Planning the Patient-Centered Health Plan for America
Single-Payer National Health Insurance around the World Part IV
Lives at Risk by John C. Goodman, Gerald L. Musgrave, and Devon M. Herrick
(Continued from the July 2014 HPUSA Newsletter)
HAVE OTHER COUNTRIES FOUND THE ANSWER?
American advocates of single-payer national health insurance propose to16
• Eliminate HMOs and most other forms of managed care
• Have all health care financed by the government, with no premiums or copayments from those covered
• Control costs by assigning global budgets to hospitals and setting fees and salaries for physicians
• Prohibit private insurance or personal payment for any service covered by the single-payer system. In advancing this idea, they point to other countries as examples of health care systems that are superior to our own. Are they right?
The promise of national health insurance is that government will make health care available on the basis of need rather than ability to pay. That implies a government commitment to meet health care needs. It implies that rich and poor will have equal access to care. And it implies that more serious needs will be given priority over the less serious. Unfortunately, these promises have not been kept.
• Wherever national health insurance has been tried, rationing by waiting is pervasive—with waits that force patients to endure pain and sometimes put their lives at risk.
• Not only is access to health care not equal, if anything it tends to correlate with income—with the middle class getting more access than the poor and the rich getting more access than the middle class, especially when income classes are weighted by incidence of illness.
• Not only are health care resources not allocated on the basis of need, these systems tend to overspend on the relatively healthy while denying the truly sick access to specialist care and lifesaving medical technology.
• And far from establishing national priorities that get care first to those who need it most, these systems leave rationing choices up to local bureaucracies that, for example, fill hospital beds with chronic patients while acute patients wait for care.
It might seem that some of these problems could be easily remedied. Yet, as the years of failed reform efforts in Britain and Canada have shown, the defects of single-payer systems of national health insurance are not easily remedied. The reason: the characteristics described above are not accidental byproducts of government-run health care systems. They are the natural and inevitable consequences of placing the health care market under the control of politicians.17 It is not true that health care policies in countries with singlepayer health insurance just happen to be what they are. In most cases, they could not be otherwise.
Why do single-payer health insurance schemes skimp on expensive services to the seriously ill while providing so many inexpensive services to the marginally ill? Because the latter services benefit millions of people (read: millions of voters), while acute and intensive care services concentrate large amounts of
money on a handful of patients (read: small numbers of voters). Democratic political pressures dictate the redistribution of resources from the few to the many.
Why are sensitive rationing decisions and other issues of hospital management left to hospital bureaucracies? As a practical matter, no government can make it a national policy to let 25,000 of its citizens die from lack of the best cancer treatment every year, as apparently happens in Britain.18 Nor can any government announce that some people must wait for surgery so that the elderly can use hospitals as nursing homes or that elderly patients must be moved so that surgery can proceed. These decisions are so emotionally loaded that no elected official could afford to claim responsibility for them. Important decisions on who will receive care and how that care will be delivered are left to the hospital bureaucracy because no other course is politically possible. Why do low-income patients fare so poorly under national health insurance?
Because such insurance is almost always a middle-class phenomenon. Prior to its introduction, every country had some government-funded program to meet the health care needs of the poor. The middle-class working population not only paid for its own health care, but also paid taxes to fund health
care for the poor. Single-payer health insurance extends the “free ride” to those who pay taxes to support it. Such systems respond to the political demands of the middle-class population and serve the interests of this population.
Why do the rich and the powerful manage to jump the queues and obtain care that is denied to others? Because it could not be otherwise. These are the people with the power to change the system. If members of Parliament had to wait in line for their care like ordinary people, the system would not last for a minute. Follow this series . . .
Single-Payer National Health Insurance around the World Part III
In 2002 and 2003, we reviewed The Twenty Myths of health care reform. Now a decade later the authors have updated the book, renamed it, and added important 21st century data.
Lives at Risk by John C. Goodman, Gerald L. Musgrave, and Devon M. Herrick
(Continued from the April 2014 HPUSA Newsletter)
PROBLEM: WE HAVE SUPPRESSED NORMAL MARKET RESPONSES
Some of the things we have been saying about health care are also true of other goods and services. For example, we could probably spend our entire gross domestic product on automobiles, with each of us owning several to use over different terrains and in different seasons. But no one ever asserts that this is a problem. To the contrary, most people regard it as an opportunity. The fact that automobile manufacturers have discovered so many different ways to satisfy our needs makes us better off, not worse off (pollution problems aside).
Similarly, fine wine is probably a superior good. As people’s income rises, they tend to buy more of it. And in recent years, supply has increased to meet demand, as vineyards have expanded all over the world. Again, no one regards this as a problem.
So what makes automobiles and fine wine different from health care? Why are problems that cause so much hand-wringing in health care not seen as problems in the other two markets? The answer is that in this country and in all developed countries we have suppressed the ability of the market to allocate health care resources.
The suppression of the market in health care began more than 100 years ago. It started with controls on who could be a physician and how those licensed to practice should behave. By the mid-twentieth century, controls were extended to the hospital sector and then to health insurance. By the 1970s, with government paying more and more medical bills, policy makers realized that prices and markets were not able to do their job. Similar trends occurred in other developed countries.
What does it mean to suppress normal market forces in health care? Not long ago, if a doctor competed aggressively against other doctors, say, the way auto companies compete against each other, he or she could be in real trouble. For example, if the doctor posted his normal fees and compared them to other doctors’ fees, if he compared the quality of his practice to that of another physician or if he advertised at all he could be expelled from the county medical society. That, in turn, would lead to a loss of privileges at all the hospitals in his area. If the offense were bad enough (irritating enough to his fellow physicians), he could lose his license to practice medicine.
Until very recently, the hospital sector was dominated by nonprofit institutions whose sole task was to facilitate the doctors’ goal of treating patients.
Not only were hospitals not supposed to function like businesses, they went out of their way to avoid certain common business practices. For example, for a hospital to compare the quality of its care to the quality offered by a competitor would have been unthinkable. Advertising itself was unthinkable. Not only did hospitals not post their prices, no one paid them other than the occasional uninsured patient. At the time Medicare (for seniors) and Medicaid (for the poor) were adopted in the 1960s, virtually every hospital in the United States was paid by insurers based on cost-plus reimbursement. And when the federal government set up Medicare, it joined the cost-plus system, paying for health care the way it paid for weapons systems. All in all, the health care system in this country and throughout the developed world functioned according to rules that resembled a medieval guild more than a complex modern market.
Times have changed. And they have changed more in the United States than anywhere else. Other countries have left in place the medieval guild approach to medicine and tried to control costs in crude ways that we will examine. In this country, however, we have made dismantling the guild and promoting competition a public policy goal.
Doctors today can compete in almost any way they like. They can post prices; they can advertise; they can boast about the quality of care they deliver.
Hospitals can do the same. And insurers can pay hospitals based on any arrangement that can be reached through no-holds-barred voluntary exchange in the marketplace. But although the shackles have been removed and although the law no longer protects it, the 100-year-old culture that has dominated medical practice has not disappeared.
Pick up almost any daily newspaper and you will find evidence that the medical marketplace is still not functioning like other markets. “Hospitals Say They’re Penalized by Medicare for Improving Care,” blares a front page headline in the New York Times.14 “More Care Is Not Better Care,” leads a Times guest editorial, citing evidence that Medicare spends twice as much on seniors in Manhattan as it does Portland, Oregon, without getting any improvement in quality or patient satisfaction.15
But there are two consoling observations: first, the medical marketplace is becoming more competitive, and second, things are much worse in every other country. Read the entire article. . .
Continued in the October 2014, HPUSA Newsletter . . .
Single-Payer National Health Insurance around the World Part II
In 2002 and 2003, we reviewed The Twenty Myths of health care reform. Now a decade later the authors have updated the book, renamed it, and added important 21st century data.
Lives at Risk by John C. Goodman, Gerald L. Musgrave, and Devon M. Herrick
(Continued from the January 2014 HPUSA Newsletter)
PROBLEM: THE DESIRE TO SPEND WILL GROW IN THE FUTURE
Let’s now turn to a second well-documented, but rarely discussed, fact about modern health care systems.
Whatever we are spending on health care today, we are probably going to want to spend more tomorrow. This is true for two reasons: first, the average age in all developed countries is rising and health needs increase with age, and second, health care is a “superior good,” which means as income grows people choose to spend more of it on health care.
At 15.2 percent of the GDP, the United States spends more of its income on health care than any other nation, a sum that equals $1.6 trillion.11 This fact is a usual source of criticism both at home and abroad. But if you think 15 percent is high, you haven’t seen anything yet. Currently, senior citizens (over sixty-five years of age) spend about 45 percent of all their consumption (regardless of who pays for it) on medical care. By 2020, it is estimated that three-fourths of all consumption by seniors will be on health care.
Is such spending good or bad? That depends on whether people are getting their money’s worth for the dollars they spend. If people are getting value for money, nothing is wrong with devoting more resources to health care. If they are not getting value for money, something is wrong with it. This way of looking at the issue is very different from what one hears in most public policy discussions. The standard complaint is that health care “costs” are rising. And innumerable conferences, briefings, books, articles, essays and so forth have sought to “solve the problem” of rising health care costs.
Note that in a general sense “spending” and “costs” are the same thing.
If people are aging and their incomes are rising, one can predict with great confidence that they will want to devote more of their income to medical care. Not only is this not a “problem,” it is a natural and inevitable part of life. Indeed, to the degree that this phenomenon is viewed as a problem, it is not a problem that is going to be solved. It will only get worse through time.
We noted above that in a system with no prices, decision makers cannot determine what value people place on different services. Thus, they cannot know what’s being oversupplied or undersupplied. A similar problem arises with respect to total spending on health care. Given that it should rise over time, by how much should it rise? How would one know? Without markets through which people can reveal their preferences for health care versus other goods and services, it’s anybody’s guess.
American employers who complain about the “problem” of rising health care costs are in a similar situation. Because decisions about health care typically are made collectively at the workplace and because the premiums employees pay rarely reflect real costs, employers have no way of discerning their employees’ willingness to trade off higher wages for more health care, except through union negotiations and other imperfect devices.
Fortunately, when American employers make a mistake, its consequences are confined to their companies and their workforces. But when the managers of national health insurance make mistakes, the whole nation suffers.
Single-Payer National Health Insurance around the World Part I
In 2002 and 2003, we reviewed The Twenty Myths of health care reform. Now a decade later the authors have updated the book, renamed it, and added important 21st century data.
Lives at Risk by John C. Goodman, Gerald L. Musgrave, and Devon M. Herrick
Published in cooperation with the National Center for Policy Analysis
ROWMAN & LITTLEFIELD PUBLISHERS, INC.
Lanham • Boulder • New York • Toronto • Oxford
Introduction: Thinking about Reform
As we move further into the twenty-first century, it is clear that we are living with a number of institutions that were not designed for the Information Age. One of those institutions is health care.
Virtually everyone agrees that our health care system needs reform. But what kind of reform? Some on the right would like to see us return to the type of system that prevailed in the 1950s. Some on the left would like to see us copy one of the government-run systems established in the mid-twentieth century and variously called socialized medicine, national health insurance and, more recently, single-payer health insurance. For example, Physicians for a National Health Program, claiming membership of 8,000 physicians and medical students, contends that “single-payer national health insurance would resolve virtually all of the major problems facing America’s health care system today.”
We believe that neither of these two alternatives will work. But before we explain why, let us stop to consider some central problems that every reform faces. Most commentaries on health policy tend to ignore three very important facts about modern health systems:
1. We can potentially spend our entire gross domestic product (GDP) on health care in useful ways.
2. Whatever portion of our income we are spending on health care today, we are likely to want to spend more in the future.
3. We have suppressed normal market forces in dealing with characteristics one and two.
These facts are not in dispute. Rather, they are readily acknowledged by all health policy analysts.
Also, the first two characteristics are not unique to health care. They are true of many other goods and services as well. But when combined with the third characteristic, they have devastating implications.
PROBLEM: OPPORTUNITIES TO SPEND MONEY
ON HEALTH CARE ARE ALMOST UNLIMITED
Medical research has pushed the boundaries of what doctors can do for us in every direction. The Cooper Clinic in Dallas now offers an extensive checkup (with a full body scan) for about $1,500 or more.2 Its clients include Ross Perot, Larry King, and other high-profile individuals. Yet, if everyone in America took advantage of this opportunity, we would increase our nation’s annual health care bill by a third. More than 900 diagnostic tests can be done on blood alone,3and one doesn’t need too much imagination to justify, say, $5,000 worth of tests each year. But if everyone did so, we would double the nation’s health care bill. Americans purchase nonprescription drugs almost twelve billion times a year and almost all of these are acts of self-medication.
Yet, if everyone sought a physician’s advice before making such purchases, we would need twenty-five times the number of primary care physicians we currently have.4 Some 1,100 tests can be done on our genes to determine if we have a predisposition toward one disease or another.5 At, say, $1,000 a test, it would cost more than $1 million for a patient to run the full gamut. But if every American did so, the total cost would run to about thirty times the nation’s total output of goods and services!6
Notice that in hypothetically spending all of this money we have not yet cured a single disease or treated an actual illness. In these examples, we are simply collecting information. If in the process of search we actually found something that warranted treatment, we could spend even more. One of the cardinal beliefs of advocates of single-payer health insurance is that health care should be free at the point of consumption, regardless of willingness or ability to pay. But if health care really were free, people would have an incentive to obtain each and every service so long as it had any value to them.
In other words, everybody would have at least an economic incentive to get the Cooper Clinic annual checkup, order dozens of blood tests, check out all their genes and consult physicians at the drop of a hat. In short order, unconstrained patients would attempt to spend the entire gross domestic product (GDP) on
health care even though, as a practical matter, that would be impossible.
“Free” health care is of course not really free. It is care paid directly by employers, government or some other entity, and indirectly by workers and taxpayers. The more employers pay for health care the less employees receive in wages. The more the government pays, the less after-tax income taxpayers have. Therefore, allowing patients to go on an unconstrained shopping spree in the medical marketplace would ultimately impoverish all of us.
No serious person wants this result. Not even the advocates of single-payer health insurance want it. Instead, they envision placing many obstacles in the path of patients and doctors in order to constrain spending. These obstacles may not be prices, but they most certainly involve costs, such as the cost of waiting for care. Although its advocates call national health insurance “singlepayer insurance” these days, its distinguishing characteristic is not control of demand. It is control of supply.
Like the systems of Canada and Britain, American health maintenance organizations (HMOs) also make health care free to their enrollees at the point of delivery. They then control access to care, especially expensive care, on a case-by-case basis. Whether or not an HMO patient gets an MRI brain scan, for example, depends upon the symptoms and the probable outcome of the scan, as well as its cost. HMOs, therefore, control costs by curtailing demand.
Nothing like that happens in countries with national health insurance, however. For one thing, doctors in Canada would have no idea how much a scan actually costs and therefore would have no basis for comparing costs with probable medical benefits. The number of brain scans is controlled in Canada, not on the basis of a case-by-case review of patient conditions, but because of spending constraints to limit the number of MRI scanners.
Many American doctors have endorsed the single-payer idea, in part because they envy the ability of Canadian doctors to practice medicine without managed care-type, third-party interference. What they overlook is that, at least from a budget perspective, Canadian officials have no reason to care what decisions doctors make. They limit the number of scanners, and therefore the expense of scanning, before doctors see even a single patient. American physicians who support single-payer insurance also tend to discount lack of access to expensive diagnostic equipment in Canada, believing that the problem could be ameliorated by just spending more. They do not realize that the only reason the Canadian system works at all is because the government controls supply. If Canadian doctors (who, again, have no idea what anything costs) had access to an unlimited supply of MRI units, they might spend Canada’s entire GDP on brain scans!
In general, countries with national health insurance control costs by imposing arbitrary limits. They strictly control the number of doctors who can be specialists. They limit access to modern medical technology. The more expensive the service, the more difficult they make access. As a result, in countries with national health insurance, people wait. They wait in the offices of general practitioners. They wait to see specialists. They wait for surgeries. And waiting is a rationing device comparable to money prices in a market system.
In this book we will stress many differences between the U.S. health care system and government-run health care systems. But on the demand side, the differences are not as great as one might suppose. Although health care is not free at the point of consumption for the average American, it is almost free. On the average, every time a patient spends a dollar on hospital care in our country, only two cents comes out of the patient’s own pocket. The other ninety-eight cents is paid by a third party (an employer, insurer or government.). On the average, for every dollar patients spend on physician care, only twelve cents comes out of their own pockets. And for the health care system as a whole, patients pay directly only eighteen cents of every dollar they spend. The rest is spent by some other entity.7
On the demand side, the problem with a system with no money prices is that people view each good or service as though its price were zero. As a result, they tend to try to consume the item so long as it has any value at all. The problem this creates is enormous waste. People seek services until the value to them is almost zero, even though the cost of these services may be quite high. The upshot is that people consume services for which the social benefit is well below the social cost. In Britain, for example, people have to pay out of pocket to see a movie, go to the theater or witness a sporting event.
But the only costs to see a physician are the costs of travel and waiting time. So although the government makes an enormous investment in their training, British physicians spend an inordinate amount of time on trivial complaints.
In the United States, things are not that much better. Although no one wants to enter a hospital, once there, the typical patient in this country has an incentive to use hospital services until they are worth only two cents at the margin (or about 1/50th of the actual cost). Aside from the costs of time and travel and the risk of being around other sick people, patients have an incentive to utilize physicians’ services until they are worth only twelve cents on the dollar. And for the health care system as a whole, our incentive is to spend until the services we receive are worth only eighteen cents on the dollar. No wonder there is so much waste!
In principle, there are not many solutions to this problem. Someone must choose between health care and other uses of money. The question is, who will that someone be? The answer of single-payer advocates is medical bureaucracies answerable to politicians. And much of this book will be spent looking in some detail at how rationing decisions are made in these systems.
A second method for choosing between health care and other uses of money is the method of managed care. The paradigm is the HMO. As noted above, HMOs have far less rationing by waiting than do national health insurance schemes. One reason for the difference is that HMOs tend to make rationing decisions based on medical and economic rather than political considerations. Because some policy analysts believe that a system of competing managed care organizations can solve the problems of single-payer health insurance, we devote a chapter to that idea.
The third method of choosing between health care and other uses of money is to allow patients themselves to choose. A vehicle that facilitates such choices is a health saving account (HSA), from which patients pay medical expenses directly. Funds not spent on health care grow in the account and may be used for other purposes. Singapore has had a compulsory system of “medisave” accounts since 1984.8 Medical savings accounts (MSAs) were introduced in South Africa in the early 1990s and today represent 65 percent of the market for private health insurance in that country.9 The United States experimented with a pilot program for several years and as of January 1, 2004, HSAs are available to all nonelderly Americans.10
So far, these accounts have mainly been used to pay relatively small medical bills, less than a few thousand dollars. These are the expenses that fall under a health insurance deductible. But as the accounts grow and if health insurance evolves toward the casualty model, the accounts could play a role in almost every aspect of health care. Consider homeowner’s casualty insurance, for example. If hail damages a roof, an insurance adjuster surveys the damage and agrees to a sum sufficient to cover the cost of repair—usually by a repair service the insurer knows. But the homeowner is not restricted to this option. He or she can choose other, more expensive repair services or even choose to replace the damaged roof with a nicer roof.
In principle, health insurance could work the same way. In the case of expensive heart surgery or cancer care, the insurer could direct the patient to a hospital or clinic and agree to pay the full cost. But the patient would be free to take the same reimbursement amount and apply it to another hospital or clinic, paying any extra charges from an HSA account.
In the world of casualty insurance, auto repair shops act as agents of automobile owners. Roofing repair services act as agents of homeowners. Suppliers of these services do not see themselves as agents of third-party insurers.
In a similar way, HSAs could free patients to become the real decision makers, choosing between health care and other uses of money in virtually every part of the health care system. In such a world, doctors, nurses and other providers would see themselves as agents of their patients rather than agents of impersonal bureaucracies.
Read the complete book: http://www.ncpa.org/pdfs/livesatrisk/Lives-at-Risk_NCPA.pdf (PDF | 5MB)
Continued in the April, 2014 HPUSA newsletter. . .
2012: The Make or Break for America
AGENDA GAMES: How Today’s High-Stakes Political Combat Works.
By B. K. Eakman
EPILOGUE: THE “IT” YEAR OF 2012
First, the “It” girl—a concept that means more than mere “perfection.” The “It” factor captures that certain “something” one can’t quite define, but that redirects the attention from anything else whenever “It” appears.
Professional entertainers and those celebrity-centric people who follow this sort of thing attribute the term to Elinor Glyn, who wrote the magazine article that inspired the It film in 1927 starring Clara Bow—although the honors for this particular perception of “It” actually go to Rudyard Kipling.
But no matter. In frenzied succession, there followed a series of “Its”: female celebrities, “It” hairdos, “It” fashions, “It” songs, foods, and even exercise regimens. All seemed to define their era, the prevailing mentality, or even an entire generation.
By extension, the “It” phenomenon took on another meaning, as in “This is ‘it’!” Whenever “It” appeared, everyone was to understand that “It” was irreplaceable; that “It” would never be—
and could never be—superseded. So, “It” also took on yet another connotation: “The End,” or “The Defining Moment.”
In American politics, the “It” moments came with the close of World War II (“happy days” were here again), with the Communist takeover Saigon (the first “war” America ever “lost”)—and in 2012, the first time the Republic had ever been thought of as “threatened.” The “It” years—the years everything changed, up close and visible.
Since the 1970s, traditionalists and patriots have seen “It” coming, and dreaded that there would come a time when American ideals would not just be ridiculed in the media, but dismantled by the courts. They worried that elections would eventually be manipulated to such a degree that American values and ethics could no longer be sustained. In the year 2012, the crossroads became clear.
But for this author, it happened in a most unexpected way.
The following is a true story:
I was sitting with a neighbor in a café over lunch. It was the week before Christmas, 2011. Though this neighbor had never been a particularly close friend (given our wildly divergent political views), we had lived in the same community for so many years, and even helped each other out on so many occasions, that we were, one could say, on very good terms as long-time acquaintances, if not exactly confidantes.
Many of my other neighbors jokingly called this woman the “resident Commie” behind her back, mostly because she proudly and openly admitted to being a Marxist in the hippie-dippy days of our 1960s youth. She had participated in protests and demonstrations, somehow managing to squeeze them in amongst her college studies and various doctoral degrees.
But on this particular day, she was protesting something altogether different. She confided, to my astonishment, that she was leaving the Washington area—this place where everything is vital and “happening”: the museums, the Kennedy Center, the Fireworks over the Capital on the Fourth of July, the plentiful ethnic restaurants, and Capitol Hill. She was headed for fairer fields in the Great Southwest, of all places—home to the same Confederacy and “rednecks” she had often denigrated.
“But why?” I asked, perplexed. “I mean, you just revamped your entire house two years ago!”
Because, she said, “I don’t like the turn the lifestyle has taken here.” What’s more, she saw “no change in sight, regardless of who’s elected.”
My neighbor was blissfully unaware, apparently, that the District of Columbia and its surrounding bedroom communities exemplified the very lifestyle for which she had once demonstrated, marched and chanted slogans during our coming-of-age years—the only era, we both once thought, that really mattered.
Regardless of our politics (we didn’t even know each other then), we imagined ourselves on the cusp. We were first-wave Baby Boomers, born immediately after the War. The “times, they were achangin’,” and lucky us, we were part of “It”! We were the “It Generation,” the Ones Who’d Change the World.
The disappointed, graying visage looking at me from across the table came as something of a shock. Instead of being a smug representative of our “It” generation—her side had “won,” after all—there was only “Me.”
Despite her multiple Ph.D.’s in cutting-edge disciplines such as women’s studies, political “science” and environmentalism, in my neighbor’s mind, the “Its” had accomplished next to nothing, leaving the “Me Generation” in charge.
Like most young people our age, I was never part of the “It” crowd, having stupidly declared a major in a financially responsible (if not particularly emotionally satisfying) career. I’d looked around for (and gratefully found) Mr. Right, rewarded my parents with respectable, if not exactly stellar, grades, and “ate my peas” (to use a quip from President Obama).
So, I was mightily disturbed to hear that now, nearing retirement age, anybody at all was actually in charge, much less this “Me Generation.”
“It” was all very confusing… When did “It” turn into “Me”?
Was it merely “all so simple then,” as per the song from the tear-jerker film, The Way We Were, starring Barbra Streisand and Robert Redford?
Well, from the way my neighbor was now shaking her gray locks, things certainly hadn’t turned out as expected.
“Too many rules…,” she complained. “And surveillance cameras—can you believe it, @#$% surveillance EVERYWHERE?” In cathartic-like fashion, she elaborated:
… Can’t even take your dog for a romp in the woods without some @#$% lazy pig snooping around making sure you have a baggie clipped to your belt! And no trash cans! All these taxes, and not a single @#$% garbage bin to dump your baggie full of droppings! Do they really think people want to walk for an hour in the great, green outdoors with a bag full of p_ _p in their hands?
And speaking of TAXES! For what? The lights go out every time we have a little rain! In the Capital of the Nation, for God’s sakes! I mean, this isn’t 1950! Aren’t we due a few upgrades for all this money we’re shelling out? And my prescriptions….”
By now my neighbor’s voice had reached enough pitch to draw attention:
“Do you believe,” she continued, “that just two weeks after being hospitalized for a hysterectomy, my pharmacy gets grief from the frigging government over a two-bit bottle of pain medication! I mean, you’d think I was asking for crack, when all I wanted was a refill that my doctor had already approved!”
I smiled. In commiseration…among other things….
As my neighbor carried on with her laundry list of grievances, my mind wandered: For some reason, I fancied how she might have looked as a 10-year-old, riding a bike and thrilling to the feel of the wind blowing through her hair. I imagined her frolicking into the school building in the morning, flagging down a friend in the hallway—no gauntlet of metal detectors and pat-downs standing in her way. No concerns that some monster would jump out of nowhere and start shooting.
I imagined her laughter and delight as she and her siblings lighted “sparklers” on the Fourth of July. She might have caught me smiling, but it was not at her rant. Rather, it was at the image of her enjoying buying a gooey ice-cream sandwich from a machine at the local theater on a Saturday afternoon, with no notion of some entity called the “food police.” Or as a teenager, with a bunch of other kids at Tops Drive-in, ordering a burger—and the best, thickest milkshake in town.
I pictured her…or maybe I was picturing us—or maybe the little girl in my mind’s eye was…me…?
The 1960s Boomers. The “Me Generation.”
Whatever became of those of us who were hopelessly…well, “nerdy” in today’s lingo? Never “brave” enough, or “popular” enough, or self-serving enough to qualify for the “It” crowd. All those “Me’s” who didn’t have the leisure (much less the parental support) to demonstrate against anything! We didn’t know it then, but We were still in the majority—on our way to independence, selfsufficiency and self-reliance. Unfortunately, press accounts of the 60s pretended otherwise, so we had no idea. “Changes … they were a-comin’,” the pundits said. And the world would belong to the counterculture radicals. It would be the “It” kids—like my nowgrown neighbor—the “radicals” and the “counterculture” fighting against the Establishment—who would rule America.
Yet, somehow “We, the People” had found each other and reconnected, in cities all around the country via the Internet. We may not have been actual classmates, but we had similar stories, and deep down each of us knew an “It” day is a-comin’.
And now, apparently, so did my left-leaning neighbor.
So, she had decided to run, to run away—down to “Dixie,” of all places.
I wondered if she realized that the great liberal activist folk singer we all loved, Joan Baez—even with her astonishing voice and range—today would never make it past the stage door with her signature piece, “The Night They Drove Old Dixie Down.” The word “Dixie,” in any context, is so politically incorrect that it cannot be uttered in public. Like the old Christmas standby, “I Saw Mommy Kissing Santa Claus,” Baez’s “Dixie” song is a relic of the past, when terms like “husband,” “wife” and “fiancé” were not referred to as “partners” in TV ads.
What a difference a few years makes! I mused.
My neighbor, unfortunately, will not escape the rules she helped precipitate—and now despises—in the Great Southwest. So, who, will stand as the “resisters” now? Which side will throw in the towel—or maybe throw down the gauntlet? “It” was kind of hard to say.
The world’s billionaires and the “mainstream” media work long and hard to narrow America’s choice of candidates, be it national, state or local races—and no matter who, technically, sits atop the heap with the most endorsements from average Americans. Yet, both the media and the political parties tell us, over and over, that “every vote counts.” Most people think it doesn’t.
What if “We, the People” did the unexpected? What if a candidate played the game and tricked the pollsters? Polls, after all, are mostly extrapolations from a sampling of a few hundred individuals. The media pays attention to them? Should we?
With a start, my attention returned to my grumbling neighbor. Just how “radical” was she? Would someone like her—a member of the “It” 60s-counterculture—be a help or a hindrance now?
Maybe my neighbor’s frame of mind was merely signaling a “fight or flight” response—like before the Nazis invaded Poland in the 1930s, or before the tanks rolled into Hungary in the 50s, or ahead of the Rwandan genocide in the 1990s… Maybe she’d go to the polls at election time and vote the way she always had—Left.
In any case, my neighbor’s angst made me think: Maybe this was really “It”!
World Health Report 2000 was an intellectual fraud of historic consequence
The Worst Study Ever? | By Scott W. Atlas | Commentary Magazine | April 2011
A profoundly deceptive document that only marginally measured health-care performance at all.
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.”
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.”
At its most egregious, the report abandoned the very pretense of assessing health care. WHO ranked the U.S. 42nd in life expectancy. In their book, The Business of Health, Robert L. Ohsfeldt and John E. Schneider of the University of Iowa demonstrated that this finding was a gross misrepresentation. WHO actually included immediate deaths from murder or fatal high-speed motor-vehicle accidents in their assessment, as if an ideal health-care system could turn back time to undo car crashes and prevent homicides. Ohsfeldt and Schneider did their own life-expectancy calculations using nations of the Organisation for Economic Co-operation and Development (OECD). With fatal car crashes and murders included, the U.S. ranked 19 out of 29 in life expectancy; with both removed, the U.S. had the world’s best life-expectancy numbers (see table above).
But even if you dismiss all that, the unreliability of World Health Report 2000 becomes inarguable once you confront the sources of the data used. In the study, WHO acknowledged that it “adjusted scores for overall responsiveness, as well as a measure of fairness based on the informants’ views as to which groups are most often discriminated against in a country’s population and on how large those groups are” [emphasis added]. A second survey of about 1,000 “informants” generated opinions about the relative importance of the factors in the index, which were then used to calculate an overall score.
Judgments about what constituted “high quality” or “low quality” health care, as well as the effect of inequality, were made by people WHO called “key informants.” Astonishingly, WHO provided no details about who these key informants were or how they were selected. According to a 2001 Lancet article by Celia Almeida, half the responders were members of the WHO staff. Many others were people who had gone to the WHO website and were then invited to fill out the questionnaire, a clear invitation to political and ideological manipulation.
Another problem emerges in regard to the references used by the report. Of the cited 32 methodological references, 26 were from internal WHO documents that had not gone through a peer-review process. Moreover, only two were written by people whose names did not appear among the authors of World Health Report 2000. To sum up: the report featured data and studies largely generated inside WHO, with no independent, peer-reviewed verification of the findings. Even these most basic requirements of valid research were not met.
The report’s margin of error is similarly ludicrous in scientific terms. The margin for error in its data falls outside any respectable form of reporting. For example, its data for any given country were “estimated to have an 80 percent probability of falling within the uncertainty interval, with chances of 10 percent each of falling below the low value or above the high one.” Thus, as Whitman noted, in one category—the “overall attainment” index—the U.S. could actually rank anywhere from seventh to 24th. Such a wide variation renders the category itself meaningless and comparisons with other countries invalid.
And then there is the plain fact that much of the necessary data to determine a nation’s health-care performance were simply missing. The WHO report stated that data was used “to calculate measures of attainment for the countries where information could be obtained . . . to estimate values when particular numbers were judged unreliable, and to estimate attainment and performance for all other Member States.”
According to a shocking 2003 Lancet article by Philip Musgrove, who served as editor in chief of part of the WHO study, “the attainment values in WHO’s World Health Report 2000 are spurious.” By his calculation, the WHO “overall attainment index” was actually generated by complete information from only 35 of the 191 countries. Indeed, according to Musgrove, WHO had data from only 56 countries for Health Inequality, a subcategory; from only 30 countries for Responsiveness; and from only 21 countries for Fair Financing. Nonetheless, rankings were “calculated” for all 191 countries.
Musgrove gives specific examples of overtly deficient data that was directly misused by WHO. He stated that “three values obtained from expert informants (for Chile, Mexico, and Sri Lanka) were discarded in favor of imputed (i.e. estimated) values” and that “in two cases, informants gave opinions on one province or state rather than the entire country.” Musgrove wrote to Christopher Murray, WHO’s director of the Global Program on Evidence for Health Policy at the time, on August 30, 2000, about the study’s handling of the missing statistics: “If it doesn’t qualify as manipulating the data, I don’t know what does . . . at the very least, it gravely undermines the claim to be honest with the data and to report what we actually find.”
If World Health Report 2000 had simply been issued and forgotten, it would still be a case study in how to produce a wretched and unreliable piece of social science masquerading as legitimate research. That it served so effectively as a catalyst for unprecedented legislation is evidence of something more disturbing. The executive and legislative branches of the United States government used WHO’s document as an implicit Exhibit A to justify imposing radical changes to America’s health-care system, even in the face of objections from the American people. To blur the line between politics and objective analysis is to do violence to them both.
Despite the compelling studies that undermine this erroneous document, many government officials, policymakers, insurers, and academics have continued to use it to justify their ideology-based agenda, one that seeks centralized, government-run health care. Donald Berwick, later up for the position of Obama’s director of the Center for Medicare & Medicaid, used its questionable data to make a grand case against the U.S. health-care system in 2008: “Even though U.S. health-care expenditures are far higher than those of other developed countries, our results are no better. Despite spending on health care being nearly double that of the next most costly nation, the United States ranks thirty-first among nations on life expectancy, thirty-sixth on infant mortality, twenty-eighth on male healthy life expectancy, and twenty-ninth on female healthy life expectancy.” (This last bit came from updated 2006 WHO data.)
What we have here is a prime example of the misuse of social science and the conversion of statistics from pseudo-data into propaganda. The basic principle, casually referred to as “garbage in, garbage out,” is widely accepted by all researchers as a cautionary dictum. To the authors of World Health Report 2000, it functioned as its opposite—a method to justify a preconceived agenda. The shame is that so many people, including leaders in whom we must repose our trust and whom we expect to make informed decisions based on the best and most complete data, made such blatant use of its patently false and overtly politicized claims.
About the Author: Scott W. Atlas is a senior fellow at the Hoover Institution and professor of radiology and chief of neuroradiology at the Stanford University Medical Center.
A Member of the European Parliament’s Warning to America
On a U.S. talk-radio show recently, I was asked what I thought about the notion that Barack Obama had been born in Kenya. “Pah!” I replied. “Your president was plainly born in Brussels.”
American conservatives have struggled to press the president’s policies into a meaningful narrative. Is he a socialist? No, at least not in the sense of wanting the state to own key industries. Is he a straightforward New Deal big spender, in the model of FDR and LBJ? Not exactly.
My guess is that, if anything, Obama would verbalize his ideology using the same vocabulary that Eurocrats do. He would say he wants a fairer America, a more tolerant America, a less arrogant America, a more engaged America. When you prize away the cliché, what these phrases amount to are higher taxes, less patriotism, a bigger role for state bureaucracies, and a transfer of sovereignty to global institutions.
He is not pursuing a set of random initiatives but a program of comprehensive Europeanization: European health care, European welfare, European carbon taxes, European day care, European college education, even a European foreign policy, based on engagement with supranational technocracies, nuclear disarmament and a reluctance to deploy forces overseas.
No previous president has offered such uncritical support for European integration. On his very first trip to Europe as president, Mr. Obama declared, “In my view, there is no Old Europe or New Europe. There is a united Europe.”
I don’t doubt the sincerity of those Americans who want to copy the European model. A few may be snobs who wear their euro-enthusiasm as a badge of sophistication. . . .
All right, growth would be slower, but the quality of life might improve. All right, taxes would be higher, but workers need no longer fear sickness or unemployment. All right, the U.S. would no longer be the world’s superpower, but perhaps that would make it more popular. Is a European future truly so terrible?
Yes. I have been an elected member of the European Parliament for 11 years. I have seen firsthand what the European political model means.
The critical difference between the American and European unions has to do with the location of power. The U.S. was founded on what we might loosely call the Jeffersonian ideal: the notion that decisions should be taken as closely as possible to the people they affect. The European Union was based on precisely the opposite ideal. Article One of its foundational treaty commits its nations to establish “an ever-closer union.”
From that distinction, much follows. The U.S. has evolved a series of unique institutions designed to limit the power of the state: recall mechanisms, ballot initiatives, balanced budget rules, open primaries, localism, states’ rights, term limits, the direct election of public officials from the sheriff to the school board. The EU places supreme power in the hands of 27 unelected Commissioners invulnerable to public opinion.
The will of the people is generally seen by Eurocrats as an obstacle to overcome, not a reason to change direction. When France, the Netherlands and Ireland voted against the European Constitution, the referendum results were swatted aside and the document adopted regardless. For, in Brussels, the ruling doctrine—that the nation-state must be transcended—is seen as more important than freedom, democracy or the rule of law. . .
Why is a European politician urging America to avoid Europeanization? As a Briton, I see the American republic as a repository of our traditional freedoms. The doctrines rooted in the common law, in the Magna Carta, and in the Bill of Rights found their fullest and most sublime expression in the old courthouse of Philadelphia. Britain, as a result of its unhappy membership in the European Union, has now surrendered a large part of its birthright. But our freedoms live on in America. . .
So you can imagine how I feel when I see the U.S. making the same mistakes that Britain has made: expanding its government, regulating private commerce, centralizing its jurisdiction, breaking the link between taxation and representation, abandoning its sovereignty.
Mr. Hannan is a member of the European Parliament. This essay is adapted from the Encounter Books Broadside, “Why America Must Not Follow Europe.”