GOVERNMENT HEALTH CARE SYSTEMS ARE FAILING: BY RESTRICTING PRIVATE HEALTH CARE CHOICES, THE NHS AND OTHER BELOVED SINGLE-PAYER SYSTEMS WERE DOOMED FROM THE START.

• Author: Amezdroz, Elise

IN SUMMER 2012, about 27 million Britons tuned in to the London Olympics' opening ceremony, dreamed up by the Oscar-winning director Danny Boyle. Central to the show was an homage to the National Health Service (NHS), the United Kingdom's singlepayer health care system, that featured hundreds of volunteer nurses dancing around bedridden children. Transcending political affiliation, support for the NHS may be the strongest uniting force in the United Kingdom. As the Conservative Party politician Nigel Lawson put it in a thinly veiled shot at the Church of England, the NHS is "the closest thing the British have to a religion." Less than a decade after the London Olympics, the COVID-19 pandemic deeply strained the system's human and financial resources. The number of British doctors considering early retirement doubled over the first year of the pandemic. More than half of the NHS' doctors worked extra shifts, over a quarter of which were unpaid. Total health care spending was 24 percent higher in 2021 than in 2019. And in November 2022, NHS Resolution--the organization that handles NHS patients' claims--allocated [pounds sterling]1.3 billion ($1.6 billion) in anticipation of an increased volume of claims related to the pandemic. In December 2022, the U.K.'s top health care leaders warned that the country faced a "prolonged period" of excess deaths due to people not having timely access to care.

Simply put, the NHS is collapsing. Physicians and nurses are leaving the profession at an unprecedented rate, and students are entering other fields. Seven million Britons--more than one in 10--are waiting for treatment. And while COVID certainly accelerated the NHS' decay, it did not cause it. The system had been showing symptoms of an underlying problem for decades. Indeed, the NHS was destined to fail from its very inception.

That's not just true of the NHS. It's true of many of the world's most vaunted government-run health care systems. They have deep flaws built into their very design, and now they're showing signs of severe strain.

BISMARCK AND BEVERIDGE

MODERN MEDICINE WAS born in the wake of the Industrial Revolution. With technological progress came biological discoveries that made longer, healthier lives attainable. But medical access was expensive, so newly wealthy Western states devised plans to put health care services within the reach of the masses. Those new systems generally followed one of two models: Bismarck or Beveridge.

The Bismarck model originated in the 1880s in Germany, when the conservative statesman Otto von Bismarck envisioned a system where people crowdfund for their health care expenses and receive services from entities that can be privately or publicly owned. Over time, governments began subsidizing low-income citizens' care. Countries with Bismarck-style systems today include Germany, Switzerland, and South Korea. Those countries' health care systems have been experiencing significant cost growth, but they tend to deliver timelier, higherquality care than the Beveridge countries. That's because, even if they are highly regulated and subsidized, they were designed to use privately owned and operated health care operations rather than stamp them out.

The Beveridge systems came later, and they were predicated on a government-centric model in which private systems were either banned outright or heavily restricted.

In the late 1940s, the progressive economist Lord William Beveridge designed the National Health System in the United Kingdom. Under the Beveridge model, the government is the primary payer and provider of health care services. Citizens finance care through taxes and are entitled to free or heavily subsidized care at the point of delivery. To keep prices down and manage supply, the government was positioned as the central financier of health care. This system would come to be known as "single-payer."

This model's promise of free service relies on coercing medical professionals into providing care on government's terms. What happens when those professionals do not accept the terms? They exit the system, or find ways around it, and so access to services becomes scarce.

Short of brute force, governments have limited options to deal with the inevitable mismatch between supply and demand. Beveridge-style systems can ration care, increase spending and taxation, or simply accept low-quality services. This is the dilemma facing Beveridge systems in the U.K., Sweden, and Canada today, all of which are struggling with some combination of shortages, delays, fiscal shortfalls, and quality-of-service issues that are undermining both the health of their citizens and the egalitarian ideals the systems were built on.

These countries built health care systems under the presumption that the laws of...