Healthcare cost and benefits in democracy 4 (kind of) April 1, 2020 cliffski I read the infamous article yesterday that a lot of UK people are screaming and hurling abuse at over twitter. Basically a commentator wrote about the tradeoffs between continuing with a lock down in the UK due to COVID19, or letting people go back to work, and the relative impact on health in the short and long term. 99% of people hurling abuse did not read the article, and if they did, they did not understand it. Here is a shorter & simpler version of the argument: The UK lock-down will prevent X deaths from people with an average life expectancy of Y and a general state of health of Z. The economic cost of the lock down will result in W extra deaths from suicide/obesity/other factors and K extra deaths due to the reduced funding for healthcare over P years as the economic cost of the lock-down bailout package is repaid Therefore it MIGHT be the case that the cure is worse than the disease and we should stop it, allowing X people to die. Now pretty obviously, whether or not the argument is right depends MASSIVELY on the values for X,Y,Z,W,K and P. These figures are all highly speculative, and open to interpretation and re-evaluation, and we cannot be sure of any of them…but thats fine, it doesn’t change the core of the argument, an argument which we already have enshrined in UK government in an organisation called NICE. NICE is the national institute for health and care excellence, and its job is basically to look at drugs/treatments the NHS might like, and work out if they make economic sense for the NHS to use them. Given non-infinite money, and cash spent on treatment Y cannot be sued on treatment Z, so obviously NICE has to do a balancing act to ensure that the most lives are save for a given health budget. Sometimes, people get upset about NICE refusing drugs, and thats understandable when it affects you, but I cannot help but see what NICE does as logical, and essential. Budgets are never infinite, choices MUST be made. In Democracy 4, the player makes these decision all the time. If you set the state healthcare (or alternative policy such as vouchers) budget to maximum, then health will go up. The link may not be linear, but it will definitely go up. However, the budget for this needs paying for, which if you are unlucky, can mean a debt crisis, or cutbacks in other areas leading to recession, thus unemployment, obesity, poverty…all things that will…reduce the standard of health… This feedback mechanism, where in some cases raising X to boost Y, also reduces A, which causes B which then paradoxically REDUCES y… is a common theme both in the game, and in real world economics. Basically…real-world-shit is complicated! Its also something that is intuitively hard for us to grasp. As primitive mammals we didn’t need to think 6 moves ahead. We barely needed to think 2 moves ahead, which is why Democracy 3/4 is an interesting challenge and feels interesting to play. Its also why most people suck at chess, and go. We are not good at this. Sadly this is disastrous for public policy. NICE *HAS* to exist, despite peoples anger, and the calculation as to the economic cost of a healthcare measure OBVIOUSLY has to happen. Modern political discourse (shit-flinging on twitter about comparing this to eugenics) means that it can never be openly debated by grown up politicians. We force them to lie… So a politician may say we will do WHATEVER IT TAKES to get the virus under control. This is a lie. You also hear people say “If the only effect of this $50 million policy is that it saves one persons life…its been worth it.” This is also a lie. But modern sound-byte culture means the truth can never be discussed. I think I need to work on reflecting this a lot more in Democracy 4. Maybe we need event to pop up and say more media-style things like this: “Lucy Matthews, age 24, has died due to breathing difficulties partly resulting from the high level of pollution on our streets. She leaves behind a daughter Emily, age 4. Her death could have been avoided if the country had introduced emission limits on cars.” That might be a bit harrowing, or distressing, or maybe a bit…manipulative, but I think it would accurately reflect the dilemma for real politicians who have to balance the knowledge that they are absolutely choosing to let some people die, with every decision they make. Thats just inevitably part of the job. Should I add that sort of thing?