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Politics : A US National Health Care System? -- Ignore unavailable to you. Want to Upgrade?

To: Road Walker who wrote (1836)	8/12/2007 9:02:23 AM
From: Lane3	Respond to of 42652

on most measures of performance, including quality of care and access to it. I was glad to see this piece differentiate between quality and access. It's important to analyze them separately in determining what to do with the health system.

To: Road Walker who wrote (1836)	8/12/2007 3:01:39 PM
From: TimF	Read Replies (1) \| Respond to of 42652

Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. "...To see the illogic for myself, I downloaded the relevant WHO report and the study it was based on. But before I could verify the factors included in the health performance index, I had to figure out which index to look at. It turns out that the U.S. ranks 37th on the “overall performance index.” But on this index, while it’s true that France is #1, Canada does not rank in the top 10 – it’s only #30. There is another index, “overall health system attainment,” on which the U.S. ranks #15 (while France and Canada are #6 and #7, respectively). As far as I can tell, the two indices are based on the same underlying data, but with the “overall performance index” calibrated according to some measure of how well the country is theoretically capable of doing. I’m still trying to figure out exactly how this calibration works. In any case, it looks an awful lot like someone cherry-picked the results to make the U.S.’s relative performance look worse than it is. Contrary to CNN.com (and possibly Michael Moore – I haven’t seen the movie yet), there is no index that has both Canada and France in the top 10 and the U.S. at 37. But back to Masten’s point. Both of these indices include “financial fairness” (FF) as a factor with 25% weight in measuring the system’s performance. FF is measured first by finding a household’s contribution to health expenditure as a percentage of household income (beyond subsistence), and then looking at the distribution of this percentage over all households. The wider is the distribution, the worse a nation will perform on the health performance index (other things equal). But it should not be surprising at all that a larger percentage of poor people’s income will be spend on health than would be spent by the rich. Insofar as healthcare is treated as a necessity, we should expect that people will spend a decreasing fraction (not a decreasing amount, but a decreasing fraction) of their income on healthcare as their income increases. Rich people tend to spend a larger percentage of their income on luxuries than do the poor. More importantly, the distribution of household contributions will obviously decline when the government shoulders more of the health spending burden. In the extreme, if the government pays for all healthcare, every household will spend the same percentage of their income – zero – on healthcare. In other words, this measure of health outcomes necessarily makes countries that rely on private payment look inferior. It gets worse. The ostensible reason for including FF in the healthcare performance index is to consider the possibility of people landing in dire financial straits because of their health needs. It’s debatable whether this factor deserves inclusion in a strict measure of actual health performance – but let’s suppose it does. FF does not actually measure exposure to risk of impoverishment. FF is based on cubing (!), for each household, the difference between that household’s contribution and the average household’s contribution to healthcare. Consequently, FF is negatively affected by households that spend a larger percentage of their income on healthcare than others. But FF is also negatively affected by households that spend a much smaller percentage of their income on healthcare than others! This is senseless, but it’s a natural result of focusing on distribution instead of the effectiveness of the healthcare people receive." agoraphilia.blogspot.com Message 23673018

To: Road Walker who wrote (1836)	8/12/2007 3:03:17 PM
From: TimF	Read Replies (1) \| Respond to of 42652

WHO's Healthcare Rankings, Part 2 posted 1:52 PM by Glen Whitman As I noted in the last post, WHO’s ranking of healthcare systems relies on a measure of performance that includes “financial fairness,” which has nothing to do with the quality of healthcare. At best –and even this is highly questionable – it says something about how many people face financial hardship as a result of the healthcare they receive. But this is not the only problematic factor in the WHO rankings. The rankings result from an index based on five factors, weighted as follows: 1. Health Level: 25% 2. Health Distribution: 25% 3. Responsiveness: 12.5% 4. Responsiveness Distribution: 12.5% 5. Financial Fairness: 25% Only two of these – health level and responsiveness – are direct indicators of health outcomes. Even these are subject to some objections (such as that health level is affected by things like crime and nutrition), but they’re at least relevant. But neither health distribution nor responsiveness distribution properly belongs in an index of healthcare performance. Why not? Because inequality (that’s what “distribution” is all about) is distinct from quality of care. You could have a system characterized by both extensive inequality and good care for everyone. Suppose, for instance, that Country A has responsiveness ranging from “good” to “excellent,” while Country B has responsiveness that is uniformly “poor.” Then Country B does better than Country A in terms of responsiveness distribution, despite Country A having better responsiveness than Country B for even the worst-off citizens. The same point applies to the distribution of health level. To put it another way, suppose that a country currently provides everyone the same quality of healthcare. And then suppose the quality of healthcare improves for half of the population, while remaining the same (not getting any worse) for the other half. This is obviously an improvement – some people get better off, and no one gets worse off. But this change would cause the country to fall in the WHO rankings, other things equal. [UPDATE: Clarification of the above example. As a result of the change, average health quality would rise, but inequality would rise as well. The former effect would tend to increase the country's WHO ranking, while the latter effect would tend to decrease it. The overall effect is ambiguous, even though common sense says the effect should be unambiguously positive.] Now, it’s not silly to consider the quality of care received by the worst-off or poorest citizens. But distribution statistics emphatically don’t do that! They measure relative differences in quality, without regard to the absolute level of quality. A better approach would include in the index a factor for the health quality of the worst-off individuals. Or you could construct a separate health performance index for (say) the bottom 20% of the income distribution. These approaches would surely have problems of their own, but they would at least be focusing on the real concern. WHO’s current approach, sadly, doesn’t even do that much. Labels: damn lies and statistics, healthcare agoraphilia.blogspot.com Message 23673023