Fail to understand logic, fail to understand healthcare reform

I had wanted to comment on the latest series of article on SDP's website defending its "National Healthcare Plan" when the first one was posted last week, but decided to wait and read the whole series before commenting.

The writer is a health economist, but nevertheless there are some points in his arguments which I dispute. The three articles are too long to reproduce in full here, so I summarise and discuss each of the articles in the series below. Do read the original articles linked to yourself.

In part 1, the author begins by introducing the concepts of "disease burden", "mortality", and "morbidity", and argues that little is being done now to collect data for these indicators. Despite this lack of data (which is in fact available), the author believes that "between a universal healthcare system and one that is not, the former has a greater chance of saving lives, provided it gives priority to evidence-based policies".

Now intuitively one would agree with that statement - after all, if people do not or cannot access healthcare due to costs, then they will not benefit from the nation's healthcare system. However, this assumes that cost is a barrier to people accessing healthcare. Yet in SDP's "National Healtcare Plan", the possibility of a "buffet syndrome" is dismissed with the statement that "[t]he behaviour is less likely seen in chronic non-symptomatic illnesses like hypertension or diabetes, where it is more likely to encounter non-compliance with treatment or medication, even in patients who are having their treatment paid by third parties" (emphasis mine) - so if SDP believes that the problem with chronic disease management is non-compliance rather than cost, then how will a "universal healthcare system" be better at "saving lives"?

The writer then goes on to praise SDP's plan in generic terms, without giving specific reasons as to why he thinks that "[t]here are many proposals in the SDP’s plan to suggest that morbidity in the patient-population will be better managed", or that "SDP’s healthcare plan shows promise of better management and reduction of burdens that diseases impose on Singapore society".

In part 2 of the author introduces the concepts of "total healthcare expenditure" (THE), "cost of ill health in the economy" (CIHE), and "cost of ill health in a society" (CIHS).

Again, these are intuitive concepts which the laymen can easily understand and appreciate. The writer notes that the amount spent on THE may not be indicative of what the government spends on reducing CIHE and CIHS in total, because the resources expended on tackling many of the problems that result in a higher CIHE and CIHS are not in fact classified as our THE. At the same time, non-government expenditure by the people such as "hiring maids to provide home care" and "special needs teachers or extra tuition teachers for... children with learning disabilities" are costs that are not factored in when calculating the THE.

In short, the writer argues, the THE is not a good indicator of how much the government spends reducing CIHE and CIHS, and it does not measure how much the people spend on what is traditionally not included when calculating the THE.

So far so good. But of we look at what the writer thinks are the major health problems which are not being considered as part of our THE, being "alcohol misuse, drug addiction, gambling, smoking," and "families hiring maids to provide home care for their loved ones [with chronic diseases]" and "parents [hiring] special needs teachers or extra tuition teachers for their children with learning disabilities", then we need to ask ourselves how SDP's plan will be more effective than the current healthcare model in reducing the CIHE and CIHS arising from these "problems".

Now if "alcohol misuse, drug addiction, gambling, smoking," increase our CIHE and CIHS, then how will a buffet-style healthcare funding model reduce the problem? In other words: how will telling people with problems of alcohol misuse, drug addiction, gambling, and/or smoking that the government (and by extension the people) will pay for the health consequences of your choices even more than what they do now reduce the size of the problem?

As for spending on maids and special needs teachers, the question is: are these not problems which are better tackled with targeted help instead of a blanket 90% subsidy for all healthcare?

In the final part of the series, the writer begins by arguing that most nations already have universal healthcare, and points out that our current obsession with capping government healthcare spending is myopic as it fails to look at the burden that diseases impose on society.

He then argues that under the SDP system, healthcare spending will be more cost-effective "because SDP’s model is patient-centric, focusing heavily on alleviating patients' hardships, improving their well-being, and preventing their future health risks". However, he does not in fact tell us how this will be the case.

With regards to sustainability of the system, the writer believes that it "is sustainable as long as the universal healthcare system gives evidence-based policies due consideration and priority".

He summarises his series into the following two points.

1. Universal healthcare coverage is a "no-brainer", but the exact features of the system should be guided by evidence and not ideology, and the system must be evaluated continually after implementation.

2. When evaluating a healthcare system, we must not look only at THE, but also at the reduction in CIHE and CIHS.

On the whole the writer's arguments follow each other: if you have a universal healthcare system, people will have better access to healthcare and better health outcomes, and this will bring you returns in the form of lower loss to the economy and society downstream. Excessive cost can be prevented because the expenditure will be guided by evidence and not ideology.

Sounds great so far (except for the points which I disputed earlier).

But while the writer claims to be non-partisan, it is clear that his argument is guided by ideology when he wrote that (emphasis mine):

"the division in Singapore over universal healthcare is actually a division between the “I” group and “We” group. The “I” group is selfishly looking at just their own world in terms of how much more they must pay, how much longer they must wait in the queue, etc.

The “We” group gives greater priority to impact of healthcare polices on society at large. They are concerned with how many more lives can be saved, by how much hardship of patients and their families can be reduced, and so on."

Given that the whole "National Healthcare Plan" is guided by ideology and aimed at - let's face it - winning votes, how much confidence can we place in the executors of this system that its operations will be guided by evidence and not ideology?

Finally, I don't really see how our current healthcare system is different from the writer's vision of a healthcare system that is "patient-centric, focusing heavily on alleviating patients' hardships, improving their well-being, and preventing their future health risks", where the government is cognisant of CIHE and CIHS, and where operations are guided (in theory) by evidence and not ideology.

Indeed, I think the only difference between the current system and what SDP is proposing is not *why* we do it, not *how* we do it, but *who* pays for it.

How you run a healthcare system can in fact have nothing to do with how you pay for it - you can have a system where individuals pay for their own healthcare but where providers are guided by evidence, and you can have a system where patients do not pay out of their own pockets but where treatment is not guided by evidence. The writer's mistake in his entire argument is that he assumes that a "universal" healthcare system where the bulk of payment is subsidised (as proposed by SDP) will mean that policies will be guided by evidence and not ideology (when in fact the two can be totally unrelated), that people will access healthcare more appropriately (something which SDP itself believes is not the case), and that CIHE and CIHS will be reduced; and the reason why he makes that mistake is, I believe, because he is guided by ideology instead of evidence.