Popular Ranking Unfairly Misrepresents the U.S. Health Care System
By: Richard G. Fessler, MD, PhD
The media and political community have made a big deal out of the fact that the U.S. ranks 37 out of 191 countries on the World Health Organization’s Health Care Ranking System. Is this tool a credible way to compare quality health care delivered in the U.S. vs the rest of the world?
Let’s be perfectly clear about this, the United States Health Care is second to none! Ask the tens of thousands of patients who travel internationally to the US every year for their health care. As an example of the quality of health care delivered in the US, Americans have a higher survival rate than any other country on earth for 13 of 16 of the most common cancers. Perhaps that is why Belinda Stronach, former liberal member of the Canadian Parliament and Cabinet member (one of the health care systems touted as “superior” to the US) abandoned the Canadian Health Care system to undergo her cancer treatment in California.1
But to understand how WHO derives this misleading statistic, which has been ballyhooed widely by both the media and politicians alike, you need to understand how it is created. WHO’s health care rankings are constructed from five factors each weighted according to a formula derived by WHO. These are:
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
“Health level” is a measure of a countries “disability adjusted life expectancy”. This factor makes sense, since it is a direct measure of the health of a country’s residents. However, even “life expectancy” can be affected by many factors not related to health care per se, such as poverty, homicide rate, dietary habits, accident rate, tobacco use, etc. In fact, if you remove the homicide rate and accidental death rate from MVA’s from this statistic, citizens of the US have a longer life expectancy than any other country on earth.2
“Responsiveness” measures a variety of factors such as speed of service, choice of doctors, and amenities (e.g. quality of linens). Some of these make sense to include (speed of service) but some have no direct relationship to health care (quality of linens). These two factors at least make some sense in a ranking of health care, but each is problematic as well.
The other three factors are even worse. “Financial fairness” measures the percentage of household income spent on health care. It can be expected that the “percentage” of income spent on health care decreases with increasing income, just as is true for food purchases and housing. Thus, this factor does not measure the quality or delivery of health care, but the value judgment that everyone should pay the same “percentage” of their income on health care even regardless of their income or use of the system. This factor is biased to make countries that rely on free market incentives look inferior. It rewards countries that spend the same percentage of household income on health care, and punishes those that spend either a higher or lower percentage, regardless of the impact on health. In the extreme then, a country in which all health care is paid for by the government (with money derived from a progressive tax system), but delivers horrible health care, will score perfectly in this ranking, whereas a country where the amount paid for health care is based on use of the system, but delivers excellent health care will rank poorly. To use this factor to justify more government involvement in health care, therefore, is using circular reasoning since this factor is designed to favor government intervention.
“Health Distribution and Responsiveness Distribution” measure inequality in the other factors. In other words, neither factor actually measures the quality of health care delivery, because “inequality of delivery” is independent of “quality of care”. It is possible, for example, to have great inequality in a health care system where the majority of the population gets “excellent” health care, but a minority only gets “good” health care. This system would rank more poorly on these measures than another country that had “equal”, but poor, health care throughout the system.
In summary, therefore, the WHO ranking system has minimal objectivity in its “ranking” of world health. It more accurately can be described as a ranking system inherently biased to reward the uniformity of “government” delivered (i.e. “socialized”) health care, independent of the care actually delivered. In that regard the relatively low ranking of the US in the WHO system can be viewed as a “positive” testament to at least some residual “free market” influence (also read “personal freedom”) in the American Health Care system. The American health care consumer needs to understand what the WHO ranking does and does not say about American health. Don’t be fooled by “big government” politicians and the liberal media who are attempting to use this statistic to push for socialized medicine in the United States. It says essentially nothing about the delivery of health care or the quality of that delivery in the US. It does say that, so far, the American health care consumer has at least some personal freedom to seek the best health care available, and is not yet relegated to the “one size fits all” philosophy of government sponsored health care systems.
- Susan Delacourt, “Stronach travels to U.S. for cancer treatment.” The Star, September 14, 2007.
- Sally C. Pipes, “The Top Ten Myths of American Health Care”. Pacific Research Institute, pp 132-133, 2008.
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