#270: The Worst Health Care Study in the World

Published May 2, 2011

In the latest edition of Commentary, Scott Atlas of the Hoover Institution, a professor of radiology and chief of neuroradiology at the Stanford University Medical Center, does yeoman’s work in collecting and documenting the ridiculousness of the continually cited World Health Organization’s “World Health Report 2000”. While you’ve probably read about the WHO’s flawed methodology, Atlas points out how often it was deployed and cited during the debate over President Barack Obama’s health care law by supposedly serious people (including CPR’s favorite person, CMS’s Donald Berwick), even in the face of its blatantly offensive warping of statistics.

Atlas writes:

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.

What’s more, WHO themselves told the world exactly how warped their survey “data” was:

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.

So you design your own vague descriptive elements, bend the numbers to your will, and then survey your own staff to get their reactions to these numbers – and still get taken seriously by the leaders of the world? What an easy way to get exactly the outcome you prefer from any study ever!

Read the whole piece from Atlas, and be sure to refer people to it should you come across further citations of this embarrassing fraud of a study.

An aside: This is a newsletter about health policy. But on a day like today, I hope you don’t begrudge me sharing this: Last night, Sunday Night Baseball was on as I worked in another room, in part on this report. My Blackberry stays off on Sundays, and I didn’t hear the announcer share the news. But I heard the chants of “U.S.A.” getting louder and louder, rising through the stadium, and I knew something had happened, something right, and something long coming.

There was something heartbreaking and wonderful in that – in hearing of the demise of someone who had tried and succeeded in murdering so many friends and colleagues from something as inherently American as a baseball game. One of the things that makes America great is that we are never satisfied simply to endure. Instead, throughout our history, the nation has been guided by those who take the more difficult path, who strive onward and upward to carve out a better life for our children, and do what it takes to ensure they grow up in a just, free, and decent world.

— Benjamin Domenech



NPR reports that a new survey from the American College of Emergency Physicians finds emergency room crowding – as we’ve all known for years – isn’t caused by people who don’t have insurance, but “it’s caused by people who do, but still can’t find a doctor to treat them.”

A full 97 percent of ER doctors who responded to the ACEP survey said they treated patients “daily” who have Medicaid (the federal-state health plan for the low-income), but who can’t find a doctors who will accept their insurance.

At the same time, 97 percent of ER doctors also said they treat patients daily who have private insurance and primary care doctors, but whose primary care doctors sent them to the emergency room for care. Apparently that’s because the patient’s need for care arose during a time when that private doctor’s office was closed.

Since these insured patients are more – not less – likely to use the emergency department, 89 percent of physicians in the survey said they believe the number of visits to emergency rooms will increase as the new health law is implemented.

Welcome to reality, NPR. Shame you didn’t report on this back when it mattered to the health reform debate, of course.

For more on this issue, see Douglas Holtz-Eakins and Michael Ramlet’s report from last year on ER cost and utilization data from the RAND Corporation and HHS.



Here’s something quite useful from the Cato Institute: a primer for non-lawyers on the case against PPACA. Cato Chairman Robert Levy asks, “Are there any remaining limits on the breadth and scope of federal power?”

The Department of Health and Human Services has asserted three constitutional provisions as sources of authority for the mandate – the Taxing Power, the Commerce Clause, and the Necessary and Proper Clause. Each of those purported sources is deficient.

First, the penalty for not buying health insurance is not a tax. Even if the penalty were a tax, it would fail the constitutional requirements for income, excise, or direct taxes. Second, the power to regulate interstate commerce extends only to economic activities; it does not permit Congress to compel such activities in order to regulate them. Third, the mandate is not necessary; indeed, it is merely a means to circumvent problems that would not exist if not for PPACA itself. Nor is the mandate proper; it cannot be reconciled with the Framers’ original design for a limited federal government of enumerated powers.

An essential aspect of liberty is the freedom not to participate. PPACA’s directive that Americans buy an unwanted product from a private company debases individual liberty. And it’s unconstitutional.

Worth reading and sharing.

SOURCE: Cato Institute


In a new white paper, Devon Herrick of the National Center for Policy Analysis says states could access billions of dollars in savings without cutting off access to needed care. He recommends several strategies to better manage and lower Medicaid drug costs, relying on data from the Lewin Group and other researchers. His proposals include:

  • Encouraging generic drug use when appropriate.
  • Paying competitive market rates for drug dispensing.
  • Coordinating and tracking drug therapies.
  • Establishing reimbursement rates for drug makers similar to what commercial drug plans pay.
  • Empowering patients with control of some of the dollars spent on their drug therapies so that they become better consumers.

“The Lewin Group estimates that the state and federal governments could save $32.7 billion over 10 years by improving the efficiency of their Medicaid drug programs without detriment to enrollees’ health,” Herrick writes. An optimistic figure, but not incredibly so.

SOURCE: National Center for Policy Analysis


The top White House health care advisor during the Obamacare debate, Nancy DeParle, has now had her calendar shared with conference after weeks of stalling from the White House. It looks just like you might expect: “over 100 meetings between DeParle and business groups and unions.”

Some of the groups that met most frequently with DeParle include AARP, which represents old people, the unions SEIU and AFL-CIO, the pharmaceutical drug sector, and the insurance industry’s trade association, AHIP.

DeParle’s meetings included numerous one-on-one encounters with the CEOs of specific companies, like a July, 2009 meeting with Tom Ryan, the CEO of CVS-Caremark.

On some occassions, the union SEIU and the left wing think tank Center for American Progress met with DeParle jointly.

Some meetings were far more widely attended than others. Included in the calendar are “stakeholder” forums with as many as 40 attendants.

For instance, on Nov. 11, 2009 – when federal abortion funding in the legislation was a hot topic of debate in Congress – DeParle met with 13 left-wing women’s groups including NARAL, NOW, Feminist Majority, Planned Parenthood and EMILY’s List.

Documents not provided by the White House include any notes or minutes of what took place at the meetings and correspondence relating to changes to the legislation as a result of the meetings.

A full picture of the people who passed this law can be gathered by reading this special report from Phil Klein last year in HCN.

SOURCE: Daily Caller


Writing at The New Atlantis, Jim Capretta shares a detailed look at the inflation-indexed vouchers that exist within Obamacare – with a followup on the even more complicated details.

The president and his allies have been attacking House Budget Committee chairman Paul Ryan’s Medicare reform plan for indexing, on an annual basis, the “premium support credits” provided to future program entrants to the consumer price index (CPI).

These attacks seemed more than a little hypocritical to me. After all, didn’t Obamacare do exactly the same thing? Section 1401 of the law requires the “premium credits,” or vouchers, provided through the state exchanges to be adjusted in the years after 2018 “to reflect the excess (if any) of the rate of premium growth … over the rate of growth in the consumer price index.” That would seem to mean that beneficiaries getting insurance through the exchanges would pay for cost growth above the CPI, and the government’s contribution toward the premium would grow with the CPI. Further, this adjustment is only to occur in years when the aggregate cost of the premium credits and cost-sharing subsidies in the exchanges exceed 0.504 percent of GDP.

It turns out, however, that the law is written so poorly and ambiguously that other conclusions might be reached about what the words of the law actually mean. That seems to be the case with the Congressional Budget Office, as its cost projections for premium credits in the exchanges grow at a rate above the CPI in the years after 2018, even though CBO believes that aggregate spending will exceed that threshold of 0.504 percent of GDP.

Read the piece, but don’t try too hard to follow this explanation – it’s confusing and so random, it makes you wonder if the legislation was put together by a bunch of tired twentysomething staffers mashing unworkable bills together late at night. Don’t wonder: that’s what happened.

SOURCE: The New Atlantis