During the long debate over health care reform in 2009 and 2010, the advocates for the legislation made several key arguments, suggesting most of all that a health care financing system that covered a large number of the currently uninsured would be fairer — that a primary goal of health care reform was redistribution. This argument reflected the conclusions of a 2000 study by the World Health Organization, which made fairness the most important single aspect in its evaluation and comparison of health care systems around the world.
This argument was not sufficient on its own to get the massive Affordable Care Act made into law. So advocates made several other arguments, including one that was buttressed by several studies that seemed to indicate, though not with great confidence in the numbers, that the lack of insurance led to a significant number of excess deaths among the uninsured population (tens of thousands each year). Hence, reform would lead not only to more equality, but also to higher quality and better outcomes.
Some who were opposed to the legislation pointed to the fact that the new program would add hundreds of billions in new federal outlays at a time when the federal deficit was running in excess of 40% of federal expenditures, and by spurring demand without any increases in supply, inevitably drive up health care inflation.
The advocates for reform countered by arguing that the bill, according to CBO estimates, was in fact a deficit reduction measure, and that over time, due to higher taxes on wealthier Americans and reductions in some Medicare expenditures, the bill would be fully paid for with a net surplus remaining — a contribution to deficit reduction. Finally, advocates argued that as a result of the legislation, the rate of increase in annual health care costs in both federal programs and private insurance would come down after new policies were developed following review of many new “studies” and reports by commissions reporting results to the secretary of HHS.
So what was not to like in a bill that provided more fairness and higher quality, reduced the deficit, and slowed the rate of health care inflation? How could a majority of Americans both then and now be opposed to such wondrous social legislation?
One of the reasons for the legislation’s unpopularity was related to its legislative history — a bill jammed through by budget reconciliation in the Senate, and the only major piece of social legislation in American history passed on a party line basis, with virtually no input from the opposition party in its over 2,000 pages of new rules. In addition, it is certainly the case that many Americans were skeptical of the claims about the magic deficit reduction elixir that the Democrats in Congress had allegedly found. There was great skepticism about the real cost of the legislation, which could be much higher if a significant number of corporations elected to drop their health insurance coverage and instead pay a modest penalty, leaving their workers to join the new and heavily subsidized exchanges.
Then there was the CLASS Act, a new long term insurance program within the reform bill that collected premiums for several years, but showed no outlays during the same period. Not surprisingly, this contributed some pixie dust to the tune of tens of billions to that magical deficit reduction calculation in the first ten years of ObamaCare. Some actuarial analysis suggested the program would be a long term financial disaster, and one Democratic senator called it a “Ponzi scheme.”
Finally, within a short period of time of the passage of the legislation, the administration started granting waivers to various parties from various provisions of the new law, with many of the waiver recipients groups that were, not surprisingly, politically connected to the Democratic Party. With each waiver, some of the projected deficit reduction disappeared.
But one reason that is almost never offered as an explanation for why many Americans have remained skeptical of the claims about the new health care reform bill is that they no longer behave like sheep when presented with the claims by “experts” who are, in many cases, no more than partisan advocates. The Climategate scandal, which appeared to show scientists working to insure their data fit their preordained conclusion about man-made global warming, may have contributed to skepticism about many of the claims about ObamaCare.
An article in the current issue of Commentary (subscription only) suggests that the WHO study, which provided the “moral” basis and primary justification for ObamaCare, is deeply flawed. The study, which ranked the United States 37th of 191 countries in overall performance, relied on incomplete data, flawed comparisons, and estimates by “experts” to fill in the many data gaps. But mostly, it evaluated health care systems not on outcome, but on inputs — who pays for it, how much do they pay, and who is covered. This would be similar to evaluating the performance of a school system on the dollars of tax money spent per student, and on the student teacher ratio, but not on educational outcomes (for the record, teacher unions oppose any such outcomes measurement).
For the WHO study, higher scores were awarded for health care systems which came closest to the goal of providing the same insurance coverage for all, paid for by governments, and with minimal individual out-of-pocket contributions (other than for higher taxes, where the rich would pay more). Where individuals paid for their coverage, the ideal was a system where the rich paid more for the same insurance coverage provided to all residents.
The WHO might well have called their analysis “a comparative analysis of the level of redistribution of income used to pay for universal government-run health care coverage.” The WHO study designers clearly oppose the idea of individuals having more control of their health care expenditures, rather than having them directed through third-party payers. In total, 62.5% of a nation’s overall performance score came from consideration of measures of fairness and distribution. The U.S ranked 54th in fairness in the WHO study.
Critics of the U.S health care system also pounced on the U.S performance in measures of quality in the WHO study. Since we spend a far higher percentage of GDP on health care than other nations, we should get better results . It turns out that the results are better here than anywhere else in the world in many areas, including cancer survival rates. But the WHO study relied on life expectancy as the key surrogate for quality. Here, it appeared the U.S underperformed, with life expectancy a few years below that of other developed countries, and infant mortality a few points higher than in these same countries.
Not surprisingly, the comparisons are flawed here as well. As Scott Atlas, the author of the Commentary article, explains:
At its most egregious, the report abandoned the very pretense of assessing health care. WHO ranked the U.S. 42nd in life expectancy. In their book, The Business of Health, Robert L. Ohsfeldt and John E. Schneider of the University of Iowa demonstrated that this finding was a gross misrepresentation. WHO actually included immediate deaths from murder or fatal high-speed motor-vehicle accidents in their assessment, as if an ideal health-care system could turn back time to undo car crashes and prevent homicides. Ohsfeldt and Schneider did their own life-expectancy calculations using nations of the Organisation for Economic Co-operation and Development (OECD). With fatal car crashes and murders included, the U.S. ranked 19 out of 29 in life expectancy; with both removed, the U.S. had the world’s best life-expectancy numbers.
The infant mortality comparisons were even more defective. The U.S included all births in the denominator of total births, including low birth weight babies and infants who do not survive very long. Many of the European nations excluded these babies from both the numerator (infants who died) and the denominator of total births, as pointed out in an article by Dr. Linda Halderman.
The higher American infant mortality rate was preordained by this comparison of apples versus oranges.
Increasingly, the “science” in the “social sciences” has moved away from disinterested scholarship, and turned into advocacy. Journalism has taken a similar route. The social justice achievements that can be won are just too important to be left to people who are not on the team, and who have not reached their conclusions before they begin their studies. It is the result that matters, not the methodology that gets you there, or even the truth that might be found in an honest examination of an issue.