Perhaps no notion is more closely tied to national health insurance than the idea of equal access to health care. Every prime minister of health in Britain, from the day the National Health Service started, has said equal access is the primary goal of the NHS. Similar things are said in Canada and in other countries. The British government—unlike most other governments—studies the problem from time to time to see what kind of progress they’re making.

In 1980, they had a major report that said, essentially: “We really haven’t made very much progress in achieving equality of access to health care in our country. In fact, it looks like things are worse today, in 1980, than they were 30 years ago when the British National Health Service was started.” Everybody deplored the results of that report, and they all promised to do better. There were a lot of articles written, a lot of conferences, and a lot of discussions. Another 10 years passed and they pondered another report, which said that things had deteriorated further. Today we are long overdue for a third report, but no one expects the situation to have improved.

It’s true that racial and ethnic minorities are under served in the United States. But we are hardly alone. In Canada, the indigenous groups are the Cree and the Inuits. In New Zealand, they are Maoris. In Australia, the Aborigines. Those populations have more health care problems, shorter life expectancies, higher infant mortality, more health care needs, and they get less health care. When health care is rationed, racial and ethnic minorities do not usually do well in the rationing scheme.

A Canadian study showed vast inequalities among the health regions of British Columbia. In some cases, there were spending differences of 10 to 1 in services provided in one area compared to another. That probably would not surprise most health policy analysts; you just don’t usually get this kind of data. But if we had the data, we would probably find similar inequalities in access to health care all over the developed world. When people have to make decisions about who is going to get care and who is not, they frequently choose the younger patient. Surveys of the elderly show that senior citizens in the United States say it’s much easier to get surgery, see doctors, see specialists, and enter hospitals, than say seniors in other countries.

To think that everyone is going to get the same treatment in a national health care system is both foolish and somewhat naive. People will be looked at on a basis of how they can contribute to society, and those who are elderly, poor or handicapped, will either get overlooked by the system or purged from it.