How low can you go?

By Megan McArdle

In discussing health care, one often hears about how low America ranks on the WHO survey--37th in the world! This is true. But there are a couple of problems with it.

First of all, that survey is getting a little elderly; it hails from 2000. In the normal course of economics writing, that's pretty dated; my editors at The Economist would never have let me discuss health systems using a ranking that outdated. In general, an economics writer has to have a pretty darn good reason for using data more than a couple of years old.

Also, as John Stossel notes, many of the measures it uses, such as life expectancy, may be exogenous to the health system:

The WHO judged a country's quality of health on life expectancy. But that's a lousy measure of a health-care system. Many things that cause premature death have nothing do with medical care. We have far more fatal transportation accidents than other countries. That's not a health-care problem.

Similarly, our homicide rate is 10 times higher than in the U.K., eight times higher than in France, and five times greater than in Canada.

When you adjust for these "fatal injury" rates, U.S. life expectancy is actually higher than in nearly every other industrialized nation.



Now a liberal might argue that crime and auto accidents could be resolved by other items on the progressive agenda. I disagree (for starters, from what I understand, America's higher homicide rate long predates the emergence of the European welfare states), but that's a legitimate argument in favour of a broader progressive platform. However, it undercuts the belief that single payer is going to magically improve things.

Other indicators seem almost cherry-picked to make America drop down on the rankings. Equality of distribution, for example, is heavily weighted; so heavily weighted that quality of basic care suffers in comparison. That's why places like Morocco, the Dominican Republic, and Costa Rica clean our clocks.

Now, personally, I don't really care about equality of distribution per se. I don't care if Bill Gates gets super-awesome treatment; what I want to know is, are people suffering and dying from lack of care?

Obviously, those things are linked, and it's not unreasonable that an egalitarian would put that on their list of criteria. But one would hope that the WHO rankings would reflect, to a first approximation, where you'd rather get sick. Does anyone really think that they'd rather be the average consumer of health care in Colombia, than in Columbus, Ohio?

But what about the worst off, you might say? What about them? The WHO table isn't even a good ranking of where I'd prefer to be poor. I'd far rather be an uninsured day laborer in San Francisco, than in the Dominican Republic. For that matter, I'd rather be uninsured anywhere in the United States than an average citizen in Costa Rica.

This is a problem for those touting our low ranking. I can't say I know what our ranking should be; a lot depends on value judgements that it would be hard to gather consensus for. But whatever our true ranking is, I'm pretty sure we're not behind a significant chunk of Latin America. You don't see a lot of uninsured illegal immigrants trying to get home for the awesome health coverage.

This article available online at:

http://www.theatlantic.com/business/archive/2007/08/how-low-can-you-go/1798/