In Excellent Health: Setting the Record Straight on America's Health Care
360
In Excellent Health: Setting the Record Straight on America's Health Care
360Overview
Product Details
| ISBN-13: | 9780817914462 |
|---|---|
| Publisher: | Hoover Institution Press |
| Publication date: | 09/01/2013 |
| Series: | Hoover Institution Press Publication |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 360 |
| File size: | 6 MB |
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In Excellent Health
Setting the Record Straight on America's Health
By Scott W. Atlas
Hoover Institution Press
Copyright © 2011 Board of Trustees of the Leland Stanford Junior UniversityAll rights reserved.
ISBN: 978-0-8179-1446-2
CHAPTER 1
The WHO Ranking of Health Systems Redux: A Critical Appraisal
The ambitious World Health Report 2000 that ranked health care systems of nearly two hundred nations stands as one of the most influential and widely cited social science studies of health care systems in history. For the past decade, this study has served as the de facto basis for much of the discussion about the health care system and health reforms in the United States. It is routinely cited by a wide range of concerned parties — government officials, policy experts, popular media, and laypersons — in the public discourse about health care. The heavily editorialized 2007 movie Sicko sensationalized the WHO rankings to denounce U.S. health care and promote socialized medicine, while earning an estimated 36 million dollars. Its most notorious claim — the relatively low U.S. rankings as defined by WHO of 37 (by "overall performance") but also the less well-publicized ranking of 15 (by "overall attainment") — ultimately assumed great importance by providing supporters of the Democratic Congress and President Barack Obama's transformative health care legislation with a data-driven argument for radical reforms. Most commonly, the WHO study is asserted as objective evidence, especially in light of the fact that it is the world's costliest, of the overall failure of America's health care, as illustrated by comments like, "We should expect a better return on this investment."
In October 2008, candidate Obama used the study to claim that "twenty-nine other countries have a higher life expectancy and thirty-eight other nations have lower infant mortality rates." On June 15, 2009, as he was beginning to make the case for his health-care bill at the annual conference of the American Medical Association, the new president said: "As I think many of you are aware, for all of this spending, more of our citizens are uninsured, the quality of our care is often lower, and we aren't any healthier. In fact, citizens in some countries that spend substantially less than we do are actually living longer than we do." The perfect encapsulation of the study's findings and assertions came in a September 9, 2009, editorial in Canada's leading newspaper, the Globe and Mail: "With more than 40 million Americans lacking health insurance, another 25 million considered badly underinsured, and life expectancies and infant mortality rates significantly worse than those of most industrialized Western nations, the need for change seems obvious and pressing to some, especially when the United States is spending 16 percent of GDP on health care, roughly twice the average of other modern developed nations, all of which have some form of publicly funded system."
On the other hand, when the WHO study was published, its conclusions were met with great surprise by many health policy experts. In the highly respected peer-reviewed journal Lancet, Johns Hopkins University professor Vicente Navarro observed that while both Spain and Italy were near the top of European nations in the WHO report, these countries "rarely were considered models of efficiency or effectiveness before." The rankings showed a marked disconnect with the reality experienced by citizens of many countries. The WHO ranking of Spain's health care as third in Europe and the seventh best in the world coincided with unprecedented public demonstrations against Spain's health care authorities which protested long waiting lists causing deaths and the miniscule three-minute average time spent with patients by primary care doctors. In concurrent surveys, 28 percent of Spanish citizens said they needed to "completely rebuild" their health care system, and another 49 percent said "fundamental changes were needed."
And while the WHO ranked Italy as number two in the world in "overall efficiency," 40 percent of Italians wanted complete rebuilding and another 46 percent said fundamental changes were needed. In striking contrast to the WHO report, Spain's citizens were more displeased with their health care than any other major European country ... except Italy. It might come as a surprise to our elected officials, the public, and the media that when asked about the WHO report Mark Pearson, head of health for the Organization for Economic Cooperation and Development (OECD), the thirty-member organization of the world's largest economies, frankly admitted, "Health analysts don't like to talk about it in polite company. It's one of those things that we wish would go away."
Beyond contradictory data from citizens who actually use the health systems lauded by the WHO, and despite the exalted stature automatically granted to the WHO report by the all-too-willing advocates for more government control in health care, the WHO study has been roundly criticized by experts in health policy. An unrecognized and overlooked body of peer-reviewed literature, written by academic experts who have examined the study in detail, has exposed serious defects in the WHO report. On close inspection, fundamental flaws in methodology, large margins of error in data, and highly subjective inputs based on ideological bias have been found which thoroughly undermine the legitimacy of the comparative rankings in the WHO study. Ultimately, the document is only marginally a measure of health care performance at all; instead, it is a rank of countries in accordance with their alignment to a specific political and economic ideology — socialized medicine — despite its claims to objectively measure "quality."
Even more than a decade after the report's publication, today's discussions about health care still are heavily based on the WHO rankings, which indicates the study's ongoing impact. It is clear that far broader exposure of the overt lack of objectivity of the study and its obvious weaknesses is warranted. Despite all evidence that the appearance of statistical fact in international rankings is a mirage, and in the face of a plethora of peer-reviewed repudiations of the seminal WHO report specifically demonstrating that it was, in truth, an agenda-driven document that knowingly published flawed data and opinion as fact, some of the most prestigious journals and agencies stubbornly keep validating its conclusions by continuing to accept and publicize its data as valid. The New England Journal of Medicine, broadly considered as representing the best of peer-reviewed medical science, recently published a follow-up piece from the editors of the same WHO Health Report. In its first paragraph, the piece restated the bottom line of the WHO 2000 publication: "The World Health Report 2000, Health Systems: Improving Performance, ranked the U.S. health care system 37 in the world." It then essentially repeated the same refrain, as if it were established as fact: "It is hard to ignore that ... the United States was number 1 in terms of health care spending per capita but ranked 39 for infant mortality, 43 for adult female mortality, 42 for adult male mortality, and 36 for life expectancy." Because there is apparently no escape from what is an unscholarly acceptance of invalid conclusions about American health care even by what should be reliable sources of unquestioned objectivity, a reappraisal is even more essential. All parties considering U.S. health reforms, whether government officials, the public, or the media, must understand this study and its severe limitations before using it to justify their arguments about the need for radical change to the U.S. health care system.
Subjectivity and Bias in the Chosen Measures of Health Systems
Any objective assessment of the WHO report must begin with an evaluation of its design methodology, the fundamental basis for the validity of the entire study and its rankings. Just like the core basic sciences, research in social sciences must, first and foremost, have solid experimental design. Without appropriate design, the data to be analyzed will inevitably generate flawed conclusions that may have no basis whatsoever. This basic principle, sometimes loosely referred to as "garbage in, garbage out," is widely accepted by all researchers and is critical to any legitimate conclusion derived from data.
One of the obvious and most serious problems with the study design is the overtly subjective nature of the assumptions underlying the data and its analysis. While the WHO authors expressed the goal that their study "will lay the basis for a shift from ideological discourse on health policy to a more empirical one," the study has an overt bias that unfortunately reflects pre-existing ideology. "In the past decade or so there has been a gradual shift of vision towards what WHO calls the 'new universalism' ... respecting the ethical principle that it may be necessary and efficient to ration services," the report states in its opening pages. It argues that, "Governments need to promote community rating (i.e., each member of the community pays the same premium), [and] a common benefit package and portability of benefits among insurance schemes;" and, "In middle income countries the policy route to fair prepaid systems is through strengthening the often substantial, mandatory, income-based and risk-based insurance schemes," as if such specific policies are universally agreed upon. A highly subjective, even judgmental tone of the WHO report is evident with statements like, "Many countries are falling far short of their potential, and most are making inadequate efforts in terms of responsiveness and fairness." The study assumes the validity of its own chosen concepts and then constructs a ranking system designed to demonstrate them.
The WHO health care rankings resulted from an index of what the authors arbitrarily deemed health-related statistics, many of which are far from universally accepted. The overt bias in the entire study is revealed by the design and explanation of the factors comprising its index. This was based on five selected factors and then "weighted" to emphasize certain features (see Figure 1.1 below), as follows:
1. "Health Level": 25 percent
2. "Health Distribution": 25 percent
3. "Responsiveness": 12.5 percent
4. "Responsiveness Distribution": 12.5 percent
5. "Financial Fairness": 25 percent
Even at first glance, this overall index includes factors that are complex, subjective, and difficult to define. For example, the WHO evaluated "responsiveness," largely a catch-all phrase for the supposedly unequal distribution of health care resources, relative to the WHO authors' beliefs. The dominance of subjectivity is revealed in WHO statements like, "Among other things, responsiveness means reducing the damage to one's dignity and autonomy, and the fear and shame that sickness often brings with it;" and, "Since poor people may expect less than rich people, and be more satisfied with unresponsive services, measures of responsiveness should correct for these differences." The intent of molding health systems to a particular ideological construct, rather than to assess actual health care quality, is explicitly declared in such statements as, "The object is not to explain what each country or health system has attained, so much as to form an estimate of what should be possible." This necessarily means that WHO authors will be the determinant of what "should" be possible by way of their "attainment index." The WHO authors deem themselves able to establish "an upper limit or 'frontier,' corresponding to the most that could be expected of a health system ... derived using information from many countries but with a specific value for each country." WHO is somehow able to decree what any specific country should be able to achieve in health care and rank that country's success in achieving it.
Beyond the subjective statements in the study, the selection and definition of the major factors comprising the index for the rankings and the way they were determined reflect individual bias rather than objective research. As an example, "responsiveness" was one of the five major factors that was generated from calculations contributing to what WHO defined as "respect for persons" whose 50 percent contribution to that score in turn derived from "respect for dignity," "confidentiality," and "autonomy." The other half of "responsiveness" was derived from "client orientation," which was in turn determined by "prompt attention," "quality of amenities," "access to social support networks," and "choice of provider." Almost none of these subcategories can even remotely be called objective.
Similarly, let us consider the discussion of another of the five index categories — "Financial Fairness" — which makes up 25 percent of the country's score. Any fairness, whether pertaining to medical care or something else, is inarguably an assessment based on value judgments. Fairness in the WHO study was defined based on the philosophical belief that "the way health care is financed is perfectly fair if the ratio of total health contribution to total non-food spending is identical for all households, independently of their income, their health status or their use of the health system." This reflects a value judgment that richer people should pay more for health care, even if they consume the same amount, and people who become sick — even if due to high risk behavior — should not pay more. According to WHO, the "ability to pay" overrides everything. According to WHO, "financial fairness is best served by more, as well as by more progressive, prepayment in place of out-of-pocket expenditure. And the latter should be small, not only in the aggregate but relative to households' ability to pay." This is a blatant endorsement of wealth redistribution and centralized administrative authority over health care, a value judgment that should have had nothing to do with WHO's assessment of actual quality of health care, but nevertheless was used to define quality. For the authors of the WHO study, the policy recommendation preceded the research.
As a further point of fact, this criterion is not generally applied to other essential goods like food, clothing, and housing. In fact, it is common sense and an unavoidable consequence of economic reality of systems other than socialism that the poor will always spend a greater percentage of their income on any given item, compared to high income earners with more disposable income. WHO's Financial Fairness category intentionally tilts the rankings against countries that rely on market incentives and rewards countries that finance health care by centralized government-controlled single-payer systems. Putting forth the WHO rankings as a means of justifying more government involvement in health care is an exercise in circular logic, because the rankings themselves were designed to favor greater central government control. Even beyond the philosophical ideology in play, the data inadvertently generate misleading conclusions. Even if one accepts the WHO view that "ability to pay" should be the sole determinant of payment for health care, the Financial Fairness criteria illogically penalize any country in which some families are especially unlikely to suffer financial hardship from health costs, regardless of the hardships on other households. That is, the WHO ranking would view a system with financial hardship suffered by all as superior to one where only some people suffer financial hardship.
Emphasis of Factors Irrelevant to Actual Health Care Quality
Beyond subjectivity, the index contains and emphasizes data that many would consider totally unrelated to actual health care. Two of the major index factors, "Health Distribution" and "Responsiveness Distribution" do not even measure health care itself — they are both strictly measures of equal distribution of health and equal distribution of health care delivery. These categories focus on the equivalence, rather than the quality, of health care. In theory, a country might have a health care system that offers excellent care for everyone, but also has inequality. In more concrete terms, if a country provides everyone the same quality of health care, and subsequently improves that quality measure for half of the population while it remains the same for the other half, the WHO index could show a negative impact. Even though some people are better off and no one is worse off (clearly a positive), the increase in inequality could have a negative impact on the WHO index.
(Continues...)
Excerpted from In Excellent Health by Scott W. Atlas. Copyright © 2011 Board of Trustees of the Leland Stanford Junior University. Excerpted by permission of Hoover Institution Press.
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Table of Contents
Contents
List of Figures and Tables,Author's Note,
Foreword by John Raisian,
Preface,
1 The WHO Ranking of Health Systems Redux: A Critical Appraisal,
2 The Limited Value of Life Expectancy Comparisons in Ranking Health Systems,
3 Infant Mortality as an Indicator of Health and Health Care,
4 Measuring Medical Care Quality in the United States,
5 Evaluating Access to America's Medical Care,
6 Specialists and Medical Innovation: The Best of the Best,
7 Maintaining Excellence While Reducing Costs: An American Solution,
Notes,
About the Author,
About the Hoover Institution's Working Group on Health Care Policy,
Index,