FIRST ROUND

U.S. vs. Singapore: A Mix of Ideas

The United States has a mix of clashing ideas: private insurance through employment; single-payer Medicare mainly for those 65 and older; state-managed Medicaid for many low-income people; private insurance through exchanges set up by the Affordable Care Act; as well as about 28 million people without any insurance at all. Hospitals are private, except for those run by the Veterans Health Administration.

Singapore has a unique approach. Basic care in government-run hospital wards is cheap, sometimes free, with more deluxe care in private rooms available for those paying extra. Singapore’s workers contribute around 36 percent of their wages to mandated savings accounts that may be spent on health care, housing, insurance, investment or education. The government, which helps control costs, is involved in decisions about investing in new technology. It also uses bulk purchasing power to spend less on drugs, controls the number of medical students and physicians in the country, and helps decide how much they can earn.

Singapore’s system costs far less than America’s (4.9 percent of G.D.P. versus 17.2 percent). Singapore doesn’t release the same data as most other advanced nations, although it’s widely thought that it provides pretty good care for a small amount of spending. Others counter that access and quality vary, with wide disparities between those at the top and bottom of the socioeconomic ladder.

Our pick: United States, 4-1

AARON: United States. Singapore is intriguing, because it’s so different from other systems. But its huge mandatory savings requirement would be a nonstarter for many in the United States.

My comments: “Singapore’s workers contribute” up to 10.5 “percent of their wages to mandated savings accounts (Medisave account) that may be spent on health care” and “insurance””.

This is I believe in a sense – probably the highest national health insurance contribution (pre-pay basis) in the world.

CRAIG: United States. Singapore, a scrappy underdog, has become a fan favorite of conservatives. But its reliance on health savings accounts is problematic: When people are spending more of their own money on health care, they tend to forgo both effective and ineffective care in equal measure.

My comments: Healthcare spending share: Public 33%, Private 67%?

According to the article “Subsidise MediShield premiums for needy, says NCMP” (Today, Nov 13, 2013) –

Will increase Government’s share of healthcare spending from 33 to 40%?

“In response, Health Minister Gan Kim Yong said the Government will shoulder a greater proportion of healthcare costs, from the current 33 percent to 40 percent or more. It is reviewing the subsidy structure at Specialist Outpatient Clinics and looking to help the lower-income and pioneer generation of older Singaporeans to pay for MediShield Life premiums, so they need not worry about healthcare in their old age.”

Self-contradictory?

Don’t you find it somewhat self-contradictory to say that “the Government will shoulder a greater proportion of healthcare costs, from the current 33 percent to 40 percent or more”- and yet on the other hand say that Medishield premiums will have to increase, Medisave contribution rate will have to increase, etc?

Increased Medishield Life, Medisave – have to increase some more?

We have been hearing the same rhetoric in recent years that the Government will spend more on healthcare – yet at the same time, we keep increasing healthcare costs (drugs are priced at cost including overhead and operations costs, medical procedures, etc), Medishield Life premiums and Medisave contribution rates, etc?

So, if you keep increasing everything on healthcare, what exactly does “will increase” the Government’s share from the current 33 to 40 percent really mean?

No timeline for “will increase”?

Also, shouldn’t there be a target timeline for the increase – such as to 35 percent by the end of which year, 40 percent by the end of next year or something?

Will there be periodic updates in the future on the progress of this “will increase”?

Otherwise, how do we hold the Government accountable on this promise to increase?

As an analogy, if I tell you that I will help you more, but I never say by when – then what good is it to you in reality?

AUSTIN: United States. It’s hard for me to overlook Singapore’s lack of openness with data.

Comment: Transparency and accountability of healthcare statistics and policies have historically been a contentious issue in Singapore.

For example, Medisave may not be protected from the hospital creditor?

According to the CPF Board’s website,

“For a member who passed away on or after 1 July 2006 during his/her hospitalisation, he/she can use his/her Medisave savings to pay for the last inpatient hospital bill in full, without being subjected to the existing Medisave withdrawal limits. This is because the need to save for future healthcare needs is no longer relevant”.

http://mycpf.cpf.gov.sg/CPF/my-cpf/Healthcare/PvdHC3.htm

Hospital also a creditor?

Whilst this helps both public and private hospitals to recover their fees from deceased patients, it may deprive the deceased’s dependents of much-needed CPF funds.

With the Basic Healthcare Sum (BHS) currently at $52,000, this may be the maximum amount that a deceased’s dependents may be deprived of.

As the BHS increases every year, this amount may increase in future years.

For example, if a hospital is owed say $52,000 and the medical fees are not eligible to be paid under the existing Medisave withdrawal limits and eligibility rules – under the old rules, the hospital would not be able to claim the amount from the deceased’s Medisave balance because CPF is protected from creditors, including hospitals.

Try not to die in a hospital?

Therefore, if you are in such a situation (no other assets that the hospital as a creditor can claim, other than your CPF and HDB) – try not to die in a hospital, so that your Medisave account balance will be protected from any debts owing to the hospital, because you have already exhausted your Medisave withdrawal eligibility and withdrawal limits.

When this rule changed in 2006, was any announcement made in Parliament or in the media?

ASHISH: United States. The lack of data in Singapore is a problem, and it had higher rates of unnecessary hospitalizations and far higher heart attack and stroke mortality rates than the United States. Plus, the U.S. has a highly dynamic and innovative health care system. It is the engine for new diagnostics and treatments from which Singapore and other nations benefit.

My comments: As to “The lack of data in Singapore is a problem” – for example – according to the CPF Board’s annual report 2016 (page 141) – the MediShield Life Fund (2015) – Total financial assets through profit or loss – was $2.7 billion.

According to the article “Parliament: Nearly half of MediShield Life claims paid out went to Singaporeans over 65” (Straits Times, Nov 8, 2016) – “In total, more than $600 million was paid out under the universal insurance scheme during this time period. This is up from the $307.5 million disbursed over the same time under the old scheme.

“Overall, for older Singaporeans, MediShield Life paid out an average of $1,639 per claim,” Mr. Gan said. “(This is) a 15 percent increase from $1,425 per claim under MediShield.”

Premiums increased 153% against claims increase of 100%?

As to “between last November and September this year – a total of $614.3 million (claims) was paid out” and “over the same period in the previous year, $307.5 million was disbursed for 291,500 claims – premiums rose, mounting to $1,736 million in the 11 months from its launch – compared with $685.7 million in the same period the previous year – almost half was paid by the Government, largely as premium subsidies” (“MediShield Life helps more people a year on” (My Paper, Nov 1) – does it mean that premiums increased by 153 per cent ($1,736 divided by $685.7 million) against the increase in claims payout of 100 per cent ($614.3 divided by $307.5 million)?

Premiums increased 2.5 times against claims payout increase of 2 times?

So, does it mean that premiums increased by 2.5 times against the claims payout increase of 2 times?

What happens when transitional premium subsidies end?

Although “almost half was paid by the Government, largely as premium subsidies” – when the decreasing transitional premium subsidies end after four years – will the premiums to claims ratio still be higher than before – as the data is now showing?

44.8% claims to premiums ratio in the previous year?

Also, does it mean that the claims to premiums ratio over the same period in the previous year was 44.8 per cent ($307.5 million claims divided by $685.7 million premiums)?

35.4% claims to premiums ratio from its launch?

And the claims to premiums ratio in the 11 months from its launch was 35.4 per cent ($614.3 million claims divided by $1,736 million)?

Claims to premiums ratio dropped from 44.8 to 35.4%?

Why is it that the claims to premiums ratio has apparently, dropped from 44.8 to 35.4 per cent?

51,000 residents have outstanding premiums?

“In response, Minister of State for Health Chee Hong Tat said that as of September, around 51,000 residents have outstanding premiums due, which amount to around $12.8 million. This represents about 1 per cent of all members and includes overseas Singaporeans as well as those who cannot be contacted.

“We are reaching out to remind Singaporeans and help them with their MediShield Life premiums,” Mr Chee said. “The Government has provided subsidies to help Singaporeans pay for their MediShield Life premiums.””

200% capital adequacy ratio?

“The ratio of the MediShield fund at the end of 2012 was 165 per cent. The fund has set a target ratio of 200 per cent (required capital adequacy ratio is 120 per cent), which Health Minister Gan Kim Yong has said is in line with industry best practices.”

$2.4b MediShield fund’s assets?

In this connection, according to the report on the “MediShield Fund“ – “As at end-2013, the Fund assets stood at $2.4 billion.

Over the past five years, on average, about two-thirds of the MediShield Fund comprised reserves to fund the expected scheme liabilities.

The remainder is capital which meets the same standards required of other insurers under the Monetary Authority of Singapore (MAS)’s risk-based capital framework”.

What about the accrued % since inception?

In Table 1 – the insurance premiums of $372,132, 385,563. 404,732, 421,297 and $770,039 million, from 2009 to 2013, adds up to a total of $2,353,763 billion shown in the same table.

So, does the “Fund assets of $2.4 billion” include the interest that should normally accrue on the annual surpluses of premiums less claims, every year since the MediShield scheme started?

Surpluses before 2009?

Also, does the “Fund assets of $2.4 billion” include surpluses prior to 2009?

We have calculated from the table, that the claims to premiums ratio is 59 per cent (claims $1,395,382 billion divided by premiums $2,353,763 billion).

Most profitable scheme in the world?

Does this make MediShield the most profitable national health insurance scheme in the world?

Need 80% more?

Why would a national health insurance scheme that will ensure 100 percent of the population (including those not residing in Singapore) which has been made compulsory for every resident, need to have a capital adequacy ratio that is 80 percent more than the expected minimum for private insurers?

Make actuarial report public?

Can the actuarial report for MediShield Life be made public?

By the way, are there any countries in the world, whereby the mandatory national health insurance scheme is apparently, making money, whereas the private insurance schemes are incurring losses?

UWE: Singapore. It’s hard to defend the messy American health system, with its mixture of unbridled compassion and unbridled cruelty.