Healthcare safety net — improvements long overdue

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In his 2013 National Day Rally speech, Singapore’s equivalent of a State of the Union address, Prime Minister Lee Hsien Loong devoted considerable attention to our healthcare safety net and the gaps that need mending.

Whilst he sketched out the general direction for how we should proceed, nowhere were there any details. Particularly absent was how much the changes would cost and how the extra costs would be paid for. Perhaps he was leaving it for a public debate — he did say, “we are going to do a public consultation, seek views before we decide on the details of the scheme and it will take a year” – which isn’t a bad thing at all. However, it is quickly apparent that a good part of the cost will be borne, not by general taxation, but from individual (albeit forced) savings.

The second broad impression I got from his speech was that although the general ideas are to be welcomed, the problems they are meant to address are so obvious and long-standing, one can’t help but ask: What took you so long?

He touched on four chief areas:

1. Community Health Assist Scheme (CHAS)

2. Paying for visits to Specialist Outpatient Clinics (SOCs)

3. Using Medisave for outpatient treatment

4. Medishield for in-patient treatment

Community Health Assist Scheme

The Community Health Assist Scheme is a state subsidy for visits to participating general practitioners and dental surgeons. It is primarily designed as a subsidy scheme for low-income persons over 40 years old. The prime minister’s proposal is to remove the age floor. That’s all.

The individual is also expected to co-pay (i.e. pay part of the bill out of his own pocket). The website linked above simply says “You are required to co-pay for your treatment under CHAS. Please check with your doctor/dentist on your fees before you proceed with the treatment.” It is hard to know how helpful the scheme is without knowing the co-payment ratio. You will notice that while Lee Hsien Loong spoke glowingly about how CHAS helped a certain hypertensive Mr Tay, he didn’t mention that Mr Tay had to pay part of the bill himself.

CHAS currently issues two kinds of cards to Singaporeans deemed eligible.

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Chronic conditions include diabetes, hypertension and stroke.  The scheme has variable caps “depending on the number and severity of one’s  condition(s)”.

As pointed out earlier, there is no proposal to augment the benefits, only to remove the age floor, allowing younger adults and children in the same low-income households to be covered. How much extra this is going to cost the state purse was not revealed. It wasn’t even revealed how much CHAS is currently costing us, outside of a mention that “we have 300,000 people on CHAS”.

The prime minister is treating us like children. I have candy for you, he says, without telling us how much the candy costs. This is not to say we shouldn’t support the widening of the safety net, but he shouldn’t go around taking credit for the candy without being honest with citizens. We can’t have a proper public consultation without first laying out the facts.

More subsidies for specialist outpatient care

Even vaguer was that of “increase the subsidies for the lower- and middle-income patients who are visiting Specialist Outpatient Clinics”. It is not clear what the current subsidies are, how much the annual bill is to the state and what the government has in mind when it speaks of “increase”. He also said that “we will means-test these additional subsidies” which seems to suggest that parsimony is still the guiding star. Once again, don’t treat us like children. Lay out the facts.

You may be allowed to spend your own savings on outpatient care

Items 3 and 4 are not about the public purse paying out more. They are about taking a bigger chunk out of our own Medisave accounts. First, however, let me lay out diagrammatically what Medisave and Medishield are:

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Although Medisave is, strictly speaking, an individual’s own savings account within the Central Provident Fund (CPF) system, tight rules govern when withdrawals can be made from it. A glaring omission has been that, outside of a few exceptions, Medisave cannot be used for outpatient treatment. This even though for several years, the mantra has been to avoid warding patients wherever possible. Day surgeries, for example, have become much more common in the last ten years.

It makes eminent sense that people should be permitted to pay out of their Medisave for relatively high-cost outpatient treatments. The eyebrow raising aspect is why we haven’t done so yet.

Now Lee is promising a new candy treat: the government will open the spigot a bit more, but it is worthwhile bearing in mind that the extra money is not coming out of taxation revenues, but from individuals’ savings accounts. In effect, he is saying the individual is going to be allowed a bit more control over using his own money. Yes, that’s the way to put it.  Saying we are “strengthening the social safety net” would be misleading since not a cent is coming from the common pool of funds.

Medishield

Catching up with Obamacare

A more cynical reaction to Lee’s speech may be to point out that it would hardly do, now that Obamacare is being implemented in many US states (some refuse to sign on), to keep our own social safety net even thinner than in America. If a country that often seems nonchalant about inequality, at times celebrating it even, can introduce universal health insurance coverage, for Singapore to have an even more inadequate system must be embarrassing.

Item 4 relates to Medishield. This is really an insurance program for healthcare expenses, although annual premiums are almost always paid from individuals’ Medisave accounts. Lee announced three changes:

4a. Medishield insurance cover will stretch to end of life, instead of stopping at age 90. This is a no-brainer; the absurd thing is that it had a cut-off age at all. What did we expect people to do? Commit suicide when they fall ill after 90?

4b. Medishield insurance will be universal. No one is allowed to opt out. Those who are currently out will be brought back in. That’s how national healthcare pooling should be, otherwise those who think they are in good health with low risks will refuse to participate, leaving only high-cost persons in the system. Again, why did it take so long to do something as basic as this?

4c. There will be a raising of the maximum claimable amount, as indicated by Lee’s words: “better protection for very large hospital bills”. Unfortunately, he left it vague. (This whole business of how Medishield actually works is confusing to many people, so I will try to explain below).

Lee pointed out that Medishield insurance premiums must go up. A bigger bite will be taken from our Medisave accounts to pay for them. Once again, no money is intended from the public purse, except in the case of people who don’t even have enough money in their Medisave to pay for premiums. In those cases, “for those who cannot afford”, the government will “subsidise” the premiums.

Yet no details. I checked the Ministry of Health website four days after the speech. Nothing there.

It shouldn’t be hard to disclose the existing figures, e.g.

  • what percentage of Singaporeans are currently covered under Medishield and their demographic profile;
  • how much is collected in annual premiums;
  • how much is disbursed for pay-outs;
  • what is the ratio of current pay-outs to current premiums;
  • how this ratio is expected to change as the population ages or as the demographic profile evolves in other ways, assuming no modification to the terms of the insurance.

pic_201308_45Surely, before the cabinet approved the general outline, they would have been provided current figures, as well as projections how these figures will change if the proposed modifications are implemented. Why aren’t they promptly released to the public? Are data masseurs now at work?

More for medical, less for housing

Between letting us use our Medisave for outpatient treatment and paying larger premiums for Medishield (out of Medisave) , the writing on the wall is clear. The percentage of CPF savings routed into Medisave must go up, which means the percentage routed into the Ordinary Account will go down — unless the total percentage of salaries required to be contributed into CPF rises.

If the Ordinary Account has to be slimmed down, this will have an impact on people’s retirement savings. More immediately, those who have earmarked to the max their Ordinary Account for housing mortgage payments, stretching 20 years or more, may find that their calculations need to be re-worked. It may come as a nasty shock.

Medishield is less than it looks

Saying we have will have a universal healthcare insurance scheme may be comforting, but the devil is surely in the details. As it stands today, Medishield doesn’t lift a finger to help unless you are in considerable difficulty, but when you get into really serious difficulty, it flicks a suicide switch and stops helping. To help you grasp its mechanics, here’s a simple table. On the left-most column is the size of the hospital bill, increasing as you go down.

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See also How Medishield works.

Hospital bills up to the first threshold, which lies between $1,500 and $3,000 depending on age and class of ward has to be wholly paid for by the patient. The next major threshold is the “Claimable Limit” — a figure that is not easily researched. All it says on the above-linked site is that “Your Claimable Limit, or claim amount, is determined by the maximum limit applicable to each type of expenses, e.g. charges incurred per day of hospitalisation, surgical procedures, surgical implants, and approved specific treatments and outpatient treatments.”

Oh, wonderful, it’s so clear now.

pic_201308_44The excess portion of your hospital bill above this obscure Claimable Limit is all yours to pay.

I recently came across a migrant worker who suffered a head injury. He needed urgent surgery by a neurosurgeon to save his life and was for several days in intensive care. The total bill came to about $161,000. In his case, as a foreigner, none of these Medishield calculations apply, but his exclusion does not diminish the point I want to make: Suppose you meet with an accident like what he suffered, you’d be unconscious as you’re wheeled into a hospital, and when you wake up, you’d face a bill of that size. How much of that a Singaporean would get from Medishield is not something I can figure out, but I have a sneaky feeling that a good portion of such a massive bill would be above the Claimable Limit. Say Medishield pays half of such a bill; you’re still left with $80,000. You might get a heart attack!

That said, my rough exploration suggests that for someone in a B2 ward, Tiers 1 and 2 are rather narrow bands of $1,000 and $2,000 respectively, Tier 3 (i.e. requiring only 10% co-payment) appears quite wide, stretching up to maybe $50,000. If anyone can find a detailed table, please let me know.

Let’s use a more mundane example. Let’s say you have cardiac problems and need an angioplasty. Let’s assume you choose a B2 ward, and have to stay one day in intensive care followed by five days in the ward. I used the online calculator (provided by the above-mentioned Medishield site) to arrive at an estimate.

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As a percentage of the total hospital bill, Medishield will contribute about 41 percent. You pay about 59 percent, or $2,342.50. Is this reasonable?  This question should be part of the debate.

On the whole . . .

Despite our mainstream media singing in chorus what an “epochal”, visionary set of proposals Lee laid out, on closer examination, they turn out to be rather underwhelming. The chief impression one has is that all these should have been done long ago. What we’re doing is nothing earth-shattering, but merely to fix some glaring shortcomings of a system long throttled by an ideological determination to avoid a “welfare state”.

Even now, a big part of the cost of these improvements is going to come not from the common pool of taxation revenue, but from individuals’ Medisave accounts. However, that isn’t going to stop this government from taking all the credit, as if it’s entirely from their largesse.

32 Responses to “Healthcare safety net — improvements long overdue”


  1. 1 Rogueeconomist 22 August 2013 at 18:30

    Something I think that should be pointed out (in line with your analysis) is that enforcing universal Medishield coverage is effectively transferring the burden of payment for catastrophic medical bills for the poor, from the general taxpayer, to the CPF account holder. Why so?

    My assumption is that currently, if you are not well-off financially and you incur catastrophic medical expenses, it’s not your problem – it’s the Government’s problem. Why? Because – despite all the criticisms that have been laid at the health system – they won’t let you die simply because you can’t afford to pay. They will do what is possible to save you, and THEN, yes of course they’ll give you the bill.

    But that’s where the Government comes in. It’s simply unrealistic to expect that a large share of these uninsured Singaporeans who incur catastrophic medical expenses will ever pay anything close to 100% of their (even subsidised) bills. It won’t happen. Therefore, the bill will effectively be picked up by Medifund. Which is to say that the general taxpayer pays for it.

    Now, we move to universal Medishield coverage. This pretty much eliminates the need for Medifund to cover catastrophic expenses, since by definition it should be covered by Medishield. The only difference is who pays – the general taxpayer, or the CPF contributor?

    I’ll say that one advantage of this policy change, though, is that it could spare the poor from the rather painful task of having to essentially beg to have their expenses subsidized. It could also spare their relatives from much needless anguish about feeling as though they need to choose between the life of their loved ones, and their family’s life savings. (in reality, not a choice they have to make if they know what to ask for and how… but not everyone does)

    • 2 ape@kinjioleaf 24 August 2013 at 15:26

      My assumption differs from you.
      Those below mid-low income will tend to avoid any form of medical expenses. $8 out of pocket is significant to them, not to mention loss of income if they take MC if they’re on daily wage. To them, hospitals and doctors = $$$. In that sense, they’ll likely incur less of tax payers money.

      Mid and above but below rich do the balancing act – keep probing government for more help, at the same time, worried over if they’ll hit the suicide switch scenario mentioned by Alex. This group of people forms the major bulk relying on government coffers/tax payers since by numbers alone (60%-80% of our population?) falls within this group. Then again, they may not because they too will avoid costly treatment unless absolutely necessary.

      The top earners will probably not worry about medical expenses. They’ll buy their own insurances and any government subsidies is a bonus but they’ll definitely make full use of their entitlement.

      These are just my assumptions and my assumptions conclude that the poor don’t soak up government/taxpayers $$$.

      Whatever the case may be, we don’t know because the government is not telling. I don’t think they ever will because even a minister is unable to tell us how did he managed $8 out of his pocket for his own heart surgery.

  2. 3 Hawking Eye 22 August 2013 at 22:39

    An incisive analysis it is. The devil is indeed in the details but you have fleshed out some details to turn the spotlight on. It is destructive criticism at its best.

    Alex Au is indeed an adversary worth cultivating.

    I wish CNA (or Channel 5) can host a talk show to debate healthcare issues. The panel can include Health Minister Gan Kim Yong, Economic wizard and Finance Minister Tharman Shanmugaratnam, one two Healthcare Consultants and of course our own Alex. The idea is to get out the best for the packaging of the proposed new Medishield plan for average Singaporeans.

  3. 4 Lye Khuen Way 23 August 2013 at 08:01

    A Good read ! In case you wonder why it took so long, well, it must be something in the PM’s given name.
    LOONG. Extra long, no ?
    (Cannot resist poking fun at names, mine included !)

  4. 5 The 23 August 2013 at 10:01

    Alex – after your insightful analysis, don’t you think your topic heading is a misnomer. Improvements??? More like disprovements or deprovements, if there are such words – you know what I mean.

  5. 6 Silverfishy 23 August 2013 at 10:29

    I’m surprised you left out the Special account of the CPF. Currently the Special and Medisave accounts earn 4-5% interest a year and I bet that’s the highest risk free interest in the world today. Hence it makes sense to quickly accummulate funds in these accounts such that the interest alone is enough to cover the insurance premiums for the upgrade of the Medishield plans to provide’as charged’ coverage instead of being subject to’claimable limits’. But we shouldn’t wait until that happens before we upgrade the Medishield plan as our health status may not allow us to do so later. For the young and healthy upgrading their coverage is a no brainer since the premiums are much cheaper then anyway. Problem is it’s the lower income group that needs the upgrade most but they contribute the least to their Medisave account. There’s been on and off government top ups of Medisave accounts weighed in favour of the lower income group and more can be done here besides encouraging them to upgrade their Medishield plans.

    • 7 yawningbread 23 August 2013 at 11:38

      My rule of thumb is to keep diagrams simple. If some things are not going to be discussed in the text (in this case, I wasn’t going to touch on Special Accounts or Retirement Accounts), leave them out.

  6. 8 Aloysius 23 August 2013 at 11:13

    An aunt of mine was recently diagnosed with Thymoma Cancer, a kind of uncommon cancer of the Epithelial cells (secretion, absorbtion, transportation cells) of the Thymus, located in between the lungs near the heart. She visited a number of doctors from the public sector, from the National Cancer and then the National Heart Center, who couldn’t give her a definitive answer on the diagnosis. Two of the doctors seen gave conflicting answers onto what exactly was the problem. Later, she went to see a private doctor at Parkway Cancer Center, a private hospital.

    The doctor gave a a straight answer, ascertained the scope of the problem almost immediately, and gave proposed a solution. The difference of course, is its exponential cost of treatment. Luckily, after rummaging through her old documents, my aunt realized she was covered by insurance. Before that, she was on the verge of panicking because she couldn’t afford the better treatment.

    But is this reflective of the quality of medical treatment in larger society?

    If it is, there is a serious problem.

    If it is the case that medical treatment in the public hospitals, inhabited by doctors unwilling to prescribe the wrong treatment for fear of repercussions, or are generally not as competent and confident as doctors in private practice, then there is something wrong with the medical profession as we know it.

    Consider a person with a serious heart condition, worked hard all his life, but never accumulating much in savings because he is always paying for other things. His house, his children’s education, his other discretionary expenses. Now, this man goes to the public hospital and seeks treatment. His treatment is subsidized (substantially), and he gets a few answers. However, he has to spend 6 months queuing for his turn, 3 months testing his condition, 2 months before he gets the first treatment, and another 6 months for the follow up. In the process, his condition worsens, and he get a second heart attack resulting in a stroke, which requires even more treatment.

    This kind of scenario is no exaggeration. Because doctors in public hospitals are so overworked, they are often hard-pressed and pressured to serve their patients. They have to be careful, despite all these stressors.

    Meanwhile, doctors in private practices, paid the best who are also the best doctors available, have all the time it takes to treat and diagnose accurately wealthier, well to do patients.

    If it has become the fact in modern society that the medical profession has become like a business, where the patients who can afford the best treatment has easier access to it, then we really have to consider what the rest of society, many of who cannot even afford average treatment, are in for.

    The real contention is not so much that doctors have no right to turn their trade into something resembling a business. In a free society, perhaps they could argue and influentially affect it. The real question here is, what does medical knowledge and its consequent trade amount to in its role in society. Is it just a matter of economics?

    Aloysius
    visit me at http://www.musesg.com

    • 9 Eugene Tham 2 September 2013 at 11:43

      Your…….. statements are disingenuous and ignores the complexity of how healthcare is done.

      Regarding diagnosis, it isn’t surprising that a doctor, coming in after all the diagnostic labwork has been done is able to come up with a diagnosis faster, without the same hem hawing that earlier doctors have faster. After all, the grunt work and confusion has already been done.
      Bedside manner also plays a role here, since the perception by patients are affected by their experiences and how they’re treated.

      Your scenario on the other hand is exaggerated. While inefficiencies and the sheer case load means getting an appointment to see a doctor is a long process, triage as a principal still applies. The long wait times of a year is exaggeration.
      http://www.moh.gov.sg/content/dam/moh_web/Publications/Information%20Papers/2007/OP_Waiting%20Times_Ophthalmology-07.pdf
      Median waiting times for Ophthalmologists is around 55 days for a new appointment.

      Cardiology used to be a different ball game, but advents in IT and revamping of appointments has meant that patients are able to secure diagnostic tests and then be seen by the doctors in a shorter waiting period.

  7. 10 Jasper 23 August 2013 at 11:44

    There is an ideological disconnect between the government and its people. Most of the MPs are rich businessmen, directors, etc. Do you think they would approve anything that would raise the tax for the rich? No right? Therefore the mentality is you pay your own bill through your own CPF. Government will NEVER give you real subsidies. The only real subsidies they will give, will always be channelled to businesses first and trickle down to the rest, if you can catch any drops at all.

    So, Alex, let’s not waste time debating this because the cows will never come home. See, the only way forward lies in the hands of the next government. People have to realise this disconnect and be persuaded to vote for opposition. The brainwashing has to turn the other way. Our only hope is to get more people to do the washing in the opposite direction. Then, when enough people are washed off white, will there be any hope for a humane healthcare policy to take place. For a start, have you tried to raise the visibility of your views besides blogging? Would you consider joining a political party, or maybe run for an election?

  8. 11 faber 23 August 2013 at 13:29

    Hi yb,

    I agree with your conclusion on the further tweaks to a fast breaking system. And before details are provided, it looks like tweaks to such tweaks may have to be “discussed” over the next year before implementation,

    My point is that all these proposed changes are hardly ground shaking. If one look closely enough, as you have, these only confirm the fundamental political ideology of the ruling government that is unmoved, unchanged, unshaken, and written in stone.

    As rogueeconomist pointed out above, Medisave Life would make Medifund obsolete and pile the additional costs from taxpayers to CPF contributors. This is very in line with the government’s ideological aversion to social welfare and progressive tax regime.

    Medisave Life is no different and clear confirmation that the spots on the leopard are unchanged. It is very telling when the PM said that the scheme has to “break-even”. This is fine, but he stopped short to say whether payments would be regressive or progressive. However, it would be the former.

    While CPF contributions are progressive, Medishield (Life) premiums are regressive. Older and low-income Singaporeans and their family members would not have sufficient CPF/Medisave balances to pay for the expensive yearly premiums. Any handouts/assistance would be ‘income-tested”. While true income-testing is progressive per se, in Singapore such testing only alleviates the regressive-ness of the scheme. So, net result is still regressive-ness. And the ruling government would have another “carrot” to dangle to voters before election – handouts/top-ups/rebates/assistance in healthcare. If this is true, and I think it is, it is repugnant.

    Instead of taking bold and fundamental steps/shifts to move towards a universal healthcare system funded by progressive general tax revenues, we really are now looking at a proposed Medishield Life scheme that would universally opt-in all into a regressively funded health system.

    Simply put and taking out all the jargons of CPF contributions and premiums, Medishield Life when implemented boils down to a universal health scheme funded regressively by Singaporeans, whether old, poor, young or infant, disabled, handicapped, jobless, sick, ill or otherwise.

    faber

    NB: To those who questioned free universal health care system funded by general tax, just look back to history. Singapore started from that system.

    • 12 faber 23 August 2013 at 16:49

      Correction:- CPF contributions are in fact regressive. This is due to the caps on contributions for higher income earners and annual caps for salaries/bonuses. So, in terms of percentage over gross income low wage earners pay a much higher percentage compared to high income earners.

      faber

      • 13 faber 23 August 2013 at 22:33

        Roy Ngerng just published an excellent blog post on Singapore taxes (income tax + CPF). See http://thehearttruths.com/2013/08/23/how-are-taxes-built-for-the-rich-in-singapore/. Its a long one, but well worth the read.

        He concludes that “…In fact, Singapore most probably have the most regressive taxes in the world……”. I could not agree more with his findings. Two examples to illustrate this conclusion further.

        Roy’s analysis left out bonuses in his computations for a simpler illustration. We all know that top civil servants and politicians are paid bonuses based on performance and KPIs. In the past few years, it was rumored that such GDP bonuses hit as high as 12-18 months. As pointed out by Roy, monthly CPF contributions are capped. So high income earners (> $5,000 pm) do not pay more than the maximum CPF contributions monthly.

        What is less well known is that there is a annual cap on CPF contributions. If a high income earner gets a huge annual bonus, the bulk of these do not attract CPF contributions. And as highlighted by Roy, income tax is capped at the highest tax bracket of 20%.

        Put it in another way, a higher income earner (say $20,000 pm) pays taxes & CPF the same rate of taxes/CPF as a lower income earner ($5,000 pm) for the first $5,000. But a lot less taxes/CPF for the balance $15,000. This is the regressive-ness in the system.

        Another example of regressive-ness is found in the corporate tax structure and dividend payments. More than 10 years ago, tax on dividend was eliminated with the abolition of input franking credits. If a low income earner ($5,000 pm) earns all his income from dividends, he is effectively paying net 17% of tax, as this is the flat corporate tax rate and dividends are paid from after tax profit. If a very high income earner ($20,000 pm) earns all his income from dividends, this person is still paying the effective net 17% of tax. This is regressive.

        There are many other examples of such regressive nature/characteristics in the tax system. If we were to take all these into consideration, Roy’s conclusion is the TRUTH.

        faber

      • 14 yawningbread 24 August 2013 at 11:53

        I have doubts about Roy Ngerng’s analysis. He treats CPF contributions as equivalent to the USA’s social security payments. This is erroneous. Social security is paid into a common pool and is thus like taxation, albeit earmarked for specific purposes. CPF contributions do not go into any common pool (save for the bit that is compulsory Medishield insurance premiums) and is therefore more like forced savings. It is misleading to conduct an analysis that treats CPF like taxation when it is not.

      • 15 faber 24 August 2013 at 20:46

        Hi yb,

        Thanks for your reply and an opportunity to comment further.

        I think one should not be too hasty in dismissing Roy’s analysis as misleading or erroneous. I would encourage him and others like you to continue to produce thought-provoking articles. I am not expecting perfect analysis, given lack of information, etc.

        Roy’s piece is quite upfront with the assumptions made, information gaps, limitations, etc. Any discerning readers would know that CPF are “forced savings’ and “not taxed into a common pool”. Terminologies aside, such analysis are absolutely necessary to reveal the true nature of various schemes implemented by politicians. More so, from a government that is so prolific in coming out with new schemes/plans with 3-letter names and such.

        For example, you agree that the Medishield premiums go into a “common pool”, not a general tax pool. You would also agree that the proposed higher Medishield Life premiums would also go into a bigger “common pool’. You must not forget to include the larger CPF Life contributions (from CPF minimum sum) also go into a much bigger “common pool”. This latter is akin to social security payments, albeit designed to be regressive in nature.

        If you are a low income earner (< $5,000 pm) supporting a young family with maybe older parents, CPF contribution (for CPF Life/minimum sum and Medishield Life) is so tax-like, with no chance of ever seeing a meaningful withdrawal amounts at retirement age. Higher income earners do not look to CPF Life (which are too basic for them) for their retirement. Their worry is whether their other retirement investments are Ponzi-like or not (CPF or otherwise). Small part of these retirement investments are "forced savings" in CPF.

        An honest government having the trust of the voters would call a spade a spade. They do not have to resort to obfuscations – with complicated, bewildering, convoluted schemes – that hide their true intent and fundamental leanings.

        I wish you well.

        faber

  9. 16 CC 23 August 2013 at 13:41

    Have you read the “glowing” report by Professor William Haseltine below, and the counter-piece by Jeremy Lim? There are some figures that could help you extrapolate your insights further. Thanks for a great piece, as usual!

    http://www.accessh.org/Pdf/Affordable%20Excellence%20the%20Singapore%20Healthcare%20Story.pdf

    http://insightshealthassociates.wordpress.com/2013/08/14/myth-or-magic-the-singapore-healthcare-system-out-next-month/

  10. 17 Chanel 23 August 2013 at 13:59

    Alex,

    Thanks for the great article!! You sum it rightly that parsimony is this government’s guiding star and will always be.

    Why did it take the government to come up with the healthcare changes? It took a general election (in 2011) and 2 by-elections (Hougang and Pungol East) before the ruling party decided that the people are really furious with the state of affairs here. We should thank the various alternative political parties for the latest policies change, for without them contesting, we would still be suffering.

    Yes, Medisave is the people’s money, but the way the government (and supported by the mainstream media) say put things, they want to make us think/believe that Medisave is money from the government. Relaxing the usage of Medisave is NOT a form of government subsidy, so there is nothing to be grateful for.

    On MediShield, you forgot to mention that, apart from co-insurance payments and deductibles, there are claims caps applicable for all medical procedures. Precisely because there are so many hoops a patient needs to jump over, the out-of-pocket expenses can be very high…..frighteningly high.

  11. 19 Francis 23 August 2013 at 20:23

    I have written about insurance companies raising premiums as we age and the cap of $800 that is allowed. We have pay cash for the difference. Our premiums jump like grasshoppers but the the cap remains no matter what. The buggers do not want to listen. You get the same stoic reply each time. You are not allowed to want to have better coverage with your own money. It’s shamless and obscene what they do. Yesl the chorous of praise and back slapping follows. His Masters Voice everything else is drowned out.
    It’s so sad.

    • 20 jason 24 August 2013 at 09:28

      We weren’t even allowed to pay for a rider to cover co-insurance and co-deductibles with our own Medisave! This is not even stated in the CPF website! You have to find it out only if your insurance agent is upfront with you.

    • 21 jason 24 August 2013 at 09:36

      Further, in all my other insurance plans, the premiums are fixed. I know what I will be paying 20 years down the road. In Medishield, I have no such assurance. I don’t know when they are going to raise the premiums or change the terms in my policy. This goes against the spirit of insurance, which is about transferring my risks to the insurance company. Where got such a good deal in the outside? This government is afraid to take risks? Or cannot forecast the future?

    • 22 Stand Up and Be Counted 24 August 2013 at 11:47

      I echo Chanel’s and Francis’ sentiments on all the restrictions and caps in utilising our Medisave to pay for our own medical expenses resulting in extremely high out-of-pocket expenses, both from our MediSave and in cash. Due to the all the withdrawal limits put in place, one is almost certain to have to fork out cash despite having a healthy Medisave balance.

      The MediShield deductible is also high, starting at $1,000 for a Class C patient previously and it has since increased to $1,500 w.e.f. 1 March 2013 under the Ministry of Health’s initiative to provide enhanced MediShield benefits to Singaporeans and PRs. Needless to say, they increased the premium too. In my case, it went up 41%, from $314 to $444!

      This is our government’s doublespeak at work again, everyone has to pay a lot more premium for this so-called enhanced MediShield coverage yet the deductible is increased by $500 across the board, that’s a 50% increase from the previous base. Does this make sense?

      The $800 cap on premium payment doesn’t make sense too. Why would any compassionate government make the elderly pay in cash when there is enough in Medisave to pay for the premium in full?

      The front-loading idea that is being floated around these past weeks is yet another ingenious scheme to increase its citizenry’s burden by contributing to a national medical tontine fund at an earlier age

      I have since learned not to take the government’s words at face value anymore as they are always painting a rosy picture to make themselves look good and compassionate.

      We have amassed a huge reserve which is disproportionate to our population size yet instead of stepping up to the plate and providing more social spending for its ageing citizens, the government keeps tweaking the policies to ensure that the citizenry is “disciplined” to bear an ever-heavier burden, at inflation-adjusted rates no less!

  12. 23 Megaphone 24 August 2013 at 04:17

    A major cause of high medical cost is the limited numbers of medical students trained by local universities. Since the 80s to recent years, NUS was the only medical school and number of new doctors trained was highly limited to protect the trade. Annual intake was stagnant around 200 students for many years while the population growth exploded.

    The tight doctor manpower situation is a direct result of years of protecting the medical trade while population doubled. Now the country either import a lot more foreign doctors or hold the population steady while the new medical schools churn out the required number of doctors in the coming years.

    What foresight does this highly paid government has?

    • 24 Natisha 24 August 2013 at 15:37

      Another is the conversion of Singapore into a medical hub. It puts a strain on our resources, particularly good doctors and nurses. Many doctors left for private practice, leading to a fall in quality of healthcare in our public hospitals. This is POOR POLICY PLANNING. LHL and gang should step down. He fail us Singaporeans. He is not fit to be a leader.

  13. 25 sebastian liew 24 August 2013 at 08:07

    I hope govt cn allow insurance to pay for complementary medicine such as naturopathy, phytotherapy, homeopathy and chiropractic medicine. Many are seeking cm for wellness and prevention. Prevention is better than cure.

  14. 26 patriot 24 August 2013 at 11:45

    Hi YB,

    Thank you for taking your time to analyse this “social safety net”. Based on what have been said about the “epic-ness” of the changes in the G approach and mindset in the papers and the PAP internet brigade, any clear-minded (as opposed to the naive and/or hopelessly hopefuls) person would know the devil is in the details. And whatever details you have pointed out and we ourselves could find out, suggest the “epic-ness” is mere fluff.

    Perhaps, like one of the above reader suggest, let’s not waste time on online debate – your actions in politics will be very well-supported and received.

  15. 27 jack 25 August 2013 at 21:27

    Details will come.
    Patience is a virtue

    • 28 The 27 August 2013 at 16:20

      Errmmmm, the long suffering patients have been waiting too long. Not sure if some of the patients can survive the wait.

      Which will prevail – patience or patients?

  16. 29 GoonDoo 30 August 2013 at 17:24

    Amidst all the chest pounding & drum beat, I agree with Alex that:
    - the characterization of these slew of changes as being ‘manna from heaven’, is entirely disingenuous. Universal health care coverage should be available to all citizens of any country that has the means to provide it. Its is a RIGHT, not an entitlement to be doled out at the government’s largesse. Why weren’t these measures introduced sooner rather than now?

    - the citizens have to collectively continue to have to pay a substantial amount from their pockets, through Medishield Life to fund most of these changes.

    - the government continues to adopt an approach that ‘targetted’ help rather than universal help, is the correct approach. As Alex mentions this ‘drip from the tap’ approach does not help the majority of citizens.

    What would be more laudable is for the government to target REDUCING the out of pocket expenses of its citizens for total healthcare spend from 54% (the highest in Asia being Sg)* to say a target of 30%. Setting this bench mark will spread the benefit wider, yet does not detract from the basic principle of personal responsibility. Now this would be something I’d applaud…

  17. 30 Eugene Tham 2 September 2013 at 11:29

    Regarding the comments about the PM lack of details, it is a tad unfair to bemoan the lack of supporting details in the PM speech. The National Rally as an avenue served primarily to deliver the PM and government new policies and broad action plans/vision.

    What should have followed was a more detailed policy plan, something that has not been forthcoming other than a public discussion soon. http://www.todayonline.com/singapore/medishield-life-paying-less-large-hospital-bills-possibility

    I would mention that some of the concerns mentioned, such as raising claimable limits, removing lifetime limits has been mentioned, although Minister Gan statements about ‘indicative ranges’ for premiums suggest that the data is still being gathered and analyzed.

    Similarly, a cynical view of Obamacare is ingenious, considering that the advent of Medishield has already given Singaporeans comparable, if not superior insurance coverage compared to the States. Insurance coverage by the general populace is significantly higher than the states and the provision of a public option changes the matter significantly.

    Of course, one SHOULD point out that the US has had Medicare for its elderly for decades, a policy that Singapore, despite the current administration refuses to endorse. If anything, comparing a national insurance scheme as catch-up is misleading, as it ignores the comprehensive government aid the US gives for Medicare vs our non existent programs. Medishield Life is hardly comparable to Medicare.

    My last point is that for all the ‘revolutionary’ hype being protrayed in the media, the media and co has ignored that these were all basic, evolutionary demands made from healthcare professionals, economists for the last decade and is simply a much needed progression from allowing Medisave to be used for chronic disease management. Indeed, both PM Lee and Minister Gan mentions the report and its impact on their decision.
    One can also imagine that the same old tired arguments regarding healthcare savings being depleted will be brought up during the discussion next year, all ignoring the need for true radical, revolutionary change to healthcare funding.

  18. 31 Just my opinion 3 September 2013 at 23:30

    Why the deductible rises for those over 80 year old? They pay higher premium and more likely to incur higher medical cost. Hate to say this, but insurance companies don’t exist for charity purposes. Insurance companies did their calculations and polices are certainly not favourable to the elderly.

    http://www.income.com.sg/insurance/EnhancedShield/coverage.asp

    If elderly were to benefit from any further changes of polices, this is one area where the Government should review again.


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For an update of the case against me, please see AGC versus me, the 2013 round.

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