Which emergency room in Latin America or Middle East or Africa do you want to go for cardiac failure comopared to American emergency care?

Ask 10 friends who have needed emergency care in various countries and see how their experiences compare with U.S. visits to their local emergency rooms. Obama thinks based on the following study that our medical is terrible.

The Worst Study Ever?Scott W. Atlas — April 2011PrintPDF

The World Health Organization’s World Health Report 2000, which ranked the health-care systems of nearly 200 nations, stands as one of the most influential social-science studies in history. For the past decade, it has been the de facto basis for much of the discussion of the health-care system in the United States, routinely cited in public discourse by members of government and policy experts. Its most notorious finding—that the United States ranked a disastrous 37th out of the world’s 191 nations in “overall performance”—provided supporters of President Barack Obama’s transformative health-care legislation with a data-driven argument for swift and drastic reform, particularly in light of the fact that the U.S. spends more on health than any other nation.

In October 2008, candidate Obama used the study to claim that “29 other countries have a higher life expectancy and 38 other nations have lower infant mortality rates.” On June 15, 2009, as he was beginning to make the case for his health-care bill, 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 that 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.”

In fact, World Health Report 2000 was an intellectual fraud of historic consequence—a profoundly deceptive document that is only marginally a measure of health-care performance at all. The report’s true achievement was to rank countries according to their alignment with a specific political and economic ideal—socialized medicine—and then claim it was an objective measure of “quality.”

WHO researchers divided aspects of health care into subjective categories and tailored the definitions to suit their political aims. They allowed fundamental flaws in methodology, large margins of error in data, and overt bias in data analysis, and then offered conclusions despite enormous gaps in the data they did have. The flaws in the report’s approach, flaws that thoroughly undermine the legitimacy of the WHO rankings, have been repeatedly exposed in peer-reviewed literature by academic experts who have examined the study in detail. Their analysis made clear that the study’s failings were plain from the outset and remain patently obvious today; but they went unnoticed, unmentioned, and unexamined by many because World Health Report 2000 was so politically useful. This object lesson in the ideological misuse of politicized statistics should serve as a cautionary tale for all policymakers and all lay people who are inclined to accept on faith the results reported in studies by prestigious international bodies.

Before WHO released the study, it was commonly accepted that health care in countries with socialized medicine was problematic. But the study showed that countries with nationally centralized health-care systems were the world’s best. As Vincente Navarro noted in 2000 in the highly respected Lancet, countries like Spain and Italy “rarely were considered models of efficiency or effectiveness before” the WHO report. Polls had shown, in fact, that Italy’s citizens were more displeased with their health care than were citizens of any other major European country; the second worst was Spain. But in World Health Report 2000, Italy and Spain were ranked #2 and #7 in the global list of best overall providers.

Most studies of global health care before it concentrated on health-care outcomes. But that was not the approach of the WHO report. It sought not to measure performance but something else. “In the past decade or so there has been a gradual shift of vision towards what WHO calls the ‘new universalism,’” WHO authors wrote, “respecting the ethical principle that it may be necessary and efficient to ration services.”

The report went on to argue, even insist, that “governments need to promote community rating (i.e. each member of the community pays the same premium), a common benefit package and portability of benefits among insurance schemes.” For “middle income countries,” the authors asserted, “the policy route to fair prepaid systems is through strengthening the often substantial, mandatory, income-based and risk-based insurance schemes.” It is a curious version of objective study design and data analysis to assume the validity of a concept like “the new universalism” and then to define policies that implement it as proof of that validity.

The nature of the enterprise came more fully into view with WHO’s introduction and explanation of the five weighted factors that made up its index. Those factors are “Health Level,” which made up 25 percent of “overall care”; “Health Distribution,” which made up another 25 percent; “Responsiveness,” accounting for 12.5 percent; “Responsiveness Distribution,” at 12.5 percent; and “Financial Fairness,” at 25 percent.

The definitions of each factor reveal the ways in which scientific objectivity was a secondary consideration at best. What is “Responsiveness,” for example? WHO defined it in part by calculating a nation’s “respect for persons.” How could it possibly quantify such a subjective notion? It did so through calculations of even more vague subconditions—“respect for dignity,” “confidentiality,” and “autonomy.”

And “respect for persons” constituted only 50 percent of a nation’s overall “responsiveness.” The other half came from calculating the country’s “client orientation.” That vague category was determined in turn by measurements of “prompt attention,” “quality of amenities,” “access to social support networks,” and “choice of provider.”

Scratch the surface a little and you find that “responsiveness” was largely a catchall phrase for the supposedly unequal distribution of health-care resources. “Since poor people may expect less than rich people, and be more satisfied with unresponsive services,” the authors wrote, “measures of responsiveness should correct for these differences.”

Correction, it turns out, was the goal. “The object is not to explain what each country or health system has attained,” the authors declared, “so much as to form an estimate of what should be possible.” They appointed themselves determinants of what “should” be possible “using information from many countries but with a specific value for each country.” This was not so much a matter of assessing care but of determining what care should be in a given country, based on WHO’s own priorities regarding the allocation of national resources. The WHO report went further and judged that “many countries are falling far short of their potential, and most are making inadequate efforts in terms of responsiveness and fairness.”

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Consider the discussion of Financial Fairness (which made up 25 percent of a nation’s score). “The way health care is financed is perfectly fair if,” the study declared, “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.” In plain language, higher earners should pay more for health care, period. And people who become sick, even if that illness is due to high-risk behavior, should not pay more. 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 matter-of-fact endorsement of wealth redistribution and centralized administration should have had nothing to do with WHO’s assessment of the actual quality of health care under different systems. But instead, it was used as the definition of quality. For the authors of the study, the policy recommendation preceded the research. Automatically, this pushed capitalist countries that rely more on market incentives to the bottom of the list and rewarded countries that finance health care by centralized government-controlled single-payer systems. In fact, two of the major index factors, Health Distribution and Responsiveness Distribution, did not even measure health care itself. They were both strictly measures of equal distribution of health and equal distribution of health-care delivery.

Perhaps what is most striking about the categories that make up the index is how WHO weighted them. Health Distribution, Responsiveness Distribution, and Financial Fairness added up to 62.5 percent of a country’s health-care score. Thus, almost two-thirds of the study was an assessment of equality. The actual health outcomes of a nation, which logic dictates should be of greatest importance in any health-care index, accounted for only 25 percent of the weighting. In other words, the WHO study was dominated by concerns outside the realm of health care.

Not content with penalizing free-market economies on the fairness front, the WHO study actually held a nation’s health-care system accountable for the behavior of its citizens. “Problems such as tobacco consumption, diet, and unsafe sexual activity must be included in an assessment of health system performance,” WHO declared. But the inclusion of such problems is impossible to justify scientifically. For example, WHO considered tobacco consumption equivalent, as an indicator of medical care, to the treatment of measles: “Avoidable deaths and illness from childbirth, measles, malaria or tobacco consumption can properly be laid” at a nation’s health-care door.”

From a political standpoint, of course, the inclusion of behaviors such as smoking is completely logical. As Samuel H. Preston and Jessica Ho of the University of Pennsylvania observed in a 2009 Population Studies Center working paper, a “health-care system could be performing exceptionally well in identifying and administering treatment for various diseases, but a country could still have poor measured health if personal health-care practices were unusually deleterious.” This takes on additional significance when one considers that the United States has “the highest level of cigarette consumption per capita in the developed world over a 50-year period ending in the mid-80s.”