What Makes Singapore’s Health Care So Cheap?
nytimes.com
nytimes.com
My Singaporean Uncle got stage IV nose-cancer two years ago. He has two kids, a stay-at-home wife and a job that pays only middle income. After a year of constant, weekly treatment by an assortment of doctors, he went into remission and paid in total less than one thousand dollars.
My Singaporean ex-girlfriend had systemic organ issues over her life, that have alternately caused her seizures and blackouts. She was hospitalized for years at a time. Again, middle income family, with three kids and a stay-at-home-wife. Her family paid virtually nothing for 15+ years of treatment, and then the government paid for her university. Full-ride. Oh and they also paid her directly to attend classes. About S$1500 per semester, last time I checked.
I have so many other great stories about my mother's country.
For now, my sentiment is that Singapore's society, government and people, on balance, cares about each other. Not a power-hungry "all glory to the nation" care, or a brainless "let's give everyone everything for free" care, but a "these people are people like you and I. If I put on their shoes, how would I like to be treated?" care.
In the United States, that basic, human empathy is in question.
Singaporean here. How does one enjoy such education benefits? I haven't heard of them.
> My Singaporean Uncle got stage IV nose-cancer two years ago. […] After a year of constant, weekly treatment by an assortment of doctors, he went into remission and paid in total less than one thousand dollars.
An MRI here will cost between 700 to 1,000 dollars, even at subsidised hospitals [1]. I fail to see how a year's worth of cancer treatment would be that cheap.
We have mandatory hospitalisation and surgical insurance (MediShield Life [2]), but with the various co-payments and deductibles, a procedure would still cost anywhere between $2,000 to $4,000.
[1] https://www.moh.gov.sg/content/moh_web/home/pressRoom/pressR...
Mind you, it isn't all sunshine and roses, since in return for the government paying for basically everything, she has to work more than a few years in the MOE public school system. Although they do get paid, you make much more money as a private tutor with credentials so people fresh from the degree program are always eager to get on out.
Regarding my Uncle, this is what he told me when I asked at the last CNY, but I can accept if he was off by a few thousand.
It should be noted that such "full-ride" scholarships are generally reserved for the top students in a cohort (scoring at least, I believe, AAB at A Level), and are not available to all citizens (as compared to EU citizens who enjoy heavily-subsidised tuition and student loans).
On the other hand, Singapore has a tuition grant available for all international students who are admitted into a public university [1], with the stipulation that they work for a Singapore company for at least three years after they graduate. (This is aimed at trying to get "smart" people to settle down in Singapore.)
Singapore's system heavily favours strong academic potential (the government's idea of "meritocracy" — which is starting to show its cracks [2]) over egalitarianism.
There are sadly no "student loan" schemes to allow for independent living.
[1] https://tgonline.moe.gov.sg/tgis/normal/studentViewTuitionGr...
[2] https://www.theonlinecitizen.com/2017/09/28/dr-chee-soon-jua...
When different people want different things, who do we decide who is in charge? Should it be based on family and birth, like monarchy and aristocracy? Should it be based on who can seize power by force? What about ethnic and national identity? Or should we have a competitive testing system and metrics that select out an elite? Or maybe we should all vote on a person?
Or why even have a person at all who's in a charge? Maybe we should all collectively vote for every decision without any intermediaries? Or maybe we just give an equal portion of resources to every person, and let them individually decide what to do with it.
None of these systems are perfect. They all have deficiencies and can be gamed one way or another. Question is which one is the best for the particular situation.
[1] https://en.wikipedia.org/wiki/The_Rise_of_the_Meritocracy
Makes sense. She was going to go A-Levels after Higher Chinese but her illness threw her off, so she later went to Poly, and then did Primary School prepatory teaching, before going to NIE.
> This is aimed at trying to get "smart" people to settle down in Singapore.
I don't know if the bond is working. My Indian Classmates at NTU wanted to go straight to Silicon Valley, but got stuck at (what they called) the IBM and Amazon sweatshops. They're not happy about it.
> There are sadly no "student loan" schemes to allow for independent living.
The lottery selection on campus definitely makes it worse. My roommate at the time paid one of the lucky ones under the table for a slot but he was somehow exposed and had to move out halfway through the semester. Sad, but I got a two-bed room in the hostel all to myself!
If they were planning to go straight to SV, perhaps they should have given more thought before accepting the tuition grant offered by Singapore?
It's not necessary to do MRI for cancer patients. BTW, you just assumed the person who posted this is lying. You should question his uncle not him. He is just telling you what he heard.
The price quoted is before subsidies, and after GST. For subsidised patients, the price is usually 50% off and no tax is charged.
Singaporeans happily balance rights with responsibilities. It's a more collective outlook.
> In the United States, that basic, human empathy is in question.
I find it is the opposite. There is far too much "empathy" in the US.
This means that it's impossible to take the middle ground that the average joe can actually support. Each path becomes all or nothing.
For example it's politically impossible in the US to have free healthcare only for non-smoking healthy weight individuals.
But I don't want to pay for an obese persons knee surgery.
And I know people don't want to pay for the brain damage I might get from doing boxing.
Yeah, this is lack of empathy (and understanding of the reasons behind obesity).
Why is it any more of a mental health problem than smoking?
You have the responsibility in Singapore to conform to societies expectations.
It's a very different mentality than we have in the US.
Are Swedish people?
Etc etc.
I don't think selfishness or lack of empathy are responsible for the state of US healthcare.
I've personally found Americans are very welcoming. Especially in the south.
Many Southerners are friendly toward 1) visitors, and 2) people in their immediate social circle. When the scope broadens to people of different races, nationalities, or political/sexual orientations, the friendliness quickly fades.
Growing up in a small Mississippi city in the 1980s & 90s, I saw a small but steady influx of transplants from other parts of the country who came to work our booming aluminum siding factory. They were all received warmly at first, and seemed bowled over by the attention. But as soon as they demonstrated their alien-ness by attending the wrong church (or being nonreligious), or heaven forbid, commenting on racial or political issues, the welcome mat was pulled back. They'd last a year or two at most, and then transfer somewhere else. And people would gossip about the funny Yankees after they left. "Andy's wife was a real loony-tunes," they'd say. "Told her Sunday school group she didn't believe abortion was wrong. And you know what they said about her husband. [whispering] That he was a pervert!"
Sad, really.
I think the selfishness is just expressed differently.
Where do you think the massive taxes on cigarettes and alcohol in most first world countries comes from? The calls for taxes on fatty foods? Requirements for extra insurance to do certain extreme sports?
It's the way they say we don't want to pay for your life choices.
> But I don't want to pay for an obese persons knee surgery.
This is Poe's Law writ large.
I was saying that "far too much empathy" is not something that goes well with "screw you, you brought it on yourself".
How can you find a common middle ground with people who are overflowing with empathy?
Going off topic but gun control is a great example. There is a small group of Americans who want to take away the right to private ownership of firearms. It's a small group and not a real concern.
The problem is there is a decent chunk of Americans who are very empathy driven and you show them the picture of a little girl who was shot dead and reason goes out the window.
So what does the other side do? Push their own emotionally charged propaganda to combat it. And refuse to compromise even when they agree.
I never really paid attention to singapore but I'll surely do now.
David Sedaris talked nearly two decades ago of having a treatment at a French hospital, and finding it hard to get someone to even accept payment. Mind you, he also liked that he could smoke in the hospital.
Not only is two of these completely wrong, what does that have to do with anything anyways? The United States is 50 small countries in one big country, there is no reason why a Singapore system could not be done here.
The age of and diversity of a country have nothing to do with its healthcare system.
I'm not saying it's impossible for the US to have a better healthcare system, I'm saying that looking at what Singapour has and then concluding that people in the states lack empathy is not only unfair, but also lacking in perspective.
> The United States is 50 small countries in one big country
Not only are each of the states bigger than Singapour, but they're different to each other and at the same time they're not completely independent of each other.
> The age of and diversity of a country have nothing to do with its healthcare system.
A system that has been in place for a longer period of time, tends to become larger, more complex and harder to change. Moreover, a society that is more heterogeneous will have a harder time agreeing on an issue. Also in a democratic country, the larger the population, the more people you'll have to convince in order to change the status quo.
When can we stop to being so euphemistic and just call it corruption? I do not have to wear my PhD hat in economics to say that the relatively high cost care in the US pays for both the lobbyists' salaries and the now-even-higher dividends of the companies that choose to contract those lobbyists. Workers pay through the nose, rich folk get richer. Democracy subverted once again.
I see this sentiment touted a lot, but is there really that much difference between a Connecticuter and Rhode Islander, or a Mississipian and an Alabamian? A North Dakotan and a South Dakotan?
Japan seems to have a mixed private/public insurance system, but has government control of the fee schedule.
https://en.wikipedia.org/wiki/Health_care_system_in_Japan
"The government has well controlled cost over decades by using the nationally uniform fee schedule for reimbursement."
"Fees for all health care services are set every two years by negotiations between the health ministry and physicians. The negotiations determine the fee for every medical procedure and medication, and fees are identical across the country. If physicians attempt to game the system by ordering more procedures to generate income, the government may lower the fees for those procedures at the next round of fee setting"
"Public health insurance covers most citizens/residents and the system pays 70% or more of medical and prescription drug costs with the remainder being covered by the patient (upper limits apply)."
For Singapore: https://en.wikipedia.org/wiki/Healthcare_in_Singapore
"Singapore has a non-modified universal healthcare system where the government ensures affordability of healthcare within the public health system, largely through a system of compulsory savings, subsidies, and price controls."
Notice the "price controls"... It really doesn't seem to matter strongly exactly what mix of private/public does the actual administration. To capture first order cost savings better than what the US pays you need to control the fees.
As I understand it Bernie’s plan is a bit more than this and would expand Medicare to be a full single player plan.
At this point though it seems we have more than enough comparisons and data telling us to do something. They’re all going to be nearly night and day in terms of comparison to what we have currently.
[0] https://www.bloomberg.com/view/articles/2017-09-19/want-a-be...
The good:
* It's cheap
Prices for services are set by the government IIRC. Needed an MRI, was covered by insurance. Asked for copy of data. $25 for a CD with all my MRI data and free open source software included to view it.
* It's easy to use
Go to any doctor you want any time. Just show up at a doctor's office and hand over your insurance card
The bad:
* The doctors are not qualified
I've had many experiences with quack doctors in Japan. First doctor I went to 20 years ago gave me an ultrasound and then declared I had hepatitis.
Another doctor I went to for hives on my forehead just said "I don't know what that is". No referral, nothing.
Another doctor was telling every patient to breath through a respirator for 5 minutes. Every patient was using the same respirator, same mouth piece, no changing of anything.
Many doctor's offices are filthy. Machines are covered in goop (caked on bodily fluids?). Now that I have a smart phone I've started documenting this.
Lots of foreigners complain no matter what the symptoms they're given the same 3 to 6 medicines. Break an arm, get the flu, catch a cold, always the same 3 to 6 medicines.
* Nurses require zero training
To be a nurse just show up. Becoming a nurse in Japan requires no more training than working at fast food.
* If you want to good doctor for surgery you must bribe them
If you need some serious surgery you research who the best doctor is then hand them an envelope with $$$$-$$$$$ and beg them to take your case. This is a common topic on Japanese TV dramas and no, the dramas are not making it up. I have several friends who've needed one kind of surgery or another who paid the bribe.
* Long waits
Went to a major hospital in Kanagawa. Hospitals in Japan are not like Hospitals in the USA. In Japan you can go to the hospital for every day medical issues (colds, flu, etc...). Had to wait 2.5 hours in a room with about 300 other sick people.
I will say I don't know how common that is. Waits that long have only happened to me twice as I've only gone to a hospital for service twice. They're just something I haven't experienced in the USA partly because I don't know a single place in the USA that has a waiting room that big. I did experience similar in the UK, the long waits part not the 300 people. Doctors offices have normal waits (5-10 mins)
I'm not trying to defend the USA's system. It's got lots of problems. I like the good parts of the Japanese system. It's just not all roses. The Japanese have pretty good health but I tend to guess it's genetics+lifestyle+diet and not so much because of health care.
https://www.pri.org/stories/2009-11-10/fat-japan-youre-break...
On top of that, uninsured costs of healthcare are still significantly cheaper.
The previous health minister (who's currently the transport minister) is a joke among Singaporeans, since he took credit for managing the SARS incident that happened before his stint as health minister [1], and couldn't manage to fix rising house prices or the failing public transport system in his subsequent portfolios.
[1] https://en.wikipedia.org/wiki/Khaw_Boon_Wan#Minister_for_Hea...
No surgeon should be casually dismissing these risks to a patient without getting any extra information at all.
With that said, tell your doctor and more importantly tell the MRI tech about all possible metal in your body.
More to the point, the climate hasn't changed but the percentage of obese people there, like in most countries, is increasing. You therefore can't attribute that recent increase to heat and humidity.
Rising obesity rates can be related to the weather even if it hasn't changed if there is pressure on lifestyle from other areas (e.g. Work/life balance). E.g. People in the south USA are not increasingly obese even though the weather stays the same, life style pressure plus hot and humid climate combine to create the problem; climate makes the problem more difficult to fix once it appears.
The Singaporeans and Malaysians I know mostly tend to be heavier than Asian friends and acquaintances from other countries. Dunno if the stats bear that out or if I'm just an outlier. Likewise, I don't think that the climate is so different than other nearby countries, but the food is. Tons of fried, oily, greasy carbs. It's absolutely delicious, but you can feel your arteries slamming shut just looking at half of the things you'd get in a hawker centre.
Once the sun's down, I didn't mind the weather one bit. I just avoided going out during the day.
It's a great place for barefoot running, and midnight shopping.
> what makes it beloved among many
> conservative policy analysts, is its
> reliance on health savings accounts.
> All workers are mandated to put a
> decent percentage of their earnings
> into savings for the future
London needs to become a city state, then. Why subsidise those hillbillies?
With these, any healthcare system will work well.
"But when hospitals competed, they did so by... paying more for doctors..."
"Singapore heavily regulates the number of physicians, and it has some control over salaries as well."
What makes price controls for doctors wages different than failures with price controls in other industries?
It's not different conceptually, there are numerous negative consequences for the market and the doctors. It's different in terms of what's morally tolerated on the basis that healthcare is now viewed, very widely, as a right. Even in the US that's increasingly becoming the public view, which is why the Republicans (with the Presidency + both houses of Congress) couldn't get close to fully removing the ACA (eg the protections around existing conditions is overwhelmingly popular even for the majority of Republican voters).
If healthcare is a right, then the people working in healthcare are what exactly? You have a right to N healthcare, that must be provided by the labor of someone else. There are two common answers to that, based on what one believes ideologically: those workers are either economic slaves, or they're knowingly accepting a social contract of sorts by choosing to be in the field.
In doing so, they have blocked profiteering, collusion and exploitation by vested interests, but this can be challenging to impossible to achieve in other countries due to the obvious reasons.
>What Makes Singapore’s Health Care So Cheap?
I think they missed the most obvious reason: China
Singapore's public health system does not shy away from purchasing a lion share of pharmaceuticals, disposables, and medical equipment from China.
And about C class, the 'conveyorised' healthcare is one of biggest cost cavers when Singapore's medical specialist salary is approaching Western levels. Doctors focus on throughput. The goal is to fix the person and kick him out of hospital as fast as possible, and not to make everything possible to extend his stay as '5 star hotel hospitals' do in USA
From my experience they are happy to kick you out right after surgery while still charging a ton of money. My girlfriend just had a surgery. Took 5 hours from entering the building to leaving the building. Cost was 40k. This is just for the surgery center. The doctors were extra.
And once they've exhausted your insurance or personal finances then they kick you out.
Google Image Search for "Swedish Seattle birthing" and the childbirth suites resemble 5-star hotel rooms, complete with in-room hot spa.
It's becoming a huge issue in US hospitals
We'd see the same thing in other industries if market interference led to the customer not being price sensitive. Like higher ed.
I've heard many stories where waiting for insurance authorizations would have literally cost people their lives, but the insurance has grounds to refuse payment without it, so the hospital ends up eating the entire cost of the person's care.
The system is so incredibly fucked up. Far beyond what most people think.
That being said, maternity wards are apparently the college campus of the hospital world, which is why you see so many of them being built in rich areas. They are insanely profitable.
One of the best things about the US removing itself from the TPPA is the fact that one of their conditions of entry was the fact that Pharmac would have had to buy branded pharmaceuticals from US companies rather than the Generics that we usually get which would have increased the cost that the country pays for pharmaceuticals massively.
No
I'm sorry but how does spending two years there as an exchange student a decade ago add any weight to your opinion? As an exchange student weren't you still part of your parents insurance? Also do you think nothing has changed in 10 years?
>>In other words, Singapore discovered that, as we’ve seen many times before, the market sometimes fails in health care.
Why is increased spending on buying new technology deemed a failure? Maybe the optimal healthcare spending level is far higher than what's spent now.
People would be far less likely to overuse health services if they felt they were paying personally.
That's a powerful idea.
Here's the quote.
In a 1995 paper in Health Affairs, William Hsiao looked at how health spending fared in Singapore before and after the introduction of Medisave. He found that health care spending increased after the introduction of increased cost-sharing, which is not what most proponents of such changes would expect.
From the end of the article:
> [American] Conservatives will point to the Medisave accounts and the emphasis on individual contributions, but ignore the heavy government involvement and regulation. Liberals will point to the public’s ability to hold down costs and achieve quality, but ignore the class system or the system’s reliance on individual decision-making.
No data to back it up, might be wrong.
I can tell you I absolutely loathe pouring money into health insurers to prop up an overused and wasteful system. I'd much rather something like this personal account idea.
> Singapore is also very small, and the population may be healthier in general than in some other countries. It’s a little easier to run a health care system like that.
but what I don't get is why so many people will simply say this without any further evidence that this is true.
if size is a benefit, will a country with a population of 1 have an extremely efficient healthcare system? how about a country with a population of 10? obviously no. But does it get better at 1m people? 10m? 100m? I think the size of the US is a red herring, and there are so many other reasons why the US doesn't work, like the way the healthcare economy is structured, social contribution, population sprawl, etc that size offers no economies of scale advantage and in fact works against it. Under the right conditions, being larger really should help a healthcare system, not hurt it.
Well, a city, in that it's significantly larger than any city in the US other than NYC.
https://en.wikipedia.org/wiki/List_of_the_largest_urban_aggl...
Yes, if you said “Singapore is of similar size to a large metropolitan area in the U.S.”, rather than “...a city...”, then, yes, the comparison would be to a category where Singapore's population would be reasonably typical, rather than just shy of the biggest.
But when you say “city”, it doesn't communicate something bigger than a city just because the thing you are comparing to a city is, itself, not just a city.
Saying it does't make it true. How about justifying why you think it matters? Because we can talk about any population in terms of percentage which factors out size. I suspect when you try and explain why size matters, you'll run into a better argument to make.
It actually isn't in any simple fashion.
What happens if state A implements health care much better than the state next door, so everyone flocks to state A and deluges the hospitals?
Do you make so that only state residents get the 'state rate' for health care?
What about the people who are stuck in the poor, badly managed states that get left behind?
I'd love to see a US state try to do some drastic health care reforms. CA has toyed with single-payer options, though it's hampered funding-wise by the federal government, and the fact that, despite popular appearances, CA has a large segment of conservative voters.
Singapore and, say, South Carolina, have similar populations, so you'd expect to be able to implement Singapore-style healthcare on a state level if your only objection is population.
In reality, though, consensus-building and lobbying dollars tend to be the biggest obstacles to US-wide reform.
But economically it's obviously nonsense.
Singapore is not only more diversified than the US, it is the most extreme case of religious diversity in the world [1]
[1] http://www.pewforum.org/2014/04/04/global-religious-diversit...