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A Harris/Harvard School of Public Health poll of 1989 showed that most Americans (61 percent) favored a Canadian-type health system, in which the government was the single payer to doctors and hospitals, bypassing the insurance companies, and offering universal medical coverage to everyone. Neither the Democratic nor the Republican party adopted that as its program, although both insisted they wanted to “reform” the health system.

HMOs have been so successful that they now occupy a dominant position in the market for health care in the United States. Approximately forty-five million Americans are uninsured. Of the remainder, about half are enrolled in some type of HMO. Most others receive some sort of managed care plan. Less than 10 per cent of Americans still have classic fee-for-service private health insurance (down from more than 70 per cent in the late ’80s). So even though many people equate HMOs with private health care, these sorts of corporations exist only because of the failure of private markets to supply appropriate health care. HMOs succeed precisely because they are more efficient than insurance markets. There should be no illusions about the character of these organizations—they are giant bureaucracies. The largest of them, Kaiser Permanente, employs over eleven thousand physicians and has more than six million subscribers in the state of California alone. This makes Kaiser larger than most of the government-run health care systems in Canada. And while the Canadian system is extremely decentralized, Kaiser Permanente is a single, vertically integrated corporation.

The key concept is efficiency. The primary function of the Canadian welfare state is not to redistribute wealth— it does almost none of that. Government is involved in the economy because, in many cases, the state is able to deliver goods and services more efficiently than the market. From highways and pest control to health insurance and pensions, government is able to get the job done better. Thus the welfare state, far from being an unstable compromise between capitalism and socialism, is a perfectly logical arrangement—one that is designed to promote the overall efficiency of our economy.

taxpayers pay nearly $150 billion annually for criminal justice costs—half again as much per capita as Canadians—about $2,000 for every family of four.29 Adding costs of security, insurance, loss, damage, or being a victim brings the numbers close to $500 billion—about 7 percent of the U.S. gross national product.

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