chicago/036480.html