Friday, July 24, 2009

What the U.S., China, Russia, and Turkmenistan Have in Common

. Friday, July 24, 2009

They all made this silly list of the "world's worst health care systems", passed along by Ezra Klein.

Let me just point out that the U.S.'s health care system was ranked 37th in the last World Health Organization survey. For what it's worth, Russia was 130th, China was 144th, and Turkmenistan was 153rd. Putting the U.S. in the same category as these other nations as "one of the worst" is deceitful. The U.S. is in the top quintile, meaning that the U.S. has one of the best health care systems in the world. Perhaps not as good as France or Germany, but still better than the great majority of countries.

Even more, the W.H.O. rankings are biased against pay-for-care systems:

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 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.

(bold added)

In other words, the W.H.O. rankings are often understood to be positive rankings based on objective criteria. In truth, they reflect strong normative preferences for egalitarian systems. These may be the right normative preferences to have, but they do not actually measure the quality of care in any absolute terms. This is why the U.S. and Cuba can be essentially tied in these rankings, despite the astounding divergences in actual quality of care.

None of this is to say that U.S. system is an especially good one, or that it cannot be improved. It should be obvious to everyone that some other countries have better systems than the U.S., and that there are lessons to be learned from those countries. But the sort of "worst system in the world" hyperbole that often emerges from progressives is counter-productive, mis-leading, and intellectually dishonest. There are some things that the U.S. does well and some things it does poorly. To create a new, improved system the U.S. must recognize the good while bettering the bad.


What the U.S., China, Russia, and Turkmenistan Have in Common
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