Walang iwanan: A rejoinder to Secretary Salceda on Universal Health Care

A firestorm of protest has met Executive Secretary Ralph Recto’s declaration to expand Philippine Health Insurance Corp. (PhilHealth) benefits for direct contributors, but exclude the indirect contributors who comprise the majority. The Philippine Daily Inquirer recognized the massive public interest impact, with the story becoming the banner headline of its July 3 issue. The headline: “Groups reject PhilHealth scheme pushed by Recto.”

These groups, consisting of 75 healthcare organizations that lead or influence their respective fields, have spoken with one voice: “The Universal Health Care Act was never intended to divide Filipinos into different tiers of health protection. Its guiding principles recognize the contributions of all workers while also giving priority to those who cannot afford to pay.” The 75 organizations call on Executive Secretary Recto to “stop diverting PhilHealth funds, and it must stop underfunding PhilHealth. If government fulfills its obligations under the Universal Health Care Act, PhilHealth can strengthen benefits for every Filipino, rather than just a few.”

Earlier (June 30), Action for Economic Reforms (AER) issued a press statement. AER welcomes increasing or expanding PhilHealth benefits, subject to health technology assessment, and emphasizes that such benefits must be extended to all PhilHealth members. The public statement has received good feedback, though we have noticed trolls uniformly smattering the Recto line. Which is: “ang indigent ay libre. Walang bayad… So panalo ka. Kaya alam ko, ’yung mga nagbabayad, dapat taasan natin ang PhilHealth benefits.” In gist, Recto and trolls say: The indigents are freeloaders. Ergo, those who pay are entitled to more PhilHealth benefits.

But in truth, all contributors — direct and indirect — pay.

Here’s the Cambridge Dictionary’s definition of contributor: “a person who contributes something, especially money, in order to provide or achieve something together with other people.”

Never mind the trolls and the warped argument. But a thought-out and considered criticism of the AER position comes from recently appointed Cabinet Secretary Joey Salceda. Salceda is the new head of the Presidential Legislative Liaison Office (PLLO). The Office itself has been reoriented to coordinate policy formulation between the Executive and Congress.

Salceda’s article, published on Substack and dated July 1, is titled: “On UHC: To be Fair to ES Ralph Recto.” By way of an author’s note, Salceda prefaced his response to AER as follows: “AER has been both a good ally and a worthy opponent over much of my public career, so I write this in that spirit.”

It is also in the same spirit — Salceda “being both a good ally and a worthy opponent” — that I craft this rejoinder to his article.

Salceda’s key argument rests on Section 9 of the Universal Health Care Act (UHCA). It states: “PhilHealth shall provide additional Program benefits for direct contributors, where applicable.” This provision, nonetheless, must be interpreted correctly — by relating it to the other parts of the law. The correct interpretation is to subsume said provision under the UHCA’s first-order principles, objectives, and features. Concretely, this provision must be consistent with the fundamental principle of the universality of healthcare. Section 2 of the UHCA is a declaration of principles and policies. It states, inter alia: “A healthcare model providing access to quality, cost-effective, and comprehensive services (promotive to palliative) without financial hardship, prioritizing those in need.”

The universality of healthcare is expressed in a “cube” framework, which is embedded in the UHCA. The cube covers the whole population with health insurance and access to healthcare (the X-axis), the financial protection to progressively reduce out-of-pocket expenses (Y-axis), and the depth and quality of services and benefits available to all (the Z-axis). The never-ending task, given the resource constraint, is how to expand the cube covering all areas. Thus the universality of healthcare is about coverage for the whole population, provision of quality healthcare benefits for all, and prevention of financial hardship.

Incontestably, the poor and low-income classes — those who belong to PhilHealth’s indirect contributors — are those who need the most protection.

Returning to the provision about “additional Program benefits for direct contributors, where applicable,” we assert that its interpretation and operationalization must be aligned with the principle of universality as well as the corollary principle of “prioritizing those in need.” Thus, Recto’s proposed additional benefits for direct contributors must likewise be accorded to the indirect contributors.

We emphasize that PhilHealth membership is defined by being a “contributor.” It does not matter whether one is a direct or indirect contributor. Operatively, a contributor shall enjoy equal access to the same benefits PhilHealth provides.

We welcome additional benefits. But no one should be excluded from additional benefits. Walang iwanan (leave no one behind). One for all, all for one.

Note, too, that the Section 9 provision for additional benefits for direct contributors contains a qualifier: “where applicable.” The context is that during the bicameral conference committee meeting, Congress noted that the insertion of this provision, which then Senator Recto insisted on, would have contradicted the spirit and letter of the UHCA. To break the gridlock, the proponents of UHCA agreed to a compromise without undermining the fundamental principles and essential features of the law. The result: The provision includes the important qualifier “where applicable.”

“Where applicable” is thus a constraint. First, “the provision of additional benefits for direct contributors” must be consistent with the first-order principle of universality of coverage. The additional benefits for the direct contributors must likewise be given to the indirect contributors.

The second constraint is any additional benefits must undergo a health technology assessment (HTA). This is mandated in the law (Section 34 of the UHCA). The HTA is a “systematic evaluation of properties, effects, or impact of health-related technologies, devices, medicines, vaccines, procedures and all other health-related systems.” The HTAC evaluation covers not only medicinal but also social, economic, and ethical factors.

In this case, the Recto proposal is vague or nebulous. Define first the proposed additional benefits for all, and subject them to HTA.

And a third constraint — a major one — is the sufficiency of PhilHealth funding. The government has defunded PhilHealth. The Supreme Court has declared that the transfer of P60 billion worth of PhilHealth funds to the National Government in 2024 was unconstitutional. But even after this definitive ruling, the government continues to violate the law by not funding in full the membership of indirect contributors, thus resulting in an underfunded PhilHealth.

How then can the government give additional benefits when PhilHealth itself is now severely underfunded? For 2027, PhilHealth’s proposed budget is P300.8 billion. But the Executive’s National Expenditure Program, which has yet to be published, is only willing to give approximately a fifth of what PhilHealth is asking.

To be credible and realizable, the government must first secure adequate funding for all PhilHealth expenditures. The government is not providing the budget for current spending, much less additional benefits.

Thus, in expanding the benefits — and we reiterate, expanded benefits for all — the government must stop defunding PhilHealth and it must depoliticize PhilHealth benefits. As a corollary, the government must increase multifold the PhilHealth budget to ensure that it can deliver the core benefits, and increase benefits, to all members.

To conclude, the UHCA has reaffirmed what is enshrined in the Constitution — the right to health and health as a public good. Thus the law formalizes and operationalizes universal health as a public good: No one is excluded, no one is discriminated against in the provision of benefits. The use of one of UHC benefits does not diminish the use by others.

So, by all means, introduce additional benefits, but ensure that everyone has access to the new benefits.

Secretary Salceda, and we hope Secretary Recto as well, will be agreeable to that.

Filomeno S. Sta. Ana III coordinates the Action for Economic Reforms.

www.aer.ph