Sunday, January 8, 2017

Public Health Strategies Part 4: Taxes

In an earlier post I mentioned a few different commonly proposed public health strategies, and how most of them fit quite nicely into a political spectrum characterised by an authoritarian-libertarian axis and a left-right axis.   In this post I’ll discuss the strategy of taxation/subsidies, which I thought fits nicely into the authoritarian left quadrant.  This is because this strategy holds the food environment primarily responsible for people not adopting healthy lifestyle behaviours rather than personal responsibility, and then uses government controls to manipulate the free market


Rationale

There are a few targets people have suggested to tax or subsidise.  There was the failed Danish tax on saturated fat, and sometimes there are suggestions that fruit + vegetables and even gym memberships (because you couldn’t possibly exercise without one) should be subsidised, but this isn’t very common.  At the moment, a tax on sugar sweetened beverages (SSBs) is far more commonly proposed and is actually being implemented in a few areas, so I’ll focus on that

There are two main rationales to support a tax on SSBs.  The first is that a tax on SSBs will increase their price and this would reduce the consumption of them, particularly in people on lower incomes, who consume more SSBs on average, as they are more sensitive to changes in price.  This is textbook supply and demand, as price goes up demand decreases.  In this respect, a tax on unhealthy food or a subsidy on healthy food could be seen as a form of nanny statism.  Generally, implicit in the support for a tax on SSBs is the belief that education programs haven’t or will not work on some people (the laggards).  This usually isn’t mentioned when a tax on SSBs is proposed (probably out of political correctness and not risking alienating others), but it is an important premise to justify taxes/subsidies, because otherwise why not use education instead?  And so a tax on SSBs appears necessary to reduce SSB consumption and therefore improve health, or, to save some people from themselves.  Or perhaps more importantly, to save the overweight/obese children with a mouthful of tooth decay from negligent parents.  But people who are against many forms of nanny statism argue that what right does the government have to control/influence individual choices that don’t adversely affect others?*  In addition, cigarettes are heavily taxed but plenty of people still smoke, and as David Gillespie points out, there is already a tax in Australia on many processed foods including SSBs in the form of the GST [1]

This leads into the second rationale for taxing SSBs which counters the previous argument.  In countries with a socialised healthcare system the consumption of SSBs creates a negative externality.  When people purchase SSBs they are paying the costs for the product but are mostly or totally externalising the increase in healthcare costs from SSB consumption increasing the risk of several chronic diseases.  As a result, it could be said that they are not paying the ‘true costs’ of a SSB.  Let’s say 1 litre of SSBs costs the consumer $1.50 but each litre of SSBs is associated with an increase in healthcare costs at about $0.30.  Therefore, in this scenario a 20% tax on SSBs is necessary to internalise the healthcare costs.  With this rationale of internalising externalities, a tax on SSBs could be considered a successful policy even if no one changes their behaviour as a result of the tax, and also doesn’t make it about nanny statism or a moral judgement (a ‘sin tax’)

Of course, the government (and health associations [2]) also has a motivation to tax things that are politically acceptable as a form of cash grab, particularly if they’re the kind of government that likes to spend money, which seems to be the main motivation for the Danish tax on saturated fat [3].  “A lesson learnt from this chain of events is that if a tax on fat is to survive it needs more than merely to be passed. It probably needs to be politically supported for health rather than fiscal reasons and to be supported or at least accepted by prominent actors in the food arena including researchers.” [3]

* This can also apply to laws against recreational drug use (that doesn’t expose people to second hand smoke for example), ‘unsafe’ playgrounds and bike helmet and seatbelt laws

Efficacy

Danish tax on saturated fat: some people in public health have praised the Danish fat tax because it reduced the intake of saturated fat [3].  However, simply implementing a well-intentioned policy doesn’t mean it’s necessarily going to have good outcomes.  The most important outcome of such policies should be related to health rather than consumption, and in this respect even diet-heart diehards should judge it to be a failure.  Based on ecological data, the Danish tax on saturated fat appears to have reduced SFA, MUFA and PUFA by 0.3%, 0.2% and 0.1% of total calories respectively (this is because foods high in SFA are often high in MUFA and PUFA on a grams per weight basis).  As a result, LDL-C would be expected to decrease by 0.008 mmol/l and HDL-C would be expected to decrease by 0.005 mmol/l, and this would be expected to increase the risk of CHD by 0.2% (-0.3% for LDL-C +0.5% for HDL-C) [4].  While it’s ideal to be able to judge the efficacy of the tax based on actual changes in population health rather than modelling, the estimated effect size here is probably too small to notice and would likely be drowned out by noise.  The Danish fat tax also had the issue where consumers could avoid the tax by purchasing heavily taxed foods in neighbouring countries without such a tax

SSB tax in Australia: a tax on SSBs hasn’t been implemented in Australia but one study in particular has estimated effect of a 20% tax on SSBs in Australia, and found the following [5]:


Males
Females
Consumption
141g/d to 124g/d
76g/d to 67g/d
Total energy intake
-16 kJ/d
-9 kJ/d
Change in BMI
-0.10
-0.06
Weight loss
0.32 kg
0.06 kg
Obesity prevalence
2.7% (0.7 percentage points)
1.2% (0.3 percentage points)
Health-adjusted life years
112,000 (4.54 d/per capita)
56,000 (2.27 d/per capita)

The estimated change in BMI as result of the tax is similar in magnitude to other studies in the US [6].  The tax is expected to cost 27.6 million AUD upfront, but generate 400 million each year and reduce healthcare costs by up to 29 million per year (savings are expected to increase over time and plateau at 29 million) [5].  This is a decrease of just ~0.024% in total healthcare expenditure (29 million/121.4 billion [7]) and is why it’s important to put those kinds of figures in context

Given that the revenue generated equates to about 0.329% of total healthcare expenditure, and that SSB consumption is likely responsible for at least a 1% of total healthcare expenditure (not aware of an estimation for this, but 1% seems like a reasonably conservative estimate), if the rationale for taxing SSBs is to internalise externalities then the tax would need to be substantially higher.  This is also true if the goal is to meaningfully improve population health

One of the problems with this model is that the health outcomes are based on BMI, which in turn are based on the very small estimated reduction in calorie intake, and doesn’t look at any effects of SSB intake independent of calorie intake and BMI.  And of course it looks at adults, whereas if it also included children the estimated effects would be greater because the analysis would include more people and because the expected health benefits are larger for younger people.  That being said, a modest (~20%) tax on SSBs in an affluent country like Australia (where the economic effect can be largely ignored by almost everyone) is certainly not going to be a silver bullet.  The food industry has a point when they say that SSBs only contribute about 3% on average to total energy intake.  ‘Extra’ foods contribute about 36% on average to total energy intake in Australia [8], so there’s a lot wrong with the average Australian diet.  Therefore, one could argue a lot of potential targets to tax, but also that there’s a lot more that needs to be changed by even a 10% reduction (~3 percentage points) in ‘extra’ foods as a result of a broad taxation policy

Other Objections

Some people argue that a tax on SSBs is a tax on the poor, as poorer people on average consume more SSB and are more motivated by changes in price, but there are a few issues with this objection.  (1) They are confusing intent with outcome.  This is a mistake many people make related to other issues where there is a race/sex/etc disparity.  The tax is not discriminatory (except against SSBs) as it’s not intended to disproportionately tax poorer people, but it’s simply that the people who consume more SSBs happen to be poorer.  It’s not like this is a tax on renting or living in apartments, which actually has more of a causal relationship with being poorer (2) People are free to purchase SSB or not.  There’s nothing forcing poorer people to consume more SSBs on average.  If they don’t want to pay the tax they can choose not to purchase them, after all SSBs are very discretionary food items.  (3) While the tax is estimated to cause large relative differences in total household expenditure (consumption multiplied by income differences), the actual increase in expenditure for low income earners is very modest (~0.2% household income, ~1% of food budget) [9] (4) A tax on SSBs is likely to disproportionately benefit the health of poorer people.  People in public health usually try to engage and improve the health of low SES people disproportionately.  After all, no one in public health is really advocating for a subsidy on salmon, avocado, blueberries and quinoa.  (5) Who do you suppose the tax revenue is likely to disproportionately benefit, almost regardless of what it’s used for?

Another objection is that a tax on SSBs will reduce sales and as a consequence some employees will have to be laid off (if the food industry objects to the tax for this reason, then you know they think it will work to some extent).  The goal isn’t (and shouldn’t be) to punish the food industry as they are reacting to consumer demand for the most part (but they should be punished when they distort science, and there are numerous examples of this).  But the food industry and their employees shouldn’t get upset that in countries with socialised healthcare, the government at some point may tax unhealthy food to improve health and/or internalise externalities, after all there is a rationale and incentive for it to do so.  While it’s unfortunate that a very small number of people may lose their jobs, it’s important to recognise that there are other jobs out there, and that changes in the world will always create winners and losers (the internet is a great example), and part of life is setting yourself up to manage such likely changes well

While I thought taxes/subsidies and bans fit nicely into the authoritarian left quadrant, a modest (~10-20%) tax on SSBs isn’t really that authoritarian.  However, a major concern, particularly from libertarians, is that a tax on SSBs sets up a precedent for governments to tax other things, where these other things may be quite inappropriate targets for improving population health, while also leading to a progressive loss in individual freedom.  This should also be of concern to people in ancestral health, low carbers and other, regardless of political opinion, as by adopting such dietary practices we acknowledge that the government and mainstream isn’t always right.  A good example of an inappropriate target is the Danish tax on saturated fat, as saturated fat is not associated with coronary heart disease in meta-analyses of observational studies [10], replacing saturated fat with polyunsaturated fat does not reduce coronary heart disease in adequately controlled randomised controlled trials [11], and reducing fat intake is hardly the best strategy for weight loss [12].  Similarly, total fat is a potential target, but increasingly less likely.  (Red) meat is another potential target for taxation for health or environmental reasons, despite evidence to the contrary [13] [14] [15].  Salt is another potential target because people in public health seem to have an almost pathological hatred of salt, despite the relationship between salt intake and mortality being on a U-shaped curve [16] and that reducing salt intake doesn’t affect blood pressure much but does have some undesirable side-effects [17].  Being in academia and around nutrition students hasn’t alleviated these concerns, it has strengthened them

This post is already quite long so I’ll simply list a few more papers if you’re interested:

  • Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study [18]
  • Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption [19]
  • Using price policies to promote healthier diets [20]
  • Modelling the potential impact of a sugar-sweetened beverage tax on stroke mortality, costs and health-adjusted life years in South Africa [21]

And finally, if you want to follow me on Facebook you now can.  Just follow this link​ and like the page

Friday, December 30, 2016

Public Health Strategies Part 3: Education

In an earlier post I mentioned a few different commonly proposed public health strategies, and how most of them fit quite nicely into the political spectrum characterised by an authoritarian-libertarian axis and a left-right axis.   In this post I’ll discuss the strategy of education, which I thought fits nicely into the libertarian left quadrant.  This is because this strategy holds a lack of education and empowerment primarily responsible for people not adopting healthy lifestyle behaviours rather than character defects, and then ultimately leaves the adoption of healthy lifestyle behaviours up to individuals once these educational needs are met

Role of Education

In earlier blog posts I discussed how one of the weaknesses of relying on individual personal responsibility is that that strategy depends on individuals having reasonably easy access to reliable information that when implemented would improve their health, substantially reduce their risk of chronic diseases (which I consider as >80-90%), and better treat or even reverse the chronic diseases they currently have

The whole point of improving health is a (reasonable) belief that poor health and chronic disease substantially impairs quality of life, whereas the sacrifices to quality of life in adopting healthy lifestyle behaviours is/should be very small or improves quality of life as early as the day you make them or the following day.  Otherwise, if the costs of adopting healthy lifestyle behaviours exceed the benefits of good health and reducing the risk of chronic disease, then education as a public health strategy is simply one big con

If we assume for the moment that humans are rational creatures, we would therefore make decisions based on objective cost-benefit analyses, and so this shift in favour of healthy lifestyle behaviours in theory should be quite automatic and shouldn’t be too difficult.  However, these analyses depend on our perception on the costs and benefits of various behaviours and our perception is based on our knowledge of the world (perceived cost-benefit).  Therefore, the rationale of education is that providing information regarding the efficacy and implementation of healthy lifestyle behaviours, and the consequences of good health and chronic disease, would shift peoples’ perceived cost benefit analyses in favour of adopting behaviours that improve their health and reduce their risk of chronic disease

You could break down this information to along simple-complex lines and along theoretical-practical lines.  The dietary guidelines are actually a fairly good example of this as they include both a complex 100s of pages long report, and a summary report including how to implement these guidelines.  I’ve included another example of what I’m thinking of below, using the scenario of vitamin K2 for osteoporosis:


Simple
Complex
Theoretical/justification
Stating that vitamin K2 helps put calcium in bones
RCT evidence with effect sizes, mechanisms
Practical/implementation
What foods are rich in K2?
Eat X serves of Y
Supplementation, blood tests to measure vitamin K2 status

Health Associations

Here’s the problem, Osteoporosis Australia doesn’t have content on vitamin K2 alongside their content for calcium and vitamin D, and the information they do have only satisfactory checks the simple-theoretical box.  They don’t provide RCT evidence from the vitamin K2 supplementation trials, they say what foods are rich in vitamin K2 but don’t give an indication on how much you should aim for with prevention and treatment (like what they did with calcium and vitamin D), and they don’t inform people on possible blood tests to check for vitamin K2 status.  Osteoporosis Australia also doesn’t have a section for protein (alongside their sections on calcium and vitamin D) which I would think is important considering the popularity of the debunked hypothesis that high protein intake contributes to osteoporosis due to the acid load of protein, despite higher protein intakes actually improving bone mineral density

I’m not targeting Osteoporosis Australia specifically as you could level similar criticisms against just about every other health association.  Many of these health associations provide the earthshattering information that their disease is caused by genes and environment, spread information that is outdated or based solely on observational studies, feature a disproportionate number of recipes for deserts if they have a recipe section, don’t discuss any science beyond the most basic, don’t mention that their disease was historically near absent and near absent in various populations prior to adopting a western diet and lifestyle.  For example, on the Diabetes Australia website you will be told that type 2 diabetes is a progressive disease and see a disproportionate number of recipes for desserts, but won’t be told about superior strategies to manage type 2 diabetes such as a low carbohydrate diet or strategies that have a good chance at reversing type 2 diabetes such as the very low calorie Newcastle diet.  On the Heart Foundation website you will be told that salt is a meaningful factor in the development of hypertension and that saturated fat increases your risk of heart disease, and once again you will see a disproportionate number of recipes for desserts, but you won’t see much on the Mediterranean diet, the PREDIMED Study or the Lyon Diet Heart Study.  On the cancer council Australia website you will be advised to eat a low-fat diet and that red meat increases the risk of colorectal cancer.  You will read about the evils of sun exposure, but won’t be told that vitamin D reduces the risk of other cancers or the possibility of a ketogenic diet potentially improving cancer prognosis.  (I wouldn’t include dietetic associations on this list, as it is clear that their primary goal is to benefit dieticians as a group rather than the health of the general public (they function much like a trade union in this respect))

Suffice to say, I think information regarding health and disease can be substantially improved, and this is a reason why I’ve gone down this path.  I think health associations should:

  • Remove things that aren’t correct
  • Provide information that allows people to increase the number of methods by which they can improve their health and reduce the risk of chronic disease
  • Justify these approaches with evidence, particularly from RCTs
  • Add some clinical information in case that their doctor doesn’t know about the latest research, because otherwise this will be limited to online forums
  • Provide more information regarding the probable causes of disease.  We may not know everything, but we certainly know more than the obvious genes + environment 

Education is not Always Sufficient

That being said, we don’t live in an ideal world where education/knowledge is sufficient to cause behaviour change.  I’m sure each of us could identify at least one area of our lives where this is the case.  But most importantly, it’s clear the education has worked in a sense that people know the basics of a healthy lifestyle (fruit and vegetables are healthy and that soft drink and desserts are not, walk regularly and do some moderate to vigourous physical activity each week, and get enough sleep) and have some understanding of their importance (one could hardly go through life and not be exposed to health information via school and the media at least).  However, that so many people are failing at the basics suggests that simply restating the basics won’t achieve much (the anointed strategy of ‘if it fails, just do the same, but bigger’) and also that education is not always sufficient to change behaviour

Some of the reason for this is that we are wired to be more like instant gratification monkeys rather than deeply logical and rational robots.  In fact this acknowledgement of our own irrationality and impulsivity is something I think that’s missing from health education and education in general*.  Many healthy lifestyle choices require a sacrifice of instant gratification now for a larger payoff in the future.  The way that that health information is presented doesn’t help this as the benefits of a healthy lifestyle is discussed in terms of risk while rarely providing information regarding the magnitude of risk reduction.  Our environment doesn’t help either, as maintaining good health and a healthy weight requires consistently making more effortful and less hedonistic choices such as the purchase of blander and less well marketed foods rather than hyper palatable, high reward and well marketed foods, as well as doing some exercise, meditation or going to sleep when something on the computer or TV is more engaging, etc**

* Something else I think that’s missing from health education is dispelling people’s beliefs that they are healthy when they’re not, although I appreciate that telling people that they’re fat, sick, instant gratification monkeys is a hard sell, but it’s probably necessary.  A recent report found that about 50% of Australians heave a chronic disease and 63% are overweight or obese, but 85% said they were in good or excellent health [1]

** I consider the environment to be the most important factor regarding health.  Remember, I don’t believe in free will, and consider everything to be a consequence of genes + environment, and our genetics haven’t significantly changed in the last few decades.  But I don’t think that a substantial change in the environment (like a regression back to the 1950’s or earlier) is a feasible public health strategy because we want cheap delicious food, labour saving devices and entertainment.  We can make some changes to incentivise healthy lifestyle behaviours (such as a user pays healthcare system and taxes/subsidies) and ban the worst offenders that no one really wants (industrial trans fats).  Beyond that, it’s really up to education and having people create their own micro-environment that promotes health

Targeting the Early Majority

In addition, while it’s probably politically incorrect to say so, some people just don’t care about health, and all the health education in the world isn’t going to change that.  Smoking has had many strategies used against it (education, taxation, bans, stigma, graphic images to invoke disgust, nicotine patches, support for quitting, etc) but people still smoke anyway, much like how people know various crimes are wrong but still commit crime anyway

The following graph is the prevalence of number of healthy behaviours in the US (not smoking, ≥7 hours of sleep, moderate or no alcohol, met physical activity recommendations, normal BMI) [2].  It may not seem too bad, but diet isn’t included, and “76% did not meet fruit intake recommendations, and 87% did not meet vegetable intake recommendations” [3] (similar to “…95 per cent of Australians did not eat the recommended servings of fruit and vegetables” [1]).  There is an explanation for everything, in this case, our high incidence of overweight/obesity and chronic disease.  We are only as good as our weakest link so unless you won the genetic lottery, you will need to do them all


I think you could draw a parallel between the theory of diffusion of innovations (see picture below), the prevalence healthy lifestyle behaviours, and health consciousness and consequently the receptivity to health education/information


Innovators + early adopters = highly motivated by health (4/5 – 5/5).  These people will seek out health information beyond what is provided by health associations.  Public health doesn’t need to target these people, but providing more complex information will make their research more convenient

Early majority = fairly motivated by health (3/5 – 4/5).  These people are fairly receptive to health information but health education may need to be improved to sufficiently inform, motivate and empower them (such as changes suggested here, plus others I haven’t thought of).  Since the theory of diffusion of innovations suggests targeting the early majority and this group is fairly receptive to health information, I don’t think health associations/etc should be too concerned with providing more detail, depth and complexity than the bare minimum

Late majority: not very motivated by health, but not a disaster either (2/5 – 3/5).  Once the early majority has adopted more healthy behaviours and become healthier, and such things have become normalised, the late majority will see that such behaviour change is both feasible and a net benefit to their life.  We might then see a social contagious model of health rather than one of obesity [4]

Laggards = doesn’t really care about health (0/5 – 2/5).  This group can get some rare and awful health scares, but these health scares rarely change behaviour.  Other strategies are probably more productive if you want to improve the health of these people (see next post)

Tuesday, December 27, 2016

Will a User Pays Healthcare System Improve Population Health and Reduce Healthcare Costs?

We have a problem.  In Australia and other Western countries we are spending an increasingly significant amount of our GDP on healthcare [1].  This trend is expected to continue as healthcare spending is increasing at a faster rate than GDP (due to an ageing population and the increasing prevalence of certain diseases such as type 2 diabetes).  This is particularly concerning as Australia is in progressively higher amounts of national debt.  Clearly something needs to change


I find the arguments that ‘healthcare creates wealth’ and that ‘it isn’t necessarily an issue because economies can be flexible’ to be like the ‘broken window fallacy’.  Our ‘sickcare’ system really just patches up broken windows.  There is an opportunity cost in that those resources could be spent on other projects if the window wasn’t broken in the first place.  My aim is to reduce broken windows

As I mentioned in the previous post, the efficacy of relying on personal responsibility (which every public health strategy does to some extent except holding out for miracle drugs and simply banning everything that’s unhealthy) as a public health strategy would be improved if our healthcare systems are structured in such a way that individuals are more incentivised to be in good health.  One way to do this is to have individuals bear more of the financial costs of diet and lifestyle diseases rather than the government

* In 2009-10 Australia spent 9.4% of total GDP on healthcare [2], with 121.4 billion spent on healthcare (~$5,000 per person) [2].  Federal, state and local governments contribute 70% towards healthcare [2], and federal, state and local governments received a combined total of 333.336 billion in tax revenue [3], therefore 25.5% of taxes went towards healthcare in 2009-10

Advantages to a User Pays Healthcare System

There are advantages and disadvantages to more socialised healthcare systems and to user pays healthcare systems.  For this blog post, I’ll just mention some advantages to a user pays healthcare system that has some potential to reduce healthcare costs for most people

Individuals would be more incentivised to improve their diet and lifestyle, rather than face the financial costs of developing and/or poorly managing lifestyle diseases, that could otherwise be prevented or treated through changes in diet and lifestyle.  This would particularly be the case if pharmaceutical drugs for lifestyle diseases were not subsidised through policies like the Pharmaceutical Benefits Scheme we have in Australia (which we seem to be paying too much for [4]).  This will shift cost-benefit analyses in favour of diet and lifestyle, much like how renewable energy would be more cost effective sooner if fossil fuels were no longer subsidised.  For example, someone with type 2 diabetes has a few options: they could either continue what they’re doing and take insulin and Metformin to try and manage their glucose levels; they could simply reduce the amount of carbohydrates they’re eating; and they could try to reverse their diabetes by using the Newcastle diet or other dietary approaches that lead to a short-term spontaneous reduction in calorie intake.  If diabetes drugs and health care associated with diabetic complications becomes more expensive then people will see less value in drugs, while changes in diet and lifestyle (which are more effective anyway) would become more appealing.  As a result, there may be a shift in the culture from popping pills and seeing them as miracle drugs, and more towards a normalisation of healthy diet and lifestyle behaviours.  However, this depends on improving access and dissemination of more than just basic health information such as: the costs and benefits of various pharmaceutical drugs, measured in both relative risk and the number needed to treat; and strategies to prevent and manage many chronic diseases (the focus of the next post)

A major cost for the healthcare system is end-of-life care [5], but quite often end-of-life care prolongs the suffering of the patient, sacrificing quality of life for a few extra months.  Some people would not value it as much as it costs and would prefer to opt out and have that money go toward things they place more value on or toward their families (this should be coupled with voluntary euthanasia).  Similarly, healthcare costs could also be reduced by people opting out of things that offer marginal benefits.  This is basically the idea that individuals are best placed to maximise their utility (↓ money, ↑ value), but standard of care and subsidies distort this

When the cost of something is low (particularly when it’s free) there is a higher demand for it and it isn’t valued as much.  There are obviously many doctor’s visits and hospital admissions that are extremely important, but there are also some trivial ones such as seeing a doctor for the common cold to get a prescription for antibiotics (which won’t work anyway because a viral infection is causing the symptoms)

There are also some minor areas where costs can go down such as lower administrative costs, less bureaucracy, competition driving costs down, being able to shop around for a particular doctor or standard of healthcare, and not needing to see a doctor to get a blood test

In addition, it would remove almost all the rationale for fat shaming or other shaming related to health or health related behaviours

Insurance

You could hardly discuss the costs of healthcare without talking about health insurance.  In my opinion health insurance, much like other forms of insurance, doesn’t make economic sense in most contexts.  That is because a healthcare system based on health insurance involves the average individual not only covering their costs in the health insurance premiums, but also paying for the overhead costs of running an insurance company, the profit the insurance companies need to make, and the additional admin costs at the doctor’s office.  So not only is the average person not getting their money back, but healthcare itself is made more expensive.  A healthcare system based on health insurance is probably a fair part of the reason why the US healthcare system is much more expensive.  It makes more economic sense, for both the individual and society, for people to self-insure the things they can by saving and investing that money for a rainy day or simply adopting universal healthcare [6]

Some of the contexts where health insurance makes sense include: (1) Where an individual doesn’t have enough capacity to save to self-insure themselves (so insuring your house is more likely to make sense).  (2) If the government subsidises health insurance through income tax concessions (an odd policy that really only benefits middle-upper income earners, who have more capacity to self-insure themselves anyway).  (3) If the government mandates that health insurance companies can’t charge women, older people and people with chronic diseases more (because everything else being equal, these people receive more healthcare on average*).  In this situation your health insurance policy will suffer because young healthy men will refuse to subsidise everyone else and opt out of the system, and only get insured when they’re old and sick.  This will either cause the system to run out of money, increase premiums and/or reduce payments beyond which was previously promised (sound familiar?)

* If you accept this, but you don’t think they should be charged higher health insurance premiums, then do you also think that young men shouldn’t have to pay more for car insurance?

Universal Basic Income

This raises the question of what to do with the extra tax revenue if a user pays health care system is implemented, and also how will low income earners and/or sick people be able to afford healthcare?

With the extra tax revenue, the government could either lower taxes by a quarter or could use that revenue for other projects, and could potentially further reduce total healthcare expenditure by putting money into project that would improve population health.  One possible project is to make public transport free.  There’s a saying in business that you can pick only 2 of the following 3 attributes: fast, good, and cheap.  Public transport is neither, because unless you’re catching a train into the city, driving is faster, cheaper and more pleasant.  Free public transport would at least give it one advantage over driving (cost) while likely being a good form of wealth distribution and improving congestion, population health and the environment

Another option that may addresses both issues well is the implementation of a universal basic income (UBI) or at least one solely for the purposes of a health savings account.  A UBI is basically where every adult citizen receives a regular small parcel of money from the government.  It is attractive to some on the left because of economic security and providing and minimum standard of living, and is attractive to some on the right because it would reduce bureaucracy and current welfare systems can be abused and don’t adequately incentivise employment.  In the future a UBI might become more attractive as there is a great potential for advances in technology leading to more automation and therefore job losses

But how much should the UBI be?  I think it should be set at a level that makes it very difficult to near impossible to live on the UBI alone indefinitely, so that some work is generally necessary.  Some articles mention a UBI of $40,000 per year (~$800 per week or a $20 per hour job) [7], which is simply far too much as it alone would require ~$720 billion (40,000 x ~18,000,000 adults), much more than current tax revenues ($446 billion for 2014-2015 [8]) while providing little incentive to work and causing massive inflation.  With the government spending ~$5,000 on healthcare per person per year, this equates to ~$100 per person per week, but the part of the UBI used for the health can be invested in a health savings account, and total healthcare costs may be reduced as explained above, therefore it may only need to be ~$50-75.  The federal government spends 154 billion on social security and welfare [9], so a UBI for living and healthcare (~275 billion) could be distributed at about $15,000 per year for each adult or ~$300 per week.  At a minimum of $200 for living ($100 maximum going to a health savings account) people won’t be starving in the streets, but won’t be living comfortably on the UBI alone.  The government would then consider the UBI to be part of someone’s income and tax their total income as normal, which addresses an objection to UBI that high income earners really don’t need extra money.  So for people in Australia almost half of the UBI would be taxed for those making over $180,000, compared with 19% being taxed for those making between $18,201-$37,000.  These taxes could go towards disability pensions, people who had a bad accident they couldn’t pay for, and people who lost the genetic lottery regarding health, although if more was needed the UBI might be a bit smaller

The incentive part of a health savings account is that it can be used for family members and whatever is left can become part of your estate (much like the Singapore’s healthcare system [8, 9, 10]).  You could further incentivise good health from the health savings account by allowing a dividend of sorts to be paid yearly based a small proportion of what is left at the end of the year.  But you would want to save most of the health savings account in the event of an accident and because most people receive more healthcare as they get older.  In addition it’s better if this was a system where the health saving account was forced as a default (but something you could opt out of if you signed something that future healthcare is dependent on your ability to pay) because otherwise too many people wouldn’t save for future healthcare (because we are wired to be instant gratification monkeys), much like how superannuation is a somewhat idiot-proof method (but one that’s a tax concession that quite disproportionately benefits high income earners) to have people save for their retirement to avoid the government paying pensions 

I don’t consider myself to be that knowledgeable in healthcare and economics but I think these are some ideas worth considering.  My thoughts on this may change with time as outcomes > ideology and intentions

Sunday, November 20, 2016

Public Health Strategies Part 2: Personal Responsibility

If you find one of the ideas in these posts on public health strategies objectionable consider waiting before jumping to conclusions because I may address your concerns in a later post

In an earlier post I mentioned a few different commonly proposed public health strategies, and how most of them fit quite nicely into the political spectrum characterised by an authoritarian-libertarian axis and a left-right axis.  In this post I’ll discuss the strategy of personal responsibility, which I thought fits nicely into the libertarian right quadrant.  This is because personal responsibility is a key value of the political right, and because personal responsibility is a strategy that maximises individual freedom and ultimately limits the influence of government and others

It’s tempting to blame what’s called the obesogenic environment (which is a decent point I'll discuss later) and ‘evil corporations’ for the rise in obesity and other chronic diseases across the globe.  Similarly, because free will cannot exist, one could justify playing the victim, that they are not personally responsible for the bad things that happen in their life including their poor health behaviours and health status, that they are a victim of being born to the wrong parents and living in an obesogenic environment

As discussed in the previous post, even though free will does not exist there is value to society and us as individuals to emphasise a belief in personal responsibility.  We have plenty of options to make healthy or unhealthy lifestyle choices; we all know the basics of what to do to improve our health (that whole foods are on average healthier than highly processed foods and that getting enough exercise and sleep are important); and no one has a gun to our heads forcing us to make the wrong choices.  The blaming of business is not really appropriate (except when they distort science and engage doctors/dieticians for hire) as businesses cannot force us to purchase their products (unlike government), but instead they are reacting to what consumers want when they decide to open more stores and make more products (supply and demand).  In addition, there should come a time when people realise that although playing the victim may give you an excuse and sympathy in the short-term, but in the long term others will become desensitised to the strategy such that it no longer has the same effect, and is ultimately unproductive as your problem will remain until you take active steps to fix it.  In this respect, holding yourself and others personally responsible is more empowering than wallowing in self-pity

The efficacy of personal responsibility as a public health strategy is difficult to assess.  Some people may argue that it’s the status quo and so is failing as a public health strategy.  However, I don’t think this is completely true

1) Taking personal responsibility for your health isn’t as incentivised as it could be.  Most Western countries have some degree of universal healthcare, health insurance, subsidised pharmaceutical drugs, and government funding into the basic sciences that can lead to drug development.  These policies and institutions mean that individuals and not completely financially responsible for the costs of poor health resulting from poor lifestyle choices, and the financial costs are instead shouldered by others to varying degrees in the form of more taxes, or from funding being taken away from other public services.  Under such conditions it would be expected that individuals would be less motivated to prevent and treat diet and lifestyle diseases themselves by improving their diet and lifestyle

2) Our society’s narrative on ageing and chronic disease is one that emphasises an inevitability of chronic disease and the role of bad luck, rather than personal responsibility.  I think some of this narrative is to protect against blaming and shaming when people are at their most vulnerable, but it has the unintended consequence of fostering a belief that humans are broken and creating a sense of hopelessness

So the potential of personal responsibility as a public health strategy is not likely to be realised in a society that has universal healthcare, social norms against personal responsibility and a pessimistic attitude towards ageing and chronic disease.  So the strategy of personal responsibility should be coupled with: (1) a major change in universal healthcare, or at least the addition of a mechanism that incentivises people not getting lifestyle diseases/adopting good health choices (focus of the next post I have planned); and (2) a change in society’s narrative of chronic disease to one that empowers people

The second point illustrates a weakness with personal responsibility as a public health strategy.  Which is that it requires that people either know or have readily available access to the knowledge that will allow them to make the healthy lifestyle choices that will dramatically reduce their risk of chronic disease or in other cases treat or reverse existing diseases.  Some of this knowledge is already widely known, but most people don’t know about even well supported interventions (such as very low calorie diets for type 2 diabetes, vitamin K2 for osteoporosis, and higher protein diets for fat loss and sarcopenia) and there will almost certainly be more options available that no one knows yet until more research is done

Sunday, November 13, 2016

Implications of not having Free Will

In the previous post I briefly challenged the idea of free will.  In philosophy, hard determinism states that current events are determined by previous events and therefore free will cannot exist.  That any thoughts or actions we take are the result of the interaction between earlier environmental factors and our genetics.  And those earlier environmental factors in turn are the result of the interaction between even earlier environmental factors and our genetics.  You can ultimately go back with this chain of causality (infinite regression) to a point where we have not yet been born.

Hard determinism is very difficult to argue against, but some philosophers argue that even though current events are determined by previous events (determinism), the fact that we have choice on a practical level means that free will exists.  This position is called soft determinism or compatibilism and can only work by changing the definition of free will.  You could describe this version of free will as functional or practical free will, as opposed to what could be called ultimate free will that is the topic of this post

The case against free will has been made stronger from recent neuroscience research, showing that our conscious awareness of having made a decision occurs after our brain unconsciously makes the decisions [1] [2].  So in a sense, both conscious decision making and free will are illusions

Rather than being an academic point, I think the absence of free will has several important implications.  In the previous post I used the absence of free will to question whether it was appropriate to blame someone for their behaviours and health status, but there are more important issues than this.  This content is going to be quite different to my usual blog posts, but I think these are ideas worth mentioning regardless

Personal Responsibility

In the strictest sense, a not having free will means that we cannot be personally responsible for our actions and so any praise and criticism is not deserved.  However, it’s still important for the functioning of society to emphasise personal responsibility and praise and criticise the behaviours of others as if they were personally responsible.  This is purely because of the positive consequences of doing so, the negative consequences of not doing so, and the fact that none of us have a gun to our head forcing us to act in a certain way (functional or practical free will)

Imagine the following scenarios:


  • Someone does poorly on their job and when questioned about it states that they are not responsible for their poor performance
  • A driver runs over a pedestrian with their car, and in court claim they are not personally responsible for running the pedestrian over
  • A student studies hard for a test and does well on it.  The student receives no praise from the teacher who decides the student is privileged for being white/Asian and being middle/upper class
  • An entrepreneur finds a gap in the market, takes risks and works hard to start and build their business, and they end up making a lot of money.  Despite selling people products they want and increasing jobs, an angry mob claims conflates inequity with inequality and demands 90% of the entrepreneur’s income

In each scenario the person cannot strictly be held personally responsible for their actions, but each scenario demonstrates the importance of: (1) emphasising personal responsibility regardless of its truth; and (2) using praise and criticism to encourage good behaviour and discourage bad behaviour, even if life isn’t fair, the world isn’t a true meritocracy, and the praise and criticism isn’t deserved.  You would want other people to hold themselves personally responsible for their actions, other people would want it of you, and you would want society to be based on it and the encouragement of good behaviour and discouragement of bad behaviour

The alternative is a bleak world, but one that is close to the utopia of social justice warriors.  It would be a socialist world where people would have little incentive to work hard or create value.  The opposite would be true as people would be incentivised to take as much as possible from society while doing as little work as possible, claiming that their unique set of genes and environmental factors resulted in them having great needs and little ability*.  The perceived merits of each person and the criminal justice system would be perverted by what Thomas Sowell calls cosmic justice.  The purpose of the criminal justice system will no longer be to deter crime and prevent repeat offences to protect the innocent.  Instead it will focus on the criminal and apply the law unequally to people from groups with current or historical privileges or oppressions to the detriment of the public.  This will raise tensions between races/sexes/etc because the ‘privileged’ group will be resentful of the special treatment of the 'oppressed' group, while the ‘oppressed’ group will be fed a false narrative of victimhood at the hands of the privileged.  People who disagree with this ideology won’t receive the same concessions.  They will uniquely be held personally responsible, labelled as evil, and silenced in the name of progress because the end always justifies the means

* Capitalism is been criticised as a system based on based on greed.  I agree, but capitalism incentivises co-operation and creating value for others, whereas socialism is a system based on sharing, but one that actually incentivises greed

Divine Justice

For this section just an FYI, I’m an atheist

This brings me to what I think is the most important implication of not having free will by far.  Many religions have a concept of an afterlife and that pleasantness or unpleasantness of which is determined by your actions while you’re alive.  This is judged by an omniscient deity in the Abrahamic religions (Judaism, Christianity, Islam) or by karma in Eastern religions such as Hinduism and Buddhism.  I’ll call this divine justice

Many aspects of religion can be interpreted to have had functions that provided a net benefit to society in some way at some stage.  For example, the Abrahamic religions have a very strong emphasis on hygiene and cleanliness and this was likely a cultural adaptation against infectious disease at a time before the germ theory of disease.  Similarly, the belief in an afterlife and in divine justice could have been a cultural mechanism to strongly encourage or discourage certain behaviour and provide consolation for the suffering experienced in life.  This could be cynically interpreted as a means to keep the general population complacent with authoritarian regimes and the massive inequalities in those ancient societies

Belief in an afterlife and divine justice may have been helpful earlier, but I think that these beliefs are ultimately responsible for some of the major problems in the world at the moment, which is why I’m writing this section

The Abrahamic religions have a belief in the same deity, who is believed to be omniscient, just, and merciful (they believe this deity possesses many other qualities, but these are ones relevant to the topic).  They also all include a belief in free will, an afterlife and divine justice.  Belief in free will is a necessary premise for belief in divine justice, and in the absence of free will, the belief that their deity possesses those qualities contradicts the belief that divine justice will affect the quality of the afterlife

Since free will cannot exist, therefore we cannot strictly be personally responsible for our actions.  An omniscient, just, and merciful deity could not possibly condemn someone to purgatory or hell based on the actions they made in life as these actions are a product of the genetic and environmental cards they were dealt.  For such a deity, divine justice would be an infinite regression back to the first cause – the big bang (or whatever came before that) or the deity creating the universe – and everyone would have to be judged as neither good nor evil and deserving no different treatment regardless of whether they were a sociopath or a saint.  It would take an exceptionally unjust, unmerciful and sadistic deity to condemn someone to an eternity of suffering for the crime of being born to the wrong parents, in the wrong place, at the wrong time

Therefore not having of free will - combined with a belief in an omniscient, just, and merciful deity - undermines the religious beliefs and practices (but not faith in a deity) one would ordinarily not partake in, but does so to appease their deity and increase their chances of a better afterlife.  Knowing this would have the effect of freeing people from any religious practices that don’t improve your life or the lives of others (because you don’t need religion to be a good person).  Most importantly, not having free will undermines a basis for religiously motivated violence/terrorism outside sectarianism (whether it’s holy war, delivering gays from sin, just killing infidels, etc) and the politicisation of religion, all because it cannot matter in the eyes of an omniscient, just, and merciful deity