Armed with supposedly objective reports showing the American
medical system is among the worst in the developed world,
candidates left and right — but mostly left — are plugging
ambitious plans to “fix” healthcare. Invariably, their plans call
for more government intervention. Senators Clinton and Obama both
want to regulate premiums and benefits while increasing healthcare
subsidies, and Clinton would go even further by requiring everyone
to buy a federally-defined health insurance policy.
But is lack of government really the problem — and if so, how
would we know? Healthcare interventionists frequently cite the
World Health Organization’s World Health Report 2000, which studied
the performance of 191 countries’ healthcare systems — and awarded
the U.S. a dismal rank of number 37. While the WHO rankings are
touted as an objective measure of the relative performance of
healthcare systems, in reality they depend on a number of
ideological or logically incoherent assumptions.
The WHO rankings are based on a constructed index of five
factors. One factor is “health level,” defined as a country’s
disability-adjusted life expectancy. Another is “health
responsiveness,” which includes desirable characteristics of
healthcare like speed of service, protection of privacy, and
quality of amenities.
Both of these are sensible indicators of health quality, but
they constitute only 37.5 percent of each country’s score. The
other 62.5 percent encompasses factors only tenuously connected to
the quality of care — and that can actually punish a country’s
ranking for superior performance.
TAKE “FINANCIAL FAIRNESS” (FF), worth 25 percent of the total. This
factor measures inequality in how much households spend on
healthcare as a percentage of their income. The greater the
inequality, the worse the country’s performance.
Notice that FF necessarily improves when the government
shoulders more of the health spending burden, rather than relying
on the private sector. To use the existing WHO rankings to justify
more government involvement in healthcare is therefore to engage in
circular reasoning, because the rankings are designed to favor
greater government involvement. (Clinton’s plan would attempt to
improve the American FF score by capping insurance premiums.)
The ostensible reason to include FF in the health index is to
account for people landing in dire financial straits because of
their health needs. Yet the FF factor worsens for every household
that deviates from the average percentage of income spent on
healthcare, regardless of whether the deviation is on the high side
or low side.
That means the FF factor doesn’t just penalize a country because
some households are especially likely to become impoverished from
health costs; it also penalizes a country because some households
are especially unlikely to become impoverished from health
costs.
The other two factors, “health distribution” and “responsiveness
distribution,” are no better. Together worth 37.5 percent of a
country’s score, these factors measure inequality in health level
and responsiveness. Strictly speaking, neither measures healthcare
performance, because inequality is distinct from quality of care.
It’s entirely possible to have a healthcare system characterized by
both extensive inequality and good care for everyone.
Suppose, for instance, that Country A has health responsiveness
that is “excellent” for most citizens but merely “good” for some
disadvantaged groups, while Country B has responsiveness that is
uniformly “poor” for everyone. Country B would score higher than
Country A in responsiveness distribution, despite Country A having
better responsiveness for even its worst-off citizens.
What if the quality of healthcare improves for half of the
population, while remaining the same for the other half? This
should be regarded as an unambiguous improvement: some people get
better off, and no one gets worse off. But in the WHO index, the
effect is ambiguous because the improvement could increase
inequality.
THE WHO RANKINGS have also been adjusted to reflect efficiency: how
well a country is doing relative to how much it spends. In the
media, however, this distinction is often lost.
Costa Rica ranks higher than the United States (number 36 versus
number 37), but that does not mean Costa Ricans get better
healthcare than Americans. Americans most likely get better
healthcare — just not as much better as could be expected given
how much we spend. If the question is health outcomes alone,
without reference to spending, we should look at the unadjusted
ranking, where the U.S. is number 15 and Costa Rica is number 45.
(And even the number 15 rank is problematic, for all the reasons
discussed above.)
The WHO rankings implicitly take all differences in health
outcomes unexplained by spending or literacy and attribute them
entirely to health system performance. Nothing else, from tobacco
use to nutrition to sheer luck, is taken into account. These
variables were excluded largely because of underlying paternalist
assumptions about the proper role of the health system.
If the culture has a predilection for unhealthy foods, there may
be little healthcare providers can do about it. Conversely, if the
culture has a pre-existing preference for healthy foods, the
healthcare system hardly deserves the credit. Some people are happy
to give up a few potential months or even years of life in exchange
for the pleasures of smoking, eating, having sex, playing sports,
and so on. The WHO approach, rather than taking people’s
preferences as given, deems some preferences better than others,
and then praises or blames the health system for them.
Those who cite the WHO ranking to justify greater government
involvement in the health system — like the plans pitched by the
leading Democratic presidential candidates — are assuming what
they’re trying to prove. The WHO healthcare ranking system does not
escape political bias. It advances ideological assumptions that
most Americans might find questionable under the guise of
objectivity.
