I have frequently heard supporters of more United States government involvement in healthcare quote the World Health Organization's Health Report 2000. This study ranks the healthcare systems of the world, and the US comes out 37th, just below Costa Rica and just above Slovenia [pp. 152-156; all page numbers are from the WHO study]. Reid, in his book "The Healing of America," refers favorably to the study many times [it appears 12 times in the index]. Many people seem to think the WHO measurements are a straightforward, objective way of ranking healthcare systems, but there are numerous difficulties:
- There are actually two different rankings of interest, the Overall Attainment (OA) ranking and the Overall Performance (OP) ranking. The OA ranking attempts to measure actual outcomes, while the OP attempts to adjust it relative to costs and literacy. On the OA measure, the US is 15, Slovenia 29, and Costa Rica is 45. The US is right between Germany at 14 and France at 16. So in terms of the WHO's own attempt to measure the quality of the system, rather than quality vs. cost, we're already in with the socialized medicine countries.
- The OA measure itself is deeply flawed. It consists of a combination of four pieces:
- Overall population health. This is at least a plausible thing to measure. However, they measure it using disability-adjusted life expectancy, which I've previously demonstrated has a tenuous relationship to the healthcare system. The US ranks 24th on this metric.
- Health inequality. This is measured based on child mortality data, which I've previously shown is complicated, difficult to compare, and not especially indicative. They want to measure this by distribution of DALE, but they don't have good data for enough countries [p. 30]; so this metric is really infant mortality and life expectancy again. But that's not the real issue here, which is the weirdness of using health inequality as a metric at all, after you've used overall health level. If England made a change to their system that caused half the population to live five years longer, and no change in the other half, the country would look worse by this metric. I find that bizarre. A metric like "What is the absolute performance of the bottom tenth percentile" might be reasonable, but this metric is not that at all. The US is 32nd by this measure, which is rephrased as "equality of child survival" in the tables [p. 177].
- Responsiveness. This is an aggregate of "respect for dignity, confidentiality, autonomy, prompt attention, quality of amenities, access to social support networks, and choice of provider" [p. 32]. I think this is at least a reasonable metric; it attempts to measure the quality of people's interaction with the system, independently of outcomes. It's a little tricky to find details, but it seems this was measured by survey data from a "network of informants" [p. 33]. The US ranks 1st on this metric [p. 184].
- Fair financing. This is a metric of the distribution of percentage of income spent on health by the poor and the rich, with less variance being better. Whether this should be included or not is a political concern. However, I will point out that if you want to argue that the US system will make people healthier and have better outcomes if we make it distributionally more fair, using this metric to rank the systems in advance is circular reasoning. The US is 54th on this metric [p. 189].
- The data is noisy. The WHO published 80% confidence intervals, and at this level of confidence, we can only say that the US's OA rank is between 7 and 24 [p. 196].
- The adjustment from OA to OP is an attempt to correct for how much we pay rather than how much we get. It is statistically challenging [p. 56], and this Science policy forum article argues that the WHO's methodology of basing this metric off of only life expectancy and literacy is problematic. The WHO themselves state that "The object is not to explain what each country or health system has attained, so much as to form an estimate as to what should be possible." I find the WHO's approach quite suspect.
So what does the WHO study really say? It says the US isn't doing that well in DALE; that makes sense given our high homicide and accident rate and genetic and cultural makeup. It says the US isn't doing that well in terms of infant mortality; that makes sense given our high preterm birthrate. The US is number 1 in terms of responsiveness. The US ranks only 54th in fairness, but unless you care about fairness for its own sake rather than for its relation to health outcomes, this doesn't tell you anything. Additionally, the confidence intervals are large enough to affect the rankings substantially.
If you feel the WHO study is a good argument for massive federal intervention in healthcare delivery, why? Is improving our rankings by these metrics important? Do you think you can improve outcomes? Our outcomes are already pretty good. Do you think you can reduce costs? The bill we've just passed costs about a trillion dollars in the first ten years, and more after that. In Massachusetts, which is the closest state-level example, costs have been much higher than expected. What's going on here? I just don't get it.
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