MOH's reply to 'Singapore Has Health-care hurdles Too'

11 Nov 2009, Streats

Question

Name of the Person: Stanley Jeremiah

Singapore Has Health-care Hurdles Too

William McGurn's column "What Singapore Can Teach the White House" (op-ed, Oct. 21) paints an inaccurate picture of Singapore's health-care system and the costs it incurs.

Singapore does not have "universal coverage," as Mr. McGurn asserts. Even the government has admitted that in a country of about three million citizens, tens if not hundreds of thousands of Singaporeans do not have any basic medical insurance coverage, which is provided through government agencies. Many of the uninsured are women and children.

In Singapore, as in the United States, there are people who are uninsured and uninsurable. Even the government's basic health-insurance program, Medishield, refuses to provide cover for those with pre-existing and congenital medical conditions. Parents of a child with a congenital condition have to carry the entire medical cost burden themselves.

It is true that medical costs in Singapore are generally lower than the U.S., but the average Singaporean does not enjoy the same per capita income or standard of living as the average American. Medical costs are significantly higher than in neighboring countries. The minister of health recently admitted in Parliament that many Singaporeans regularly cross the causeway into Malaysia to buy prescription drugs because they are much cheaper there.

The quality of Singapore's medical care is high, but as in the U.S., cost is a pressing issue. To some extent, the situation has been cushioned by the collective responsibility of Asian families, where the larger family chips in to pick up the medical cost of a parent or sibling. Yet these social structures are slowly breaking down. Singapore has an aging population and the baby boomers are the most exposed. Having paid for their parents' medical costs, they have no one to pick up to the tab for them. To avoid picking up the cost for those who cannot pay, the government includes siblings and children—including those living overseas—in their means-testing assessment. Employers provide some level of health-care insurance but these programs are often not portable.

Singapore spends roughly 4% of its annual GDP on health care—one of the lowest outlays in the developed world. The average Singaporean cannot afford to use the upscale Raffles Hospital to which Mr. McGurn refers in his article. They have to wait in line at government-managed hospitals. The 2009 budget allocated 3.7 billion Singapore dollars ($2.6 billion) to health care; by contrast, S$11.5 billion was allocated to defense.

Singapore's medical-savings accounts, known as "Medisave," are not fully controlled by their owners. Withdrawals are subject to a complex set of rules which the Ministry of Health changes from time to time—a process that often baffles the average Singaporean. In many ways, Singapore is heading in the same direction as the U.S. when it comes to health care. While a high quality of care is available, it is not always accessible or affordable. People unfortunate enough to be born with or develop significant medical conditions can find the cost financially crippling to themselves and to their families.

Reply

Reply from MOH 

1. Stanley Jeremiah wrote that “Singapore Has Health-care Hurdles Too” (WSJ, Nov 3).  We agree as there is no perfect healthcare system in the world.  But some healthcare systems do perform better than others and all can learn from one another’s experiences.  The first step to learning is to get the facts right. 

2. First, Mr Jeremiah claimed that since some Singaporeans are uninsured, Singapore does not have universal coverage.  A national insurance system is not the only means to achieve universal access to healthcare.  Developed countries like the UK have heavily subsidised public healthcare systems, funded through taxation and available to all citizens upon request. 

3. Singapore’s public healthcare system combines subsidies funded out of taxation with a voluntary medical insurance scheme, called MediShield, to help patients pay for their share of the medical expenses.  This way, we achieve universal access to affordable healthcare, while reducing Singaporeans’ out-of-pocket expenses through risk-pooling. 

4. Second, he noted that the “MediShield refuses to provide cover for those with pre-existing and congenital medical conditions”.   Participation in MediShield is voluntary.  If MediShield did not exclude coverage for pre-existing illnesses,  who would buy insurance when well?

5. Despite being a voluntary scheme, the coverage of MediShield is 85% and growing.

6. Third, he noted that “Parents of a child with a congenital condition have to carry the entire medical cost burden themselves”.  This is untrue.  The Govern­ment bears most of the costs of medical treatment in a public hospital through heavy subsidies.  Furthermore, as an ultimate safety net, we have a Government-funded programme, Medifund, through which the state will pay part or all of the medical bills of those unable to pay, subject to means-testing.

7. Public hospitals provide 80% of acute hospitalisation care in Singa­pore.  Patients in public hospitals enjoy a subsidy as high as 80% of the cost of the delivery.  Through prudent management, we have kept this cost low.  We have kept the financial burden on patients even lower through a combination of government subsidy and medical insurance.  Medisave, our health savings account, ensures that all Singaporeans are able to afford the co-payments on their hospital bills. 

8. The principle of co-payment emphasises personal responsibility for health.  It discourages over-consumption by patients and over-servicing by providers, so common in healthcare systems based on third-party payments. This crucial feature of our healthcare system explains why despite only spending 4% of our GDP on healthcare, Singa­pore delivers a high level of healthcare services and health outcomes to all, rich or poor.