Those on these boards probably have read my off the cuff posts on this topic before but I thought a prepared post would illustrate the picture better.
First things off.
1. The Singapore healthcare system is not worse off than the US. Its markably superior and it has certain benefits compared to the NHS equivalent we migrated out from. Its offer a trade off in terms of healthcare financing.
2. I am of the stance that healthcare financing doesn't significantly affect the quality of the healthcare system...... except in one regards. Capacity. Granted, this might be because of odious comparison with the NHS in the 90s, but its the same stance that our health ministers took back in the 1980s when we took us off the system. A fully state operated system like the NHS may face mismatch in funding compared to the demand required. When more investment is required or the costs rises, the funds required might not arise. Granted, Singapore itself is not a sterling example of the counter-argument but our low capacity is a matter of design.
So, with the above disclaimers....... let's get into the meat of the topic.
Anyone familiar with conservative thinking has surely heard of the Singapore healthcare model, in comparison with Obamacare over the last 4 years. Its been echoed in many articles, op eds and blogs.
Oddly enough, all of them seem to feed back off each other and rely on 3 main sources.
http://www.youtube.com/watch?feature=pl ... 7QMCEa7hVk
http://youtu.be/r7QMCEa7hVk
The world focus video.
John Tucci, "The Singapore health system – achieving positive health outcomes with low expenditure", Watson Wyatt Healthcare Market Review, October 2004.
And for the newer articles in 2013, William Haseltine Affordable Excellence, the Singapore Healthcare story.
http://www.brookings.edu/~/media/press/ ... ncepdf.pdf
Strangely, the bloggers all seem to take on the same message points, those espoused by Milton Friedman.
http://youtu.be/IcKvjrqiR5I
John Stossel.
http://www.freedomworks.org/blog/breean ... -singapore
http://www.theatlantic.com/business/arc ... em/254210/
Because the individual is forced to pay for his own healthcare expenses, he decides just what is needed, decides not to overspends and will take better care of himself. And because he can then choose to go to which doctor he wants for the best option, this introduces competition, which reduces costs and improve quality.
Let's remember those three key words.
Competition.
Individual responsibility.
Choice.
A minor problem.If you actually read the above 3 sources, they don't actually say that all 3 matters.
1.Worldfocus talks about individual responsibility but not choice or competition.
2. Wyatts talk about individual responsibility+choice, but not competition.
3. Haseltine talks about all 3, but places the importance on competition and choice.
More importantly................. none of them actually says how Medisave accomplishes all of this. All the op eds, the articles all assume that Medisave is solely responsible for these facets in Singapore healthcare system.
Somehow, Medisave allows patients to choose the best and cheapest doctors, they allow patients to take control of their own treatments and lastly, they encourage patients to limit their health expenditure by being healthy.
At best, the Worldfocus video has the then Health Minister Khaw made the statement about individual responsibility, the need to keep your medisave account healthy by saving more and keeping oneself healthy.
Haseltine argues that Medisave help prevents wastage and over-use(by limiting healthcare visits/expenditure.)
Unfortunately........ all of these has been taken out of context. And under the hands of conservative/free market enthusiasts, distorted into meaningless drivel.
As a short note, a book has been written, explicitly to rebut Haseltine analysis and provides a very detailed overview of our system.
http://www.amazon.com/Myth-Or-Magic-Sin ... 9810773625
This isn't to say that his analysis is wrong. It isn't. The facts are accurate, the analysis logical...... the problem is the conclusions are obviously american driven and misses/distorts key aspects of our systems because of his different perspective.
1. Singaporeans aren't taking better care of their health. Not on their own. The advent of Medisave or the 3M has not made a single iota on wellness care by Singaporeans. Not one single bit.
Has Singaporean health behaviour improved? YES! But none of this is linked remotely to Medisave. Vaccinations and outpatient health visit maternal care was initially organised under the free healthcare system. When we transited over to Medisave, important vaccines like the MMR and TB were still free and monitored under the aegis of the government like School Health Services, others were charged under Medisave but vaccine uptake rates were the same. Indeed, vaccination rates in recent years has fallen due to Wakefield.......................
Smoking and alcohol consumption were reduced........... But this was under the aegis of heavy social engineering and smoking cessation programs. Since Medisave had no impact on these programs, its ludricous to imagine that Medisave had an impact. The correlation is not linked.
Obesity rates in Singapore has been rising, along with this, diabetes and the like. Even the old bad boys, infectious diseases like TB and dengue fever has had nothing to do with Medisave.
If Medisave had any impact on Singapore Health behaviour, Minister Khaw would NOT have invoked Orweillian language about how Ministry of Health ineveitably meant taking care of sick people and how he wished to change that. And we do. Haseltine mentions how the government has strict controls on communicable diseases but fails to communicate how this and other government social engineering played a more important role in reducing healthcare costs than Medisave. A press article once claimed how Singaporeans are physically more fit.......... because the government mandates all males pass a combat fitness test yearly and arranges mandatory remedial training for those who fail.
It gets even more annoying because Medisave as originally designed was intended purely for hospital care. And Haseltine noted that spiraling costs led to the invention of the castrophic health insurance Medishield........... by which he meant healthcare costs rose from 11% to 13%. So........ no drop in healthcare costs under Medisave and healthcare inflation rates in Singapore is traditionally low compared to other countries, even now in our modern time, its only 5 odd percent. And let's face it, a patient has NO impact on how long he stays in the hospital and precious little on what treatment and the costs are in the hospital even in the west. This goes down to zero in the paternalistic Singaporean system(well, until the nineties anyway.)
So........ let's reiterate.
Costs rose.
Health behaviour independent of Medisave implementation.
Now, a more nuanced look does show how Medisave can be used to improve health behaviour. As detailed by Jeremy Lim, colorectal screening used the adage "Medisave claimable" to increase uptake. Or in other words, Singaporeans were using Medisave EXACTLY like a third party payer. Unwilling to pay out of pocket but when you can charge Medisave instead..................
The exact opposite of the behaviour desired by Milton Friedman.
But....... our health Minister claims individual responsibility is key! Our Prime Minister also said that too!
Hell, its right there in that video, work hard, earn more, don't smoke and keep healthy, more Medisave!
Different context.
You see...... He's saying that in order for the system to work, Singaporeans HAVE to take personal responsibility for their own health and savings.
Politics may mean that occasionally politicians use the weasel words that Singaporeans has high co-payment, so they have to take better care of their health. This is not a cause= effect situation. Its a because, so you have to situation.
Sadly, the speech he made is not available on the blog, but back when Medisave was first liberalised for chronic disease management, he explicitly stated that while he agreed and saw the need for this, his concern was that Medisave not be depleted and hence, the need for withdrawal limits(and co-payments) to help prevent the depletion of Medisave.
In other words, the GOVERNMENT, will RESTRICT, how much money you can use out of your savings account, to manage your own health. You would need to cough up the differential yourself.
A less explicit form of the statement is found here.
But I wanted to also remind our readers of the purpose of Medisave which is to help pay costly hospitalisation. That tends to happen at old age. Hence, my serious concern that our Medisave is not depleted prematurely.
Small outpatient bills should be paid out of pocket in cash. Medisave should target large hospital bills and all should be “MediShield-ed” to take care of very large hospital bills.
- See more at: http://mohsingapore.sg/2010/01/medisave ... /#more-117
Exhortations for Singaporeans to take personal care of their health-
Singaporeans must not be passive recipients of the new strategy. Indeed, for the strategy to work, Singaporeans must be active partners, taking full ownership of their own health. We can at best be a good coach and a dynamic cheer leader. - See more at: http://mohsingapore.sg/2011/01/healthca ... d9xzb.dpuf
http://mohsingapore.sg/2012/05/thoughts ... rdability/
Suffice to say, the picture painted by conservatives and libertarians on how the HSA in Singapore is used to promote individual responsibility is heavily distorted.
2. Choice.
Still, Singaporeans have the right to choose their healthcare treatment, right?
Right in terms of healthcare economics, wrong in terms of libertarian thinking.
We do have 'choice'. Healthcare spending in Singapore is consumer driven healthcare. By mandating savings(and public insurance), Singaporeans are better able to access healthcare than they would have been without it(let's ignore the Beveridge system we had)
http://mohsingapore.sg/2010/02/more-choices/#more-109
But this doesn't mean the same 'choice' libertarians mean. Are Singaporeans able, because of Medisave to choose the right, cheapest doctor? Nope.
Medisave has done precious little to actually make that happen. Instead, the government has stepped in to make this happen. First, during the last decade, they introduced median hospital bills and ordered hospitals to be more transparent in their billing, publishing the bills on their website so that patients can make a more informed choice for costs.
http://mohsingapore.sg/2010/05/patients-as-shoppers/
So......... who knew that publishing hidden medical bills forces businesses to drop their prices and actually compete with each other?
Secondly, in an attempt to right site care......... they ignored Medisave utterly and rely now on a government agency, (Agency of Intergrated Care) to help right site patients instead.
Actions speak louder than words indeed.
3. Competition.
Has competition kept healthcare costs low? I advise people to read through Jeremy lim book instead as the answer isn't a simple Yes and No.
However, what CAN be said is..... Medisave HASN"T improved competition per se. It has not provided a source of healthcare dollars that people are chasing for, like say...... Medicare in the US.
As seen in the better shoppers posts, competition has not been enforced on hospitals by the consumers. Rather, it is the government itself which is striving to enforce competition, first via the splitting of the hospitals into two seperate clusters(NHG and Singhealth) and then enforcing transparency by releasing median medical bills.
Similarly, the entry of private agencies has not made costs more transparent and more competitive, as can be seen by Dr Susan Lim
http://sg.news.yahoo.com/surgeon-susan- ... 22896.html
The reasons for Singapore relatively low medical inflation rate are myriad........ From Hsiao comment about supply and Singapore regulation of medical services so as to reduce over-prescription, restricting demand via a combination of both low supply and high co-payments, a 'public' competitor which help benchmark prices..............
Suffice to say that Medisave sole contribution to help reduce costs is through limitation of utilisation. Whether this is helpful, god only knows. I doubt anyone has successfully managed to conduct a cost analysis in which patients waste their own money(and frankly, how do you judge peace of mind as a waste?)
Lastly.......... what DOES the Singapore experiment tells us about HSA? They tell us the same things that should have been obvious.
A high co-payment system limits demand.
HSA 'work' by having the assumption that your medical costs are low when young and that you will save enough to meet your inflated needs when old. These assumptions aren't universally true.
I previously held up HIV patients as an example. These patients are typically young and the costs of ARV, antibiotics, tests are very expensive.
http://www.afa.org.sg/act/27/3.htm
Young patients don't have the savings to meet the high costs involved. Now, a comprehensive insurance plan, even a comprehensive catastrophic insurance plan( i have no idea whether this exists but various posters on SB keep insisting they do) will cover said costs(provided there's no lifetime limit) but our insurance covers hospital charges. Not outpatient visits.
Another assumption is that you saved enough for your medical needs. This is subjective. What happens if you need to save a thousand dollars on average yearly but your income is inadequate to meet that demand? Or your needs happen to fall outside of this range? Or more importantly, what if healthcare inflation rises faster than initially predicted, as has been the case for the last 3 decades?
In singapore, this is handled through 3 means. Addition of your own personal savings and assets. Intergenerational transfer(including from your children Medisave). Medifund and Comchest........ which operates as I'm told similarly to Medicaid.
Yet, none of the libertarians who espouse the merits of HSA so far has talked about its flaws or what happens if the assumptions behind it fail. Why?
To summarise, the Singapore healthcare system does not operate along the lines of how Obamacare critics think it does, even the out of context sources they use do not endorse the libertarian views espoused, no matter how frequently libertarians repeat it and quote Haseltine or Wyatt.
The concepts of individual responsibility takes on a different context in Singapore healthcare politics than it does in the US, Medisave has not shown any correlation to health behaviours whatsoever other than tampering the utilisation of healthcare services. Without such an impact, it can be shown that the argument of choice and competition is irrelevant to whether HSAs should be used in a US context and the Singaporean system uses other methods to help bring about choice and competition, even as our definition of those terms are different from how libertarians portray it. Certainly, the high level of government intervention, regulation and control would be unacceptable to libertarians who invoke fears of Hitler when the Federal government creates a state health insurance exchange.
Thank you for bothering to dig through this overtly long, wandering essay.
