Tembusu Forum: Post Event Reflections

Blog post on the SDP Healthcare Plan, single payer models, financial protection

I was privileged to be invited to speak at the Tembusu Forum, an initiative of Tembusu College (National University of Singapore) [Presentation in a previous post]. The Forum, the 7th in the series, is aimed at providing students opportunities to engage with thought leaders and experts in various fields and this particular edition was focused on healthcare.

I enjoyed the presentations and came away with three thoughts:

  1. Public debate between 2 political parties on healthcare. This was probably the first time the Singapore Democratic Party (SDP) healthcare plan has been debated publicly and with no less than Dr. Lam Pin Min, PAP Member of Parliament and Chair of the Healthcare Government Parliamentary Committee, as one of the speakers/ panelists. It was interesting to compare head-on the results of almost 50 years of the hard-nosed, utilitarian PAP model against the perhaps youthful idealism of the SDP version. My reactions at the end of the session: “Campaign in poetry, govern in prose”. That said, campaign promises have to be kept and prose needs to be inspiring enough…
  2. Single payer versus mixed payer model. Paul made a valiant pitch for a single payer universal health coverage model which the three other panelists, myself included expressed skepticism about. With the benefit of a day of ‘cooling off’, I think it is helpful to explain my position.
    1. It is true that most developed countries have single payer models with what can be called universal health coverage, and there are efficiency benefits; it is doubtful that Singapore is so exceptional the ‘normal rules’ don’t apply to us. That said, I am reluctant to discard the 3M model as it has been entrenched for so many years and the ‘path dependency’ may practically prevent major revamps. How many persons with the maximum Medisave dollars in their accounts would willingly forego the money and have the government place everything into a common pool? If we do not do that, then any new scheme is an add-on with just higher costs. Can we simply return the monies in Medisave and the MediShield premiums collected? Difficult to imagine the government returning money…
    2. Secondly, any policy maker will appreciate that the 3M framework coupled with subsidies, out-of-pocket cash payments and private insurance collectively give governments useful flexibility in the financing framework. The Singapore policy maker has the leeway to adjust Medisave claimable limits or what Medisave can be used for, thus mobilizing funds, or increase payouts from MediShield etc., whereas her counterpart in say Taiwan has only revenue generation through increased or new premiums or cutting of benefits as policy levers in fiscally challenging periods.
    3. Finally, I don’t think 3M is so broken that it needs to be abandoned. Kai Hong usefully pointed out the 3M, despite the mythology around it being the lynchpin of the Singapore model, actually finances a fraction of total healthcare spending (“Just 10-15%”). Given this, there is so much opportunity to surgically make changes to the funding mix. I will need to do more thinking about this and will go into details in the upcoming book, but off the top of my head, MediShield could transform from a catastrophic insurance scheme to one that is closer to the model in most OECD countries, i.e. comprehensive coverage with co-payments to mitigate moral hazard, Medisave usage could be more liberal, and with greater coverage of total bill size, Medifund could be more strategically used for orphan diseases, particularly vulnerable groups etc.
  3. Peace of Mind. Financial protection for peace of mind is what our health system really lacks. A system so heavily stacked towards protecting the government’s financial interests has to bias against individuals and the financial risk is almost exclusively borne by the patient and his family. The family is then forced to undergo periods of anxiety while they wait for government approval (Medifund) or ‘Many Helping Hands’ to kick in. In theory, no one should be deprived of medically necessary care but in practice, one does not know until after the fact or when difficult treatment choices with widely different financial consequences have to be made. This to me is inhumane. I wrote a commentary on this for ‘Today’ which discusses this delicate relation between state and citizen in more detail. Watch for it!

Finally, I am encouraged by the climate of openness and humility shown by all parties. We all recognize that our current system is far from perfect and where we differ is over what to do about it. We all care passionately about our fellow Singaporeans, especially those afflicted with illness, and where we differ is in opinions on the balance between citizen and country in carrying the financial burden of medical treatment.

Students and faculty were interested and asked sharp questions both during and after the panel discussion. I am heartened at the interest and enthusiasm to learn more about an issue that affects all of us so personally and think this bodes well for the future.

PS Paul had a great deck of slides which I hope the SDP circulates widely. Far more accessible than a lengthy tome.

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One comment

  1. winnie chan · · Reply

    dear Jeremy
    i have always enjoyed your writing and your sharing of thoughts.
    Pity I missed this forum.
    i am a student of the Masters of Gerontology programme at UNISIM and we are working adults studying part time. Would be great if you could have time to share your thoughts with us on an informal – a group of like minded students on healthcare financing policies..?

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