The Singapore Democratic Party (SDP) has proposed a single-payer universal insurance scheme as a more financially viable alternative to the current 3Ms – Medisave, Medishield, and Medifund – for all Singaporeans.
The proposed National Health Investment Fund (NHIF) – which was presented by the Party’s Chairman Paul Tambyah and its Central Executive Committee member Khung Wai Yeen at the SDP office in Ang Mo Kio on Sat (11 May) – intends to provide financial coverage for “compulsory basic health, accident and pregnancy” for all Singaporeans and permanent residents residing in Singapore for more than six months annually.
Funding the NHIF will entail an average monthly contribution of S$50 from every Singaporean via their Central Provident Fund (CPF) accounts.
The rest of the healthcare budget under the NHIF will be subsidised by the government via taxes.
“This payment from a single source rather than multiple sources from the 3Ms eliminates the present complicated subsidy system,” said Prof Tambyah.
Under the NHIF, Singaporeans will only pay 10 per cent of the total hospital bill, with a yearly cap of S$2,000, while the remainder will be subsidised via NHIF.
Prof Tambyah noted that in the 1960 and 1970s, Singapore had a “single-payer healthcare system”, noting that “some people think that is Singapore’s golden era of growth and development” throughout which the Republic has already “achieved very high standards of healthcare”.
Citing part of sovereign Singapore’s former Health Minister Ahmad Ibrahim‘s speech to a team sent by the World Health Organisation’s Regional Office for the Western Pacific, Prof Tambyah highlighted the Minister’s speech:
“The medical services have now become predominantly, though not entirely, a responsibility of the Government, with the mass of the population entitled to it without personal cost. The medical personnel are salaried employees of the Government, and most of the hospital facilities are governmental – all these are financed from general revenues. Private practice persists for a small upper-income segment of the population, especially in the City Area.”
The team was sent from the Philippines to Singapore to study the Republic’s healthcare system at the time.
“Unfortunately in the 1980s,” with the introduction of Medisave in 1984, said Prof Tambyah, “healthcare was viewed not as an essential, but as a commodity – as something that had to be traded, and something that can be seen as an industry for profit”.
Referring to the relatively low infant mortality rate in Singapore at the time in comparison to that in the United Kingdom and the United States, Prof Tambyah said: “In 1981, with a single-payer healthcare system, Singapore had better health outcomes than the UK and the US, which at that time were much richer than we were.
“So I don’t think it’s true to argue that a single-payer healthcare system is going to result in worse healthcare for Singaporeans, because we know that in the past, we were able to do it.”
Prof Tambyah pointed out several major issues with a privatised, “very commercialised” public healthcare system such as the one Singapore currently has, among which is rising inequality in Singapore society.
“We’re not talking about luxuries here. What we are talking about here is life and death. We’re talking about keeping yourself healthy and alive … And the statistics are pretty stunning,” he said.
Citing statistics from the National Registry of Births and Deaths, Prof Tambyah observed that the average age of death for Malay Singaporeans is seven years younger than Chinese Singaporeans, which is, in his view, a “striking difference”.
He also argued that there is also data that suggests that the results are not a result of ethnicity, but more of a function of “economics”, as he pointed out, based on Prof Wong Tien-Yin’s and colleagues’ research, that Malays in the high socioeconomic bracket have a “much better healthcare outcome” compared to Malays in the low socioeconomic status bracket.
Findings from Prof Gerald Koh and his group’s research on residents of a rental flat in Taman Jurong who were diagnosed with high blood pressure have shown that the residents have avoided screening and seeking treatment due to prohibitively expensive healthcare costs, said Prof Tambyah.
“I do rounds in general medicine, and it’s very frustrating [when] we see old people coming in with a stroke … I asked them, ‘Have you ever been diagnosed with high blood pressure before?’
“And they said, ‘Oh ya, ten years ago somebody said I have high blood pressure’ … ‘Did you take medication?’ ‘No.” ‘Did you get treatment?’ ‘No.’ ‘Why?’ ‘Oh I have no time, I was too busy, it was too expensive, nobody could bring me to the clinic, I was working two jobs …’
“So these are the realities of what doctors in the public sector see, day in and day out,” he said, adding: “If you don’t go for early screening, if you don’t go for early treatment, you’ll end up with complications.”
Prof Tambyah highlighted that the current 3Ms system is “too complicated” and is a “bureaucracy that feeds on itself”.
“Medishield, Medisave, and Medifund actually make up a very small proportion of total health expenditure,” he said, adding: “They have never made up more than 20 per cent of total health expenditure.”
Furthermore, Medisave is funded by taking a significant chunk from the people’s CPF funds, further eroding savings needed for retirement. At last count, reserves in Medisave stood at S$88bil.
Medishield Life’s exorbitant deductible amount – as high as S$3,000 – is also unsustainable for less well-off patients. The scheme also under-insures Singaporeans, hence the requirement to maintain a large Medisave account balance of approximately S$50,000 per person.
Citing a WHO discussion paper from 2002, Prof Tambyah pointed out that the 3Ms combined only accounted for about 10 per cent of total expenditure on public healthcare.
Patients themselves and their employers primarily bear the bulk of their medical expenses as out-of-pocket payments and employee benefits make up 32 per cent and 33 per cent respectively in Singapore, with the rest being from the 3Ms, and separately, from government expenditure.
The United States, which Prof Tambyah argued is known to be a very “unequal society”, spends “twice as much on healthcare as any other country” out of its total gross domestic product, as seen in data from the World Bank.
Rejecting the United Kingdom’s National Health Service model under which healthcare is often made free for its citizens and residents, Prof Tambyah suggested that Singapore’s public healthcare system is similar to that of Australia, where there is a “compulsory health insurance that everybody pays into”.
“In addition, in Australia, if you are employed, you pay for a supplemental health insurance. And that is taken out of your wages. But they still have a significant government proportion in healthcare,” he added.
When asked by a member of the audience as to where the government would source its money from for the NHIF, Prof Tambyah replied that the money would come out of “efficiencies” and “cutting back”.
“The Singapore government likes to accuse us of cutting back on defence spending, but they cut back on defence spending.
“The money is there. As I have pointed out, there is S$88bil in the Medisave fund. If you take a conservative 6 per cent return, then there’s S$5bil. That S$5bil is more than enough to cover the additional subsidies that we are talking about, without even talking about other ideas which have been proposed, including a seller stamp duty on land sales in Singapore,” he said.
In Singapore, said Prof Tambyah, “healthcare is treated like a commodity where people avoid important primary healthcare services because of the costs and end up spending a lot of money treating complications that could have been prevented”.
“As a medical professional, I feel that this is not right. We should ensure that there is equal treatment for all, care based on clinical need and not on ability to pay.”
Prof Tambyah added: “All of us believe that security is a right. We have a right to the Police to protect our home, to the military to protect our country. None of us would argue that we would prefer to live in a place where the police are professional, soldiers who are professional, who sell their services to the highest bidder.”
SDP’s proposed healthcare policies are available in full in its National Healthcare Plan: Caring For All paper here.