About That 37th Place US Ranking In Health Care From WHO

When the initial proposition or premise of an argument over a major decision is found to be false, it's usually time to stop the debate and revisit the entire context of the debate.

Such a situation has now been revealed to be true for the US health care debate. Specifically, Wonderboy and his party's members have made a point of claiming to exhaustion that the US health care systems is ranked "37th in the world." This, we are told, is the reason for redesigning the whole mess. When, that is, the administration isn't claiming that excessive health care costs as a burden on business is the leading reason to redesign the health care system.

Last Wednesday's Wall Street Journal carried a fascinating piece by Carl Bialik in his column, The Numbers Guy, entitled "Ill-Conceived Ranking Makes for Unhealthy Debate."

It should be required reading for every Congressional and administration member, as well as any voter interested in the health care debate. Because Mr. Bialik's piece is so important and, being the WSJ, it won't be searchable by non-paying readers, I've reposted substantial portions of his column, in order to accurately present the big picture of the WHO data.

Before launching into Mr. Bialik's piece, let me provide a general orientation to the topic. Having been a quantitative type from my early years in undergraduate business school, I am fairly well-versed in both doing and critiquing the work of others. Just because someone cites a study, that doesn't mean the study has any bearing on the topic at hand.

Research methodology, as composed of definitions of terms, measurement approaches, and analytical techniques, to name a few components, has many dimensions which may be evaluated for either error, or context for interpretation of results and conclusions.

Mr. Bialik very capably reveals many aspects of the WHO report which mitigate its use as the Democrats and liberals have been applying it in the current health care debate.

Mr. Bialik begins his article,

"During the health-care debate, one damning statistic keeps popping up in newspaper columns and letters, on cable television and in politicians' statements: The U.S. ranks 37th in the world in health care.

The trouble is, the ranking is dated and flawed, and has contributed to misconceptions about the quality of the U.S. medical system.

Among all the numbers bandied about in the health-care debate, this ranking stands out as particularly misleading. It is based on a report released nearly a decade ago by the World Health Organization and relies on statistics that are even older and incomplete.

Few people who cite the ranking are aware that some public-health officials were skeptical of the report from the outset. The ranking was faulted because it judges health-care systems for problems -- cultural, behavioral, economic -- that aren't controlled by health care."

So we learn at the outset that even those in the medical field don't take the vaunted WHO report at its face value.

"It's a very notorious ranking," says Mark Pearson, head of health for the Organization for Economic Cooperation and Development, the 30-member, Paris-based organization of the world's largest economies. "Health analysts don't like to talk about it in polite company. It's one of those things that we wish would go away."

More recent efforts to rank national health systems have been inconclusive. On measures such as child mortality and life expectancy, the U.S. has slipped since the 2000 rankings. But some researchers say that factors beyond the control of the health-care system are to blame, such as dietary habits. Studies that have attempted to exclude these factors from the equation don't agree on whether the U.S. system looks better or worse."

Here we see a failing on the very first element of research design. One of my graduate school mentors, Wharton Marketing Professor Jerry Wind, taught me that if I could not construct the data analysis plan and tables prior to going into the field with my research instrument (questionnaire), then I wasn't ready to field the instrument. A good researcher already has the data analysis plan detailed, with each individual analysis specified, just from knowing what the questions and form of the responses will be.

Foremost among these are the so-called objective variables, i.e., the outcome measures for which causal or related variables are being sought and which effects are being measured.

On that topic, controlling for things which may affect, but aren't strictly part of the study, is critical. In the area of medical system effectiveness, common sense dictates that you need to control for the incoming patients' uncontrollable initial conditions. This would include things like lifestyle variables- diet, exercise, even genetics. Apparently, none of this was done in the WHO study.

"The WHO ranking was ambitious in its scope, grading each nation's health care on five factors. Two of these were relatively uncontroversial: health level, which is roughly the average healthy lifespan of a nation's residents; and responsiveness, which is a sort of customer-service rating encompassing factors such as the system's speed, choice and quality of amenities. The other three measure inequality in health-care outcomes; responsiveness; and individual spending.

These last three measures struck some analysts as problematic, because a country with unhealthy people could rank above a healthier one where there was a bigger gap between healthy and unhealthy people. It is certainly possible that spreading health care as evenly as possible makes a society healthier, but the rankings struck some health-care researchers as assuming that, rather than demonstrating it."

Here, we see the problems arising from what I just mentioned. Health-care outcomes seems a reasonable topic, but "individual spending?" This latter item would absolutely be conditioned upon the initial health situation of individuals. Thus, without some control across populations measured, this measure will be meaningless.

Yet health care spending is one of the two major clubs with which liberals beat the US health care system as poorly performing.

"An even bigger problem was shared by all five of these factors: The underlying data about each nation generally weren't available. So WHO researchers calculated the relationship between those factors and other, available numbers, such as literacy rates and income inequality. Such measures, they argued, were linked closely to health in those countries where fuller health data were available. Even though there was no way to be sure that link held in other countries, they used these literacy and income data to estimate health performance.


Philip Musgrove, the editor-in-chief of the WHO report that accompanied the rankings, calls the figures that resulted from this step "so many made-up numbers," and the result a "nonsense ranking." Dr. Musgrove, an economist who is now deputy editor of the journal Health Affairs, says he was hired to edit the report's text but didn't fully understand the methodology until after the report was released. After he left the WHO, he wrote an article in 2003 for the medical journal Lancet criticizing the rankings as "meaningless."

The objects of his criticism, including Christopher Murray, who oversaw the ranking for the WHO, responded in a letter to the Lancet arguing that WHO "has an obligation to provide the best available evidence in a timely manner to Member States and the scientific community." It also credited the report with achieving its "original intent" of stimulating debate and focus on health systems."

This is stunning! First, we learn that many of the desired data items were simply absent. So rather than either reduce the scope of the study, or redesign it to use available data, the researchers simply grabbed at some presumed correlated measures in some countries, then applied those correlative associations to completely different societies and economies. This technique basically assumes the result, since one uses assumed relationships to churn out "results," which are, of course, as expected, because, well, you created them from an a priori formula.

The results are truly useless, as Dr. Musgrove contends. Further, as Mr. Murray states, the study was only supposed to stimulate "debate and focus on health systems." This would mean it wasn't intended to be conclusive, or used as conclusive evidence about anything actionable. Only to spur debate.

In effect, the WHO designed a flawed study which was only meant, anyway, to provide some rough directional findings for debate. Not to conclude that this or that country was demonstrably better or worse on health care system performance. Precisely what US liberals wishing to nationalize health care are now doing.

"Prof. Murray, now director of the Institute for Health Metrics and Evaluation at the University of Washington, Seattle, says that "the biggest problem was just data" -- or the lack thereof, in many cases. He says the rankings are now "very old," and acknowledges they contained a lot of uncertainty. His institute is seeking to produce its own rankings in the next three years. The data limitations hampering earlier work "are why groups like ours are so focused on trying to get rankings better."

A WHO spokesman says the organization has no plans to update the rankings, and adds, "We would not consider it current."

Here, we have the WHO contending that a study which is 10 years old is still current in its implications. Does anyone else seriously believe this?

More importantly, do you rip up and redesign one of the world's more complex and effective health care systems, some 15% of the US economy, on the unreliable conclusions of a decade-old study not even intended to provide firm conclusions for any actions?

"And yet many people apparently do. The 37th place ranking is often cited in today's overhaul debate, even though, in some ways, the U.S. actually ranked a lot higher. Specifically, it placed 15th overall, based on its performance in the five criteria. But for the most widely publicized form of its rankings, the WHO took the additional step of adjusting for national health expenditures per capita, to calculate each country's health-care bang for its bucks. Because the U.S. ranked first in spending, that adjustment pushed its ranking down to 37th. Dominica, Costa Rica and Morocco ranked 42nd, 45th and 94th before adjusting for spending levels, compared to the U.S.'s No. 15 ranking. After adjustment, all three countries ranked higher than the U.S.

Still, people often claim that the 37th-place ranking refers to quality or outcomes. High spending rates pushed the ranking down but didn't degrade the quality of care. Among those who have recently failed to make that distinction in published comments are Colorado Rep. Diana DeGette; Iowa Democratic Sen. Tom Harkin; and Margaret E. O'Kane, president of the National Committee for Quality Assurance, an advocacy group.

Representatives for Ms. DeGette and Mr. Harkin didn't respond to requests for comment. A spokeswoman for the National Committee for Quality Assurance said, "WHO is a respected organization. ...We have no reason to believe it is inaccurate, and we would never knowingly misrepresent or misuse another organization's data."

Here we see that many US politicians don't even know the details of the WHO study they cite. This is, as I noted in my earlier comments, perhaps the worst way in which research studies are used. Yet that is precisely what liberal US Congressional members are doing with this flawed WHO study of a decade ago.

"The flawed WHO report shouldn't obscure that the U.S. is lagging its peers in some major barometers of public health. For instance, the U.S. slipped from 18th to 24th in male life expectancy from 2000 to 2009, according to the United Nations, and from 28th to 35th in female life expectancy. Its rankings in preventing male and female under-5 mortality also fell, and placed in the 30s.

But even such analyses, more limited in scope than the WHO's effort, face similar problems: How to differentiate between the quality of the medical system and other factors, such as diet, exercise and violent-crime rates.

Some think that if the U.S. health-care system isn't responsible for troubling outcomes, trying to fix it doesn't provide the best return on investment.

"We might get more bang for the buck by setting aside some of our health-care money to support novel approaches to improve nutrition, education, exercise or public safety," says Alan Garber, an economist and professor of medicine at Stanford University. "Not every health problem has a medical solution."Nor can everything be ranked -- especially health-care systems. "I think it's a fool's errand," says Dr. Musgrove."

And here we have the "Sunday punch," as it were, from misusing the WHO study's report.

Let's take the two negative health trends in US male and female life expectancy cited above.

Any sensible person would first ask,

"Which countries moved up in the rankings, which are above the US, and what is different in those societies and countries from the US?"

You wouldn't just assume the difference was due to the countries' health care systems. Diet, lifestyles, genetics, or other cultural differences could all figure more prominently than health care systems.

There is so much detailed commentary one could make on the WHO study's flaws that it's really impossible to do so from the outside. But it's a pretty good bet that to study the various aspects of comparative health care systems' effectiveness's, a lot of smaller studies focused on specific topics in more controlled situations would have produced much more valuable, credible and actionable findings.

From what I read in Mr. Bialik's excellent piece, I have no confidence in any part of the WHO report on health data from a decade ago. It should scare you, as it does me, that our politicians are taking this report at all seriously.

The Return of the Public Option?

With the conference of the House and Senate Democrats over the several versions of health care that they have now passed, at least in committees, the so-called "public option," or government-run health care, is now back on the table.

Of course, no Republicans are included in these deliberations, as the Democrats apparently believe the American voters won't punish them for not even trying for bi-partisanship on this issue.

Will the CBO rescore any resulting bill containing the vaunted public option?
Will the resulting bill be posted online for at least 72 hours, as Wonderboy promised during his campaign for all major legislation?

We aren't getting C-Span coverage of the debates over this legislation, as promised in his campaign. Rather than the transparency he promised, we're getting the old one-party stiff-arm.

Of all the bad ideas being written into legislation, though, the public option is the worst. No matter how it is conditioned or couched, it represents the looming, eventual move by the federal government to eliminate the private health insurance industry.

This will not end well.

Perhaps enough Democrats are still not so liberal as to believe they will survive their next election after the passage of such legislation.

In a way, it may almost be better to watch these liberals pass this bill, in hopes it will return the House and perhaps the Senate, at a stroke, back to the Republicans. And maybe, as a libertarian friend of mine remarked, the GOP will remember to behave like the party of smaller government.

We can only hope.

Do They Think We Are All Stupid?

I mentioned the New Jersey gubernatorial race in this post yesterday.

As part of his assault on his Republican opponent, Chris Christie, Jon Corzinne's campaign has been running non-stop ads, courtesy of Corzinne's Goldman-sourced personal fortune, attacking Christie for allowing insurance companies to "drop mammogram" coverage.

The entire thrust of these ads are that insurance companies wouldn't cover anything unless the government mandated that they do so.

Does Corzinne think we are all stupid? And, by extension, do the Washington Democrats, as well?

I guess they must, because their argument is so fallacious and obviously wrong that it caused me to think of who would believe it?

Of course, the truth is that, in a mandate-free, more competitively-governed health insurance market, you could choose exactly the coverage you wanted, and pay for that. No less, and certainly no more.

No company "drops" unmandated coverage. It's not that simple. But by mandating something, politicians then scare unsophisticated voters into believing that any candidate who is against mandates must be "for" dropping said coverage.

I'm guessing Corzinne and, by extension, Wonderboy and his minions in the Congress, are aiming at the least-sophisticated voters. The ones already on welfare or getting government subsidies of one type or another.

Because anyone who buys, say, auto insurance, knows you can elect, at some point, when the value of your car is sufficiently low, to not pay for collision damage coverage.

Why anyone would think that you should not be able, in a competitive insurance market, to buy what you want, and not what you don't, is beyond me.

But the way Corzinne's ads keep hammering away on this falsehood, it's evident he has no respect for the intelligence of New Jersey voters.

The Conundrum of The New Jersey Voter

It's tough to be a voter in New Jersey this year. One really feels there's no practical, quality choice in the gubernatorial election.

The Democrats are, of course, propping up failed liberal Jon Corzinne. After being kicked out as co-head of Goldman Sachs' years ago, Jon bought a New Jersey Senate seat. Tiring of that, and not expecting the Democrats to retake the upper chamber, he then bought the governor's seat.

Perhaps he thinks getting his ticket punched there, twice, gives him presidential credentials. Or maybe he's just bored with working for a living, so political elective office makes sense.

Who knows?

Either way, he's taken the wreckage left by the last governor, who resigned under an ethics cloud, and worsened it. New Jersey is probably closer behind California in its fiscal mess than most people, or state citizens, realize.

Then we have "Chris Christie."

What a guy! A product of the Christie (no relation) Todd Whitman-influenced state Republican party, he's been coached to alter his positions like a custom-made suit.

I never trust someone who flips on right-to-life issues suddenly, and without reason. Christie did this so that a pro-life stance, his original view, wouldn't hinder his chances in a solidly Blue state.

However, as an independent who registers Republican, even I can see how Christie is corrupt even before winning the governorship.

The reports of his cutting a deal to spare his brother an SEC prosecution ring true. So does his paying off Justice department cronies with no-bid contracts for outsourced legal work.

Sure, sure, he got a bunch of convictions as a federal prosecutor. Sure, so did Rudy Giuliani.

But I think the comparisons stop there.

You knew what Giuliani was for, and against, even if you didn't live in New York City. Christie merely mouths platitudes about lower taxes and spending, but offers no solid plans for such empty concepts.

This is a state in the choke-hold of lawyers, of either party, in the state legislature. It's going to take a lot to restore any shred of fiscal rectitude in the state.

Faced with these unappetizing choices, one considers the independent, Chris Daggett. Daggett actually details how he'll cut a range of taxes and extend the sales tax to more items, without raising the rate. Of course, there's no plan for spending cuts in his campaign, either.

But the real question is how to vote without feeling you've rewarded vagueness, incompetence, or corruption, or wasted your vote.

I can't vote for Corzinne. Just isn't going to happen. I never liked him or his policies, and they have demonstrably failed.

I voted for Lonnegan in the Republican primary. I don't like Christie, and I don't trust him. With only a prosecutorial career and no clear ideas on governing, voting for him is like buying a pig in a poke. And, no, I'm not poking fun at his weight or girth.

But I just have doubts about voting for Daggett. It's a classic prisoners' dilemma. If I knew a lot of other voters, disgusted with both of the other clowns, would choose Daggett, then so would I.

I mean, how much worse can things get? And several local and regional news organizations have endorsed his candidacy.

But if I vote for Daggett and Corzinne wins, then I did waste my vote.

but if I vote for Christie, I'm not voting with a clear conscience.

It's all very disturbing. A microcosm, really, of my disappointments with both parties on the national level, too.

Polanski Edges Closer to Extradition

Remember the flap over Roman Polanski's arrest in Switzerland earlier this month?

It hasn't gone away.

A news article this week reported that the Swiss have refused to allow Polanski to leave jail for house arrest, citing the obvious flight risk. After all, he's in Europe because he fled a court sentencing in the US in the first place.

What is comical is that Polanski's lawyer says they will attempt to offer ever larger financial assets as collateral to get Polanski sprung.

By the way, he's 76 and probably has enough money that losing a chalet or two pales besides being imprisoned in the US for flight from his original sentencing.

Polanski is reportedly suffering from "depression because of his incarceration."

Hmm. I wonder what sort of depression or other psychological impairments the admitted rapist's 13 year-old victim suffered after he drugged her, then sexually assaulted her?

Yes, it seems the Swiss are acting in such a way as to deliver this little moral package to Wonderboy's doorstep one day soon.

How will he reconcile Hollywood's affection for him, and its denizens' demands that Polanski be pardoned for art's sake?

Stay tuned.....

A Sad Tale of Federal Regulatory Overkill & Thrift Shops

Remember the stampede in Congress to regulate toy imports from China and, then, by extension, regulate the testing and safety of toys sold in the US?

Talk about unintended consequences. I read about this at the time, but didn't really grasp the full impact.

Yesterday I visited a local resale shop to donate some items. One was a piece of clothing one of my children had outgrown. The other was an all-plastic toy.

The toy was an accessory for small metal cars. It was a simulated garage with a few electrically-powered moving parts.

When I spoke to an employee at the shop, she smiled as she took the article of clothing, then simply said,

"Sorry, we can't take the toy."

I somewhat dimly asked why not, and she reminded me that, with the imposition of recent regulations, all second-hand shops had to drop handling toys.

She told me that they can't afford the liability, should someone buy a used toy at the shop and then sue them for violating laws regarding lead, paint, or anything else now prohibited.

I looked at the toy I held, then at the woman. I knew it was useless to appeal that the toy had no paint, because it was obvious that the shop had to simply stop handling toys of all sorts.

Clearly, they had been told by their insurer that it wasn't enough for them to try to discriminate between lawful and unlawful donated toys.

It was safer for them to simply stop taking and reselling any toys.

This seems to me to be a sad state of affairs. In the current economic recession, I'm sure there are quite a few parents who would be happy to find some less expensive toys at resale shops.

But, now, that's impossible. A reliable source of used toys has been shuttered, raising costs to parents who can't necessarily buy new toys for their children all of the time.

How sad that a previously-functioning market for still-usable, used toys has been permanently destroyed by Congress' regulatory overreach.

The False Advertising For A Public Health Care Option

I happened to see an ad for public option health care yesterday. The ad in question made use of alleged "facts" that were calculated to prove the wisdom of a public option, i.e., government-run health care.

Among the things I recall about the ad were that it alleged that one insurance company controlled more than 90% of some measure of insurance, though it didn't mention what that measure was. There were similar statistics cited, without sources, to suggest that there is no competition in the health insurance sector.

Here are two other pro-public option ads you can find on YouTube.



I found it notable that this first video only engaged in ad hominem attacks. That is, the health insurance CEO is bad simply because he lives in a large house and is paid a large salary. There's no mention of his background, how long he worked to attain that position, or how well, or poorly, he has done for his shareholders.

We know nothing about the family that lost their home, allegedly due to health-related expenses. We don't know if the home was too expensive for their budget, or what their lifestyle was, and how it may have contributed to their medical expense woes.

In short, there are no contexts for either emotional appeal.



This video is just a farce. I guess the intent is to suggest that insurance companies can change policy rules on a whim. I don't think that's at all true. In fact, my guess is that, being subject to state regulations, they probably have to appear before a state insurance commission with rate increase requests.

However, for some states, like mine, New Jersey, there are so many mandates and such an inhospitable health insurance climate, that the best, cheapest plans allowing the buyer to tailor the policy for her/himself, won't do business there. Instead, we are hostage to what is, admittedly, a non-market in health insurance, in which rate increases are simply dictated.

But that's a consequence of political actions by state legislatures, not the insurance companies. I know for a fact that health insurance coverage is about half as expensive just sixty miles west of me, across the Delaware river, in Pennsylvania.

What public option proponents don't discuss is any of the following:

-Most situations of a lack of competition in health insurance were constructed by politicians.
-Industry concentration is a common occurrence in most multi-state industries.
-Insurance companies are, for the most part, publicly-owned. Thus, so-called excess profits for insurance companies are, in fact, good for their shareholders, who could be American voters and taxpayers, should they so choose to buy the equities of those insurance companies.
-Comparing US health care spending to that of other countries makes no allowance for more innovative treatments and drugs used in the US. Nor does it address whether it is good, or bad, to spend more on something like health care. Perhaps more spending denotes better outcomes, longer lifespans and higher satisfaction with outcomes.
-Comparing foreign country health care costs with those of the US, without mentioning different tort lawsuit environments, is a gross misrepresentation of the true situation. Much US health care expense is engendered in defense of unregulated tort lawsuits for damages beyond simple medical malpractice.

In short, the public option proponents grossly distort, limit and hide the context of their so-called "evidence" against a health insurance market devoid of government-run providers, but allowing inter-state competition without mandated coverages in policies.

Such a situation would, in fact, allow for the most competition, with no tax-free, hidden-cost government 'competitor' undercutting actual costs, and driving private insurers from the marketplace.

If insurance companies were allowed to easily sell policies across state lines, without the needless complexity of conforming with 50 state insurance commissions policies,' and state-created mandates were eliminated, health insurance policy costs would drop immediately.

Add tort reform, and US health care costs for the same excellent level of care would fall even further.

The simple truth is that today's health insurance market is what it is as a consequence of many state legislatures, and the federal government, through Medicare and Medicaid, not through the design of the insurance industry.