This is part 3 of theonlinecitizen's 3-part focus on healthcare, written by Leong Sze Hian.
Looking for the Substance of subsidies
The Ministry of Health's website touts the fact that subsidies for subsidised patients have been rising from $560 million in 1997 to $1.39 billion in 2005. However, increases in subsidies should never be looked at in a vacuum: they need to be viewed in the context of rising healthcare costs. This is especially relevant in the context of the poor.
For example, if healthcare costs rise by 10 per cent, and subsidies also increase by the same amount, the net impact on the poor is zero.
Thus, notwithstanding rising subsidies, the poor were most affected as healthcare spending of the lowest 20 per cent of households by income, had the highest increase of 81 per cent among all items of expenditure from 1998 to 2004.
This increase is further compounded by the decline in average monthly household income of this group by 3.2 per cent a year from 1998 to 2003.
A slew of changes in healthcare policies in recent years may have contributed to rising healthcare costs for the poor, such as the 9 per cent increase in polyclinic fees to cover renovation work; no more free treatment for infectious diseases like dengue fever and chicken pox at the Communicable Disease Centre; increase in MediShield deductible and premiums; maximum waiver of only up to 60 per cent for non-air-conditioned 6-bedded ward under Medifund; means testing for disabled care; means testing for community hospitals elderly care, etc.
Means testing borders on the stingy: means testing since 2000 for community hospitals elderly care, starts at $301 per capita income. How can a family with a per capita monthly income of $301 be considered not poor?
According to the World Health Organisation's (WHO) World Health Report 2004, Singapore's per capita government expenditure on health, at an average exchange rate, fell gradually from US$365 (S$577) in 1997 to US$274 in 2001.
The WHO Report 2005 showed that Singapore's general government expenditure on health - as a percentage of total expenditure on health - declined gradually from 41.6 to 30.9 per cent from 1998 to 2002.
General government expenditure on health as a percentage of total government expenditure also dropped from 8.7 to 5.9 per cent for the same period.
With over three per cent of Gross Domestic Product (GDP) spent on healthcare, I understand that Singapore's healthcare spending over GDP is one of the lowest in the world.
The poor are not interested in the debate or statistics on healthcare, but rather the issue of affordability and whether healthcare will continue to be a rising financial burden.
Healthcare expenditure: cutting spending, cutting corners?
The media has reported that there will be no fee and prescription subsidies for foreigners at polyclinics from next year, and that subsidies for permanent residents will also be cut by 50 per cent.
According to the Department of Statistics, foreigners number 753,400 out of the total population of 4,240,300.
If 10 per cent of the resident population are permanent residents, according to the Total Population by Residential Status, Census of Population 2000, the total number of foreigners and permanent residents should be 1,102,090.
Therefore, a cost-cutting policy change as in the case of the polyclinic fee subsidy may affect about one in four of the population.
From 1998 to 2003, about 97 per cent of total marriages were resident marriages, which refer to marriages where either or both the groom and bride are residents. I believe there are many Singaporeans with spouses or dependants who are not citizens.
Therefore, the removal and reduction in fee subsidies may add to the financial strain of these Singaporeans, too. The fact that attendances at polyclinics had increased by 14 per cent from 3,337,300 to 3,791,700 from 2003 to 2004 may indicate that more people have been turning to polyclinics because of the lower fees they charge.
Other recent cost-cutting measures like the closure of night polyclinics and the termination of free treatment for some infectious diseases at the Communicable Disease Centre, and the mandatory increase in deductibles for CPF Shield medical insurance plans, may also increase medical costs for the poor.
Consequently, poorer residents may become more inclined to delay or avoid seeking medical treatment, or resort more to self-medication.
Since Total Government Health Expenditure per person has already declined by 16 per cent from $584 to $491 from 2003 to 2004, do we really need to cut spending further, to the extent of increasing the burden on lower-income Singaporeans whom I believe have relatively more non-citizen dependants than those of higher income?
According to the Economist magazine (Nov 19), a Chinese 'government survey published last year, said nearly 30 per cent of city residents recommended for hospitalisation refuse to be admitted with some 70 per cent citing the cost'.
This highlights how relentless cost-cutting in healthcare may affect the poor.
Medical costs will also go up for the few hundred thousand Singaporeans who employ domestic maids and foreign workers. It has been said that 'with the subsidies removed, it makes sense for employers to buy medical insurance for their foreign workers'.
The cheapest medical insurance premium that I can find to cover my maid for outpatient treatment is quite high at $250 a year for a female below age 31, and there are also co-payments of $5 per outpatient visit, $15 per specialist care visit, and 10 per cent of the total eligible bill for B2 hospital care.
The annual premiums increase to $350 and $460 for those above age 30 and 40 respectively.
This change in fee subsidies may, therefore, actually affect more Singaporeans than foreigners, because in many cases, it is Singaporeans who will ultimately be footing the bill.
As the Health Ministry is also looking at withdrawing government subsidies on hospital care for foreign workers, medical costs may increase further in future, for Singaporean employers and Singaporeans with non-citizen dependants.
Waiting till the cows come home
It was reported that keeping medical records electronically saved the National Skin Centre $237,000 in labour costs at the end of the year, and cut patients' waiting time. The media also reported that two hospitals here retrenched 108 workers, presumably to cut costs.
When you go to a hospital to seek treatment for a dental problem, you may be told that, as it is not something which warrants immediate attention, you may have to wait for up to nine months if you pay subsidised fees.
However, if you opt to pay the non-subsidised rate, you can be treated immediately.
The same goes for eye operations. As the question of whether an ailment is serious enough to require treatment sooner rather than later is sometimes subjective, patients who do not want to take a chance may opt to pay the full rate.
Those who cannot afford or do not wish to pay the full rate may risk a deterioration in their condition. As a matter of principle, should the priority of treatment not be based on one's health condition, rather than ability to pay more?
Is this fair to the poor and less economically well-off?
What if the rest of the health-care system, such as specialists, polyclinics and general practitioners, follow the example of the dental and eye centres?
Hypothetically, if one's health condition worsens and irreversible damage is done because of the delay in treatment, can the medical facility and medical practitioner be held liable?
The Health Ministry should examine the ways in which hospitals manage their financial objectives and resources.
Which is a bigger problem that should be given priority: cutting waiting time by 30 minutes, or letting those who cannot pay wait for months?
Summary to this 3-part essay
The Ministry of Health (MOH) responded (ST, June 2) to Straits Times HEALTH Correspondent Salma Khalik's article "Demand for C-class beds at hospitals up sharply", ST, June 1), with "(she) observed that Class C patients now formed 40 per cent of public-hospital admissions when it was 27 per cent five years ago.
Perhaps alarmed by this observation, she concluded that this has 'put a strain on hospital finances' and speculated that this was the reason for (a) hospitals raising fees, and (b) the Ministry of Health (MOH) contemplating means-testing in hospitals".
The MOH's letter ended with "We hope that ST can do its part to help educate, inform and reassure Singaporeans. It is not helpful to alarm the public unnecessarily".
Singaporeans may like to give more feedback to the Government on the varous issues raised in this 3-Part article "The Healthcare System: Uniquely Singapore, F1 or F9?".
As such issues are raised in the media practically every month over the last two years or so, it should not be like a school debate between two opposing parties - the proposition and the opposition - between the MOH and those who ask questions or give suggestions to improve our healthcare system.
We are all on the same side
As we are all Singaporeans.
About the author:
Sze Hian has 5 degrees and 13 professional qualifications. A Wharton Fellow, alumnus of Harvard University and the United Nations University International Leadership Academy, he has served as Honorary Consul of Jamaica, President of the Society of Financial Service Professionals, Representative of the Inter-American Economic Council, Chairman of the Institute of Administrative Management, and founding Advisor to the Financial Planning Association of Indonesia.
He has been invited to speak more than 100 times in over 15 countries on 5 continents, authored 3 books and quoted over 700 times in the media.