1. It has lost its universality. A good healthcare system has to deliver healthcare services to everyone but in the US, 45 million Americans are uninsured.
2. Healthcare cost is the highest in the world and keeps rising.
3. It is extraordinarily complex.
The American system hold many negative lessons for us just as French system which is ranked No. 1 in the world has many positive lessons for us. A good healthcare system has to be simple, universal and among the top healthcare systems in the world govt play a big role in healthcare. Unlike many other industries where free market principles yield the best results, it is not the same for healthcare. Recently, due to the H1N1 spread we received some feedback on our system - a H1N1 patient expressed surprise that he got a $1000 bill for his short stay in hospital[Link]. The MOH explained that the bill is already 80% subsidised (the unsubsided bill is $5000!) as means testing is suspended for all H1N1 cases - everyone gets the full subsidy. A writer to ST forum wrote that he was quite angry that he had to pay $214 for an ambulance and H1N1 testing[Link]. "Why should being responsible cost $214?"....the writer asked. Singapore is now leading Asia in the number of new cases[Link]. Even in a pandemic situation, the PAP govt cannot shed its ideological constraints and insists that sick Singaporeans paying for testing. It would have been alright if Singaporeans all have jobs and are rich enough not to be deterred by the costly test but we have an unemployment rate of 4.9% and 30% of Singaporeans workers are in the low income category. It would have been more effective to waive the cost of testing to stop the spread of H1N1 but the PAP govt will not do it because of its ideology.... I'll talk more about this ideology later but lets see what happened to the American system to understand how a govt can steer a good healthcare system in the wrong direction and end up with a costly mess.
I will continue and finish this post later and relate the above and what is happening in Singapore and why we should watch our govt healthcare policies closely ....those of you with comments please feel free to post them.
If you watch the pinky video I posted on the American healthcare system, the root cause of rising healthcare there is due to the following:
1. Allowing healthcare to be driven by market forces.
2. Treating healthcare as a commodity.
3. Creating a system concerned with maximising profits over treating people.
The Americans created a complex system that involved many profit oriented private entities and the free market forces allocates healthcare based on who can pay for it. Before I get on to describe the state of healthcare in Singapore, lets take a look at some of the systems around the world :
"In the Japanese health care system, healthcare services, including free screening examinations for particular diseases, prenatal care, and infectious disease control, are provided by national and local governments. Payment for personal medical services is offered through a universal health care insurance system that provides relative equality of access, with fees set by a government committee. People without insurance through employers can participate in a national health insurance program administered by local governments. Since 1973, all elderly persons have been covered by government-sponsored insurance" [Link]
"The best thing about the Japanese medical system is that all citizens are covered. Anyone, anywhere, anytime — and it's cheap." [Link]
In Taiwan, they pay $20/month for insurance and if you're too poor or over 65 years old, the govt gives you money to live on and part of it goes towards this $20. [Link] This $20 (or higher for the higher income) is all they pay. It takes care of tests, hospitalisation and outpatient treatment.
In Taiwanese soap operas there is plenty of crying over life's numerous human tragedies but I challenge you to show me scene in a Taiwanese show where they cry because they they can't afford medical treatment.....it just does not happen because nobody walks out of a hospital there with a $10,000 bill.
One of the important lessons learned as seen on the above video from the healthcare systems of many countries is when private insurance is allowed to step into system the govt has to play it tough and disallow them from 'cherrypicking' who they want to cover and force them to accept everyone otherwise you end up with a pool of uninsured people and the system loses its universality.
Universal coverage so that not a single person is left out and full coverage so that little or no money comes out of pocket of individuals when they get sick - this is to makes sure that the poor won't avoid seeking treatment when they are sick - are common characteristics of some of the better healthcare systems in the world. In many of these systems the govt plays a central role as the single payer [Link] - this gives govt tremendous incentive to keep healthcare costs down by implementing the right policies and regulations.
In Singapore, the govt implemented MediSave in 1984 and MediShield in 1990. The MediSave is just a compulsory savings scheme in which CPF contributors set aside 6-8% of their income for the purpose of paying their future medical bills and those of their family members. Hmmm...the govt wants to make sure people can pay up as hospital bills go up. However, as hospital bills became bigger it became clear that MediSave wasn't enough so the govt came up with Medishield which was supposed to be a "catastrophic illness insurance scheme". There are several problems with MediShield. The first being it is it is not universal in nature. When it was introduced, it did not cover newborns and children and this gap was only closed 18 years later in Dec 2007 [Link], however, newborns with congenital health issues are still not covered (correct me if I'm wrong). MediSheld does not cover those with pre-existing conditions. People who have suffered certain mental conditions are uninsurable[Link]. If you think MediShield protects you from high bills all the time, it is time you do some checking. MediShield together its co-payment and deductible also has limits for various treatments and an annual limit [Link]. I've posted in this blog a number of medical cases in which the bills exceeded $100K - these occur with a higher frequency that what most Singaporeans think. Take the case of Charmaine Lim. Many Singaporeans are now familiar with the extremely sad story of this 4 year old who was diagnosed with stage four neuroblastoma. She is halfway through her treatment in NUH and the bill was reported to have already reached $80K[Link]. Unfortunately, the standard chemotheraphy available in Singapore gives her a 20% chance of survival. She needs US$350K for an alternative treatment in the US that raises her odds of survival to 50% (please donate, I'll be ashamed as a Singaporean if we can't raise enough for this little girl).
Means testng was introduced in the beginning of this year while Singaporeans were still struggling with the economic crisis[Link]. Means testing will hit middle class families whose members get seriously ill the hardest because it causes their medical bills to rise by 75% especially when the patient has a congenital problem and is uninsurable. In the past, they can try to keep the bills down by staying in "C" class but with means testing their medical bills can escalate by 75%. It makes no sense that means testing is done when the patient is admitted does not take into account the final bill the person has to pay. What means testing effectively does is to reduce the govt expediture on health care and pass the cost to middle class Singaporeans.
Why is healthcare cost rising so much faster than Singaporeans' income? Why is it rising so much faster than inflation?
The PAP govt's ambition to make Singapore a medical hub for the rich people in this region and the middle east resulted in an influx of 400,000 medical tourists into Singapore[Link]. A growing proportion of our medical sector is privatised to serve these tourists for profit. What this has done is cause price of limited healthcare resources to rise. So the PAP on one hand is passing rising cost of health care to Singaporeans and on the other going after profits in medical tourism that is causing our healthcare costs to escalate. 400,000 medical tourist is a huge number relative to the population of Singapore and when private companies such Parkway and Raffles Medical pursue these medical tourist profits healthcare in Singapore start to become commoditize like in the US and costs will be driven by market forces (rich Indonesians, middle easterners, ,...) and the system will become concerned with maximising profits over treating the sick. What is worrying is not where we are today but the path we have taken and where we will be in the coming years as cost continue to rise faster than income and the govt passes the a larger portion of the cost on to Singaporeans. As private sector medical hub grow and expand due to medical tourism and increased wealth of a small segment of our society, it will draw on our limited capacity and healthcare costs will rise faster than the average wage of Singaporeans. What the govt is now doing is looking into allowing MediSave to be used for overseas hospitalisation[Link]. The claim is they are doing this to give Singaporeans more options but I think for many Singaporeans they will have no option but to seek treatment where the health care standard is lower because the health care costs will be driven up beyond their means here.