This ranking is curious because the actual life expectancy of the average American differs very little from that of the average European. At birth, average life expectancy in the European Union is 78.7. For the average American it is 78. And this doesn’t adjust for factors that can affect the averages which are unrelated to health care, such as lifestyle choices, accident rates, crime rates, and immigration. Health isn’t entirely about longevity but it certainly is a major component. 

What is not mentioned by Moore, or others citing the WHO report, are the measures being used to rate the various countries and who is doing the measuring. There are many ways to nudge ratings in one direction or another that are not directly related to the actual item being measured.

For instance, one might produce a study on transportation. The purpose of transportation is to get people from where they are to where they wish to be. You might rate how quickly people can move, how cheaply they can move relative to their income, how conveniently they can move, and how free they are to move. 

You would think the United States would rate high in such a study. Americans tend to be wealthier than the rest of the world. There is widespread ownership of cars. Gasoline prices are lower than in most other countries. On average, the typical American can travel quicker, cheaper, and more conveniently than people in most parts of the world. But what if this index included other factors as well? For instance, if a major component was the percentage of commuters who use public transportation, that would push the United States far down in the ranking. A larger percentage of the people in other countries have no other option but public transportation. 

In 2000, when the report was issued, WHO was run by Gro Harlem Brundtland, a former prime minister of Norway and a socialist. She doesn’t think the results of a health system alone are important. Rather, she wants to know if the system is “fair.” In introducing the WHO report she wrote that while the goal of a health system “is to improve and protect health,” it also has “other intrinsic goals [that] are concerned with fairness in the way people pay for health care.” She is clear about the ideological factors she thinks are important: “Where health and responsiveness are concerned, achieving a high average level is not good enough: the goals of a health system must also include reducing inequalities, in ways that improve the situation of the worst-off. In this report attainment in relation to these goals provides the basis for measuring the performance of health systems.”

True to her ideological roots, Brundtland prefers socialized medicine over private care. Drawing her first conclusion about what makes a good medical system, she declares: “Ultimate responsibility for the performance of a country’s health system lies with government. The careful and responsible management of the well-being of the population—stewardship—is the very essence of good government. The health of people is always a national priority: government responsibility for it is continuous and permanent.”

One WHO discussion paper states, regarding “fairness” in financing, “we consider only the distribution, not the level, as there is no consensus on what the level of health spending should be.” Equal results, not necessarily good results, are the focus. 

When Moore or others refer to the WHO index as proof that private health care doesn’t work, they aren’t being totally honest because they fail to disclose that the index lowers the scores of systems that don’t satisfy socialist presumptions.

A Second Rigged Study

The New York Times in August editorialized that American health care “lags well behind other advanced nations.” The newspaper relied in part on the WHO rankings as proof. For the rest, it relied on a more recent study by the Commonwealth Fund. But that study, which compared the United States to five other wealthy countries, has weaknesses similar to the WHO study.

The Commonwealth Fund marked down the United States partly because “All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefits packages with no cost-sharing by the patients.” Again the American system loses points because it doesn’t provide socialized medicine. And the Times neglected to note that “no cost-sharing” means the people have paid through taxes whether they receive the care or not. 

Non-Emergency Visits

The United States also was penalized because seeing a physician for non-emergency reasons is harder to do on nights and weekends than in the other five nations. The Fund said “many report having to wait six days or more for an appointment with their own doctors.” 

The survey didn’t look at the treatment of serious conditions. Waiting weeks or months for chemotherapy is not held against a health-care system, but waiting a few days to have a check up is. Waiting time for “elective” surgery is counted (the United States was a close second to Germany), but waiting time for non-elective, serious surgery did not count, though that is precisely where socialist systems do the worst.

This issue is not unknown to the Commonwealth Fund. In 1999 it published The Elderly’s Experiences with Health Care in Five Nations, which found significant delays for “serious surgery.” Only 4 percent of the American seniors reported long waits for serious surgery. The rate was 11 percent in Canada and 13 percent in Britain. For non-serious surgery the differences were more obvious: 7 percent in the United States, 40 percent in Canada, and 51 percent in Britain. 

In the latest survey, the United States came in dead last for health “safety,” but many of the scores were only a few points apart. For instance, 15 percent of American patients said they “believed a medical mistake” had been made in their treatment within the last two years. Notice this is merely patient perception and nothing objective. But the best score was in Britain, where 12 percent said this.

The United States is also marked down because 23 percent of patients report delayed or incorrect results on medical tests they took. That is far worse than the best country, Germany, at 9 percent. But what constitutes a delay? If a result is expected in a week but takes two, that is a delay. But if it is expected in three weeks and arrives then, that isn’t a delay. Thus what constitutes a delay depends on expectations, leading to counter-intuitive results.

The United States also lost credit because fewer Americans report having a regular doctor for five years or more. But Americans are more mobile than many other people. CNN reports that Americans move every five years on average. In comparison, Britain has a moving rate of 10 percent a year, or an average of once a decade. And 60 percent of those move about three miles.

Freer to Change Doctors

Americans are also freer to change doctors if they wish. Britain requires patients to sign up with physicians, and once they do so, they are pretty much stuck unless they want to end up on the waiting list of another physician. Patients often have to wait to get on the books of a physician and only then can they be treated; that is, they wait to get on a wait list. This is true even for heart transplants. The inevitable waiting is a disincentive to change doctors.

Another measure used by the Commonwealth Fund is centralization of medical records. If a country has a system that allows doctors anywhere to tap into the patients’ records, it is rated higher. The United States has no centralized database and so is rated lower. Many Americans may prefer to have their records private and dispersed. When the Clinton plan was proposed in 1993, one of the rallying points that helped defeat it was the centralization of health records.

Out-of-pocket expenses were counted against a system as well. In socialized health care these expenses are zero or very low but are replaced with taxes. Taxes, however, don’t lower a country’s score because the care “is free.”

Countries were also judged on the number of patient complaints. But different cultures have different attitudes toward complaining. Jeremy Laurance wrote in the Belfast Telegraph recently that the National Health Service needs “a healthy dose of American belligerence.”

Finally, the United States is ranked last among the six nations surveyed  in infant mortality. What is not discussed is that nations define infant mortality differently. Any infant, regardless of size or weight or premature status, who shows sign of life is counted as a live birth in the United States. Germany, which ranks number one in the Commonwealth Fund survey, doesn’t count as a live birth any infant with a birth weight under 500 grams (one pound). How valuable is a comparison under those circumstances?

One could easily design a survey that would rank American health care high and other nations low. But this does not mean the American system is what it should be. Its successes and innovation can be attributed to the vestiges of freedom, but government has saddled the system with so much intervention that it is far from market oriented. Instead of worrying about irrelevant international rankings, we should be working toward freeing the medical market.

The World Health Organization (WHO) didn’t blink twice before shooting down the United States’ world-class health-care system. In a recently released report, “The World Health Report 2000—Health Systems: Improving Performance,” the WHO ranked the overall performance of the U.S. health system at 37th out of 191 countries surveyed.

In fact, for a study purported to be a “balanced judgment” of the world’s health systems, the WHO waited only until the third paragraph of a six-page press release to herald its conclusion that the United States’ system did poorly in the evaluation. Published in June, the WHO’s “first ever analysis of the world’s health systems” listed America well behind first-ranked France, second-ranked Italy, and various other European, Middle Eastern, and Asian countries.

At gut level, this assertion rings false. When was the last time someone chose France or Italy over America for health care? How about the third-place little island of San Marino? Since the U.S. ranking fails to correspond with the documented practice of foreign patients’ flocking to the United States for care, a brief description of the report’s terms is required.

A health system, according to the WHO, is quite inclusive. Not only does it include the doctors, clinics, and hospitals that deliver patient care, but also “all the organizations, institutions and resources that are devoted to producing health actions.” Government oversight functions, public health activities, personal health dollars, and health-care financing schemes are all part of the system.

In addition, the WHO adds goodness and fairness to the traditional service objectives of a health system. High-performing health systems should not only deliver health-care services, but also be responsive to patient expectations and provide equal treatment to all patients irrespective of finances or social status. With these goals in mind, the WHO’s critical measure of a health system’s performance was its “achievement relative to resources.”

The World Health Organization primarily faults the United States for not requiring mandatory insurance or offering social welfare programs to all citizens—in other words, for being a free country with independent citizens. Given America’s high level of health-care spending, the U.S. system does not achieve the organization’s fairness and distribution goals relative to total health-care resources. In addition, the report criticizes the move toward medical savings accounts and the fact that 56 percent of America’s health-care expenses are privately funded.

Interestingly, the WHO completely failed to broadcast that America’s health system ranked first in responsiveness to patients’ needs for choice of provider, dignity, autonomy, timely care, and confidentiality. In other words, where it matters most to patients, the U.S. system excels.

Since health-care systems are created solely to meet the needs of patients, it seems only natural to assume that responsiveness would receive top consideration when judging performance. Yet, first-ranked France ranked only 16th or 17th in responsiveness, while second-ranked Italy ranked 22nd or 23rd. Oman was given a ranking of eighth in performance, but only 83rd in responsiveness to patients. And Morocco, ranked 29th in performance, was ranked at 151-153 in responsiveness—near the bottom of the list.

According to the WHO, America did not even outperform Canada, which received a performance ranking of 30th despite the regular visits of Canadians to American hospitals and doctors. Surprisingly, the Netherlands, known for involuntary euthanasia—a less than patient-friendly policy—was rated 17th best, 20 countries higher than the United States.

WHO’s Global Agenda

Because the World Health Organization took great pains not to announce publicly that the United States took grand prize in patient care, there is reason to believe its public chastisement has little to do with America’s quality and delivery of health-care services.

Indeed, the criticism appears to be aimed at furthering redistribution of American dollars around the globe. The WHO claims governments are responsible for “mobilizing the collective action of countries to generate global public goods such as research, while fostering a shared vision towards more equitable development across and within countries.” In addition, the WHO’s overall mission is “the attainment by all people of the highest possible level of health, with special emphasis on closing the gaps within and among countries.”^[1]

The WHO writes that its vision includes “placing health at the centre of the broader development agenda,” most likely through financial transfers from countries with greater resources. It is not surprising then to find the WHO report promoting centralized collection, pooling, and redistribution of health-care funds—and chastising countries that fail to march in step with collectivist thinking.

That this centralized approach requires health-care rationing to vulnerable, sick, disabled, elderly, and politically disenfranchised citizens does not bother the WHO, an unabashed supporter of explicit rationing. WHO officials describe rationing as central to their emerging vision of “new universalism”: “Rather than all possible care for everyone, or only the simplest and most basic care for the poor, this means delivery to all of high-quality essential care, defined mostly by criteria of effectiveness, cost and social acceptability. It implies explicit choice of priorities among interventions, respecting the ethical principle that it may be necessary and efficient to ration services, but that it is inadmissible to exclude whole groups of the population.”^[2]

To enforce the necessary limits on health-care services, the report suggests that physicians and other practitioners be monitored through data collection, and if necessary sanctioned for providing patients with care classified as unnecessary or impermissible. Noting that practitioners are difficult to control, the WHO advocates the creation of a national benefit package with lists of available health-care treatments. The lists, coupled with practitioner-control mechanisms such as clinical protocols, registration, training, and licensing and accreditation processes, can then be used to enforce health-care rationing.

Collectivist Control

Besides the organization’s draconian promotion of global health-care rationing, the drive to cultivate collectivist health care can be seen through a subtle deviation from typical terminology. The WHO premises its report and assessment on comprehensive “health systems” organized by government bureaucracies rather than “health-care systems” comprised of individual providers treating individual patients. Private funding by individuals and the private practice of medicine are assiduously discouraged throughout the report.

In these health systems, governments are to assume the crucial role of “stewardship” to enforce “rational” use of health-care services. Governments are thus called on to collect health-care funds from citizens, set and direct health policy, define allowable health-care services for citizens, and provide oversight.

Because system-wide control of health-care resources is desired, WHO officials express particular distaste for America’s abundance of private financing for health care (56 percent) and Congress’s advancement of medical savings accounts (MSAs) for individual provision and payment of health care. Although they acknowledge that MSAs are a form of prepayment—the pooling mechanism they aggressively support—they assert that MSAs and private funding prevent centralized pooling of dollars without which certain public health initiatives may never be funded.

In addition, they argue that individual financing fosters fee-for-service payments—as if paying for the care you need at the time you need it is ill-advised—and makes it difficult to regulate and control the treatment practices of providers—a blessing to patients who value unrationed care.

Ironically, the report attempts to discredit MSAs for performing the insurance function insurance is meant to perform. WHO officials are displeased that “the healthy and the young, whose risk is usually low, might prepay for a long time without needing the services for which they had saved.”^[3]

WHO’s System of Control

According to the report, the control of health-care spending should be placed in the hands of bureaucrats through mandatory and pooled prepayments for health-care services. Each household’s prepayment could be based on a defined percentage of the income that remains after anticipated food expenses are subtracted from total household income. These prepayments would then be collected using employment-based insurance schemes, direct taxation, or social security programs.

Prepayment is key because it facilitates decisions about spending limits. As prepayment rises, “spending is more and more determined by the policies and budgets of public entities and insurance funds.” But when health care is financed privately, WHO officials note with dissatisfaction, the level of financing is decentralized as a result of “millions of individual decisions”—a situation the WHO apparently wants to avoid to keep its agenda intact.

Not only does the WHO desire prepayment, it wants fairness throughout the system. But its definition of fairness emphasizes equitable distribution of services, not necessarily related to individual needs for services. As the report clarifies, “If services are to be provided for all, then not all services can be provided.”^[4] According to the report, the level of annual health-care funding available to patients is to be determined once funds are pooled and priorities are set.

Fairness is also strongly advised for financing strategies. As noted in the report: “the risks each household faces due to the costs of the health system are [to be] distributed according to ability to pay rather than to the risk of illness.”^[5] Therefore, those with higher incomes are to contribute more than those with lower incomes, regardless of lifestyle choices or behaviors. Indeed, the WHO declares, “Fairness of financial risk protection requires the highest possible degree of separation between contributions and utilization.”^[6]

The organization’s skewed view of equity is seen most clearly in its contention that wealthy citizens must prepay more for health care than poor citizens because left to their own resources, a greater percentage of the poor family’s income goes to health care than that of the wealthy family. Lest we forget, this is the case for any purchase made by one person who earns less than another person. If one man earns $100,000 and another earns $10,000 and both want to buy a $1,000 used car, the cost is ten percent of the lower income but only one percent of the higher income. Following the organization’s line of reasoning, why stop with health care? If such “fairness” can be required in one type of purchase—health care—it can be mandated across all purchases of social value.

WHO officials have become present-day Robin Hoods, declaring that individuals have no right to keep what they earn. To rationalize their position, they dismiss real fairness—the ethic inherent in earning, keeping, and controlling the fruits of one’s own labors—in exchange for a perverted description of fairness that fits their own need for control.

Banking on America

Although never stated directly, the WHO’s baseless criticism of the U.S. health-care system appears to be an attempt to pressure America’s policymakers into commandeering a larger share of Americans’ health-care dollars for contribution toward global and public health initiatives around the world.

It is also entirely possible that improved health care is not the primary goal of countries seeking the American dollar. The other 190 member countries of the World Health Organization may view dollars designated for health care as a meal ticket for purchases not directly related to medical services. After all, it can be reasonably argued that improved roads, schools, environment, transportation, and agriculture all positively affect health.

Clearly, WHO officials have an agenda that is neither patient-friendly nor protective of individual freedoms cherished by American citizens. Given the opportunity, they would readily place control of every person’s earnings and every patient’s care into a few powerful hands.

American taxpayers pay over $96 million per year to the World Health Organization—roughly 25 percent of its general budget.^[7] Rather than dignifying the WHO report with further self-evaluation, Americans should question congressional support of this organization, which insufficiently understands and respects the constitutional freedoms that have made the U.S. health-care system number one with patients around the world. []

Notes

1. World Health Organization, “The World Health Report 2000,” “Overview,” June 21, 2000.
2. Ibid.
3. Ibid., “Who Pays for Health Systems?” p. 99.
4. Ibid., “Overview.”
5. Ibid., “How Well Do Health Systems Perform?” p. 35.
6. Ibid., “Who Pays for Health Systems?” p. 97.
7. Telephone interview with Nelle Temple Brown, external relations officer, World Health Organization Liaison Office, Washington, D.C., July 26, 2000.