There have been many voices calling for move to a single payer government-led model of healthcare financing. The Singapore Democratic Party has made this the lynchpin of its healthcare proposal, while various parties have highlighted the potential benefits of a single payer, e.g. increased bargaining power with pharmaceutical companies, aligned incentives for health promotion and disease prevention.
A letter in ‘Today’ written by Mr. Wayne Chan forcefully challenged the notion that more health benefits meant higher costs which meant higher taxes, arguing instead: “… a single-payer universal healthcare system based on a compulsory national health insurance model can stem the rise in healthcare costs by increasing risk pooling among a larger population, and allow for more bargaining power with pharmaceutical companies and medical service providers”.
Has this been the experience in other countries? Most certainly, Australia uses its scale to compel pharmaceutical companies to develop intricate economic models to estimate the national costs of reimbursing a particular drug, and if the models are wrong, the pharmaceutical company makes up the difference. In Taiwan, reference pricing is used and Taiwan agrees to pay only the average price charged to a basket of 10 countries. In fact, Taiwanese doctors complain bitterly of the low reimbursement rates but the government is nonchalent. I have discussed the American health management organization Kaiser Permanente previously, and how because it is effectively a single payer, has tremendous economic incentive to keep its members healthy. To this end, Kaiser spends over US$1.8 billion on preventive health and also implemented the award-winning ‘Proactive Office Encounter’ where patients attending Kaiser clinics or hospitals for whatever reason are routinely queried on ‘care gaps’ and offered screening tests etc. to plug these gaps.
Mr Chan’s letter in ‘Today’ concludes: “Such a system introduces a philosophy that we are all in this together and, as we pay directly into a national insurance system, we feel more passionately about monitoring and improving it”.
Noble sentiments indeed, but this runs completely counter to the philosophy of Medisave and CPF. The dogma has been that we are not all in this together, but rather that Singaporeans are responsible for themselves, to keep healthy and to set aside savings for healthcare individually and as families. There is also the ugly interpretation of ‘meritocracy’ where rewards for the successful are not just in the financial realm but spill into the social world: better schools for their children (due to the 1 km ruling and effect on property prices) and better healthcare- shorter queues, choosing one’s own doctors, nicer amenities.
All advocates for single payer government-led models must hence address the contest of ideas first. The ideology of ‘individual responsibility’ in healthcare has been over 30 years in the making, and is firmly entrenched in the minds of policy makers. It is not about technical efficiency. It is pointless as long as ‘individual responsibility’ reigns to even discuss whether single payer systems are more efficient.
Prof Phua Kai Hong, health economist at the Lee Kuan Yew School of Public Policy, described the concerns in the 1980s: runaway healthcare costs and volatile government budgets.
“The solution thus lay in a personal savings scheme like Medisave, with the philosophy to reward the individual for staying well. The scheme would also detach the quality of the healthcare system from the vagaries of economic growth, as past financing was heavily dependent on taxation or budgetary allocation. These objectives were also consistent with preserving the traditional values of self-reliance and strong family ties, which would be promoted as the primary social support for care of the sick and aged, embodied in the two axioms of “saving for a rainy day” and “charity begins at home”.”
There were critics, chief among them former Health Minister Dr Toh Chin Chye, who lambasted the government for even suggesting Medisave. In his speech during the parliamentary debates on the CPF Act amendments to enable Medisave, he reminded
“The provision of health care facilities must be accepted as a social responsibility. It is not that an individual who has the misfortune to be inflicted with some particular disease is solely responsible for searching the facilities to cure his illness. This is a social responsibility which is accepted by governments all over the world. This is part and parcel of the organization of individuals into societies. It is a measure of the degree of civilization.”
Closing the debate, then-Health Minister Mr Goh Chok Tong pilloried Dr Toh’s views, saying “there is a lot that all of us can do for ourselves” and that Dr Toh was bogged down by “today’s situation” and had left his telescope behind in the Ministry of Health. Mr Goh urged his Parliamentarian colleagues to take a long term view, querying how Singaporeans could maintain access to high quality healthcare if healthcare was dependent on economic performance, on growth and employment. The best solution was thus individual responsibility, personal savings and relying on family. This view has not fundamentally changed.
Perhaps the last word in the post should go to Mr Lee Kuan Yew, first Prime Minister of Singapore to understand why change will be difficult. Commenting in ‘Lee Kuan Yew: Hard Truths to Keep Singapore Going’, Mr Lee said:
My major objective in the early days was to make sure that nobody derails the idea of having individual accounts for CPF and Medisave. Whatever you earn, it’s yours. Because once you have that individual account, any suggestion that you put it into a common pool and everybody takes out from it (as with other welfare systems) is bound to lose you votes. So if Low Thia Khiang says now, let’s set up a common pool, I think he’ll lose votes in the next election. Are you prepared to put your money into a common pool, having slogged and built up your CPF nest egg? It’s yours and if you don’t use it, you can leave it to your children or your relatives or whoever you like. Why should you put it into a common pool and everybody draws out at your expense, which is what’s happening in some Western countries? The system has collapsed.