• About Singapore… – ctd. (Part 2)

    So apparently my quick post on Singapore last week has gotten some attention. Because of some emails and some other posts I’ve seen, I feel compelled to elaborate on that post. My response will take two parts. The first is more stylistic and the second is more substantive.

    Let’s get into substance. For those you you who keep ignoring everything this blog has written on Singapore, let me reassure you – I acknowledge it’s a remarkable system. It spends far, far less on health care than we do. It achieves outcomes which would make me weep with joy. It does so with a combination of public and private inputs that I think many wonks would swoon over. My argument ain’t with Singapore; it’s with people who cite it inappropriately.

    Singapore is a mix of public and private health care delivery systems. There are private and public hospitals. After that, there are lots of “tiers” in care. Basic care in open wards is cheap, sometimes even free. More deluxe care in private rooms could cost more. Some wonks love the tiers, the cost sharing, etc. They ignore that the government basically runs the public system.

    The system is largely paid for out of government subsidies and savings. Yes, personal savings. People who live in Singapore must put 36% of their wages into mandated savings accounts:

    Ordinary Account: to be used to buy a home, pay for CPF insurance against death and disability, investment and education; Special Account: for old age and investment in retirement-related financial products; and Medisave Account: to be used for healthcare expenses and approved medical insurance.

    The percentages put into each change with age. Older people must put more into Medisave than younger people. Remember this sentence when you attack me later: I think this is an interesting concept, and I think it’s a viable way to run a health care system. But until you’re prepared to go force this type of savings on Americans, then don’t sell me this system.

    There are also lots of government freebies. If you have a baby with a congenital condition, there’s now a program to give you additional money. There’s a Marriage and Parenthood Package, where you get S$6000 cash for each of your first and second children, and S$8000 for your third and fourth children. The government will also match – dollar for dollar – a fairly large amount that you contribute to a Child Development Account. Again – I’m fine with this, and if you propose something like this in America, I’ll say so. But many of the same people who “love Singapore” would see this as incentives for those on welfare to have kids to get money, no?

    Singapore relies on centrally planned and fixed budgets, for a lot of things. Conservatives hate those. The government keeps a real leash on buying new technology. Conservatives hate that, too. Singapore heavy- handedly controls the number of students and physicians that are licensed in the country. It also has some control over how much they can earn. It uses bulk purchasing power to spend less on drugs. It has lots of mandates. It has a government that has more involvement in things than you might expect.

    It’s also a country of 5 million people. It has a health care system that is considerably smaller than New York City’s.

    That said, if you want to have a discussion on the merits of making the American Health Care system look like Singapore’s, I’m on board. Let’s do it. But what I’ll fight against – and call out – are the people who do that with lots of “buts”. You want Singapore, but you don’t want the mandated savings accounts. You want Singapore, but you don’t like government involved in purchasing decisions. You want Singapore, but you oppose centralized budgets. You want Singapore, but you oppose government subsidies.

    Because what too many people want is really “more cost-sharing and more HSAs”. And they use Singapore as a proxy for that. It’s not.

    I’ll say it again. I don’t have a problem with Singapore’s health care system. I think it’s doing a remarkable job with much less than we do. I also admire how their government can seem to make changes to it, quite often, in response to how it’s functioning and received by the people. What I have a problem with are the people who use Singapore as a proxy for “less government” and “more private market”. It’s much more complicated than that.

    And, deny it if you like, but the announcement last week on how it plans to change were definitely of the “more government” mold. The fact that even Singapore, arguably the closest to a pure, libertarian model around is imposing more government constraints and support is informative. Good or bad, this news points out that model may not be sustainable.

    @aaronecarroll

    P.S. Serioulsy, go get this book already. It’s still free on Kindle.

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    • These are all, for the most parts, good points. But just because people who favor markets over central planning in health care probably shouldn’t be saying things like ‘We should do what Singapore does,’ it doesn’t mean they can’t draw certain lessons from Singapore and attempt to apply those to the U.S. And one possible lesson that can be drawn from Singapore is that HSA-style accounts, with patients responsible for participating in the market as buyers as opposed to passive objects, can work. A lot of the writing on my blog is about just this phenomenon – people who, probably more out of necessity than any desire to be part of a free market in health care, go into the market, find the care they need, and pay for itself (more often out of regular discretionary income or borrowings, not an HSA).

      Understanding the details of how other nations arrange their health care can provide lots of valuable lessons. What are to to make of the fact that in Ireland, where insurance is ‘free,’ half the population still prefers to buy private coverage? At one point (not sure if it’s still true), in New Zealand primary care was paid for privately except for the indigent, only hospital care was covered their national health system – is there a lesson there? In France, co-insurance is effectively 30% or so – what lesson can we draw from this?

      I can’t really criticize your taking some pleasure in delving a little further than simple soundbites to point out that advocates of certain systems really don’t have much of an idea what they’re talking about, given all the fun I had explaining over the last decade that Canada and the U.K. were in fact unique in their single-payer systems, that ‘most developed countries in the world have rejected single-payer.’ But that doesn’t mean we can’t pay attention to the lessons of other countries, both those that support and those that oppose our views.

      • Sean, that works for those with money but- and here is the big but- the median income in America is 26k a year and 52k a year for the entire hosuehold. That is correct. So, pray tell, where do half or more of all Americans get extra money to pay for health care? Let’s say that by some fiat law, employers could not pay for health insurance costs; do you really think any of them would convert those savings into more pay for workers? hardy har. Look at how the excess profits of companies today are being distributed; hint, not to the workers.

        I know I am repetitive here about the median income in America but I strongly believe that all the health care noise doesn’t acknowledge just how poor most Americans are. They are truly living on the edge. I can cite chapter and verse about bankruptcy due to medical costs being the leading cause of bankruptcy but some people just don’t get it.

        Thankfully, this blog does.

        The bottom line is that the wealthy will always be able to pay for decent medical care; always, have, always will. What we are talking about are the middle class and the poor. How do we help them pay for medical care?

        Savings accounts will never work for them. Ever. The ‘we don’t have enough money’ debate is truly false and evil. We have the money to pay for universal health care. We choose instead to spend it on more bombs and money for our war department. I am sure you are aware of the fact that we spend as much on our war department as the rest of the world combined (more or less).

        Think about how much we could help people if we re-directed that money to helping people with insurance costs and medical care. Imagine that. The fault is not in the stars but in ourselves.

        We choose this horrible system wherein the vast, vast majority of people are simply too poor to have a HSA.

        • Well, for starters most health care isn’t that expensive. There is very little in the world of primary care that can’t be afforded by most moderate-income and above, at least if instead of directing their health care dollars through the medical bureaucracy we simply let them spend it. I have a hard time believing that we couldn’t take a good chunk of that $16k average family health benefit and convert it to savings, with the rest going to a real catastrophic plan and back into wages.

          Alternately, we can continue down the same route as before, pretending that markets won’t work in heath care and it’s only the best central-planning available that will get us out of this. Fortunately I don’t see much of a future for that, as the people pushing for it in a few years will have to first explain to the voting public why they got things so badly wrong with the Affordable Care Act (at least, that’s my expectation).

          • In theory, yes, that 16k might be very handy but did you look at the other link I posted? Employers have shown an incredible ability not to pass profits on to their employees. I cannot, in our current environment, imagine employers letting go of that 16k save to keep it as a profit. Unless we pass a law mandating them to do so.

            Can you imagine such a law passing the insane House of Reps. we no whave; forcing employers to give money to their employees?

            A couple of days in the hospital and that 16k is gone. Heck, even a broken bone in the ER can cost that much. And, as had been pointed out numerous times here and elsewhere, shopping for health care when you have an illness is not like shopping for a car. The vast majority of people have no idea what is entailed in determining if s/he has cancer/broken bones/simple nosebleeds/herpes/etc., etc…

            Moreover, there is no such thing as a free market since we stopped using the barter system. The government is involved in every aspect of your life. The real question is how much government intervention in health care do you want? And again, this applies only to the middle class and the poor.

            What is really at stake, hidden in all this, is how much should the wealthy pay for the rest of us to get health care? Mind you, not the same level of health care available to the wealthy, just health care at all.

            (ADDENDUM: what would you do with the 5 percent of the population that consumes 50 percent or so of all health care costs? THAT is another elephant in the room. Do we continue too pay for the middle class/poor 87 year old and his/her hip replacement? Or heart surgery? Or brain surgery? What about the neo-natal kid who costs a million or more dollars? The fact is the vast majority of us aren’t using all that much health care. Yet, medical bankruptcy is off the charts. Something has to give. And the wealthy have no intention of letting wealth trickle anywhere but up as the last 40 years or so have shown us; so who pays what?)

          • Sean:
            I’m curious what about the ACA you think is “central planning”? I’m fairly certain that one of the biggest pieces of the act (the third being Medicaid expansion, which is of course now optional) is the Exchanges, which are in fact (subsidized) markets for health insurance. Yes, they are regulated by the government–is your point that they’re overregulated? Incorrectly regulated? Surely you’re not protesting that they’re not regulated enough?!? (I might make that argument, but then again I’m a *gasp* socialist!). .

            Another big piece of the ACA is increasing the reporting requirements (both quality and price) by providers (full disclosure, I work for a big one in the midwest). Granted most of this is through Medicare participation, (so there’s your big scary gov’t bogeyman haunting us all), but my understanding is that this kind of information will eventually be appropriated by the private insurance industry and (presumably) be used make markets for medical providers more transparent and therefore efficient (in the economic, though probably not administrative, sense of the word). Granted, the kinds of information being collected, collated, and represented back into the public domain will be determined and the process managed by the Government via Medicare. Nonetheless, this seems like a pretty “market-oriented” development to me (again, I’m one of these dastardly socialists, so I’m probably understanding markets incorrectly;-).

            So yeah, central planning? Please do share.

            Elboku: I understand your general point to be that the problems plaguing the US healthcare system are symptoms of broader societal issues, and that fixing these problems requires something beyond a mere re-jiggering of the technocracy to a more “right or left” orientation. If this is your point, I applaude you sir (or ma’am)–I think you “get it” in a way that some of our more pedantic peers can’t or won’t, i.e. arguing the “do markets work in healthcare” question will get us nowhere, regardless of which side is academically correct.

            • I didn’t specify that the ACA is central planning, I was referring to our general health care system and the dominant paradigm today. So lets review a few factors:

              1/2 of all health care prices set by government (Medicare, Medicaid)
              Product design set by government (essential health benefits, etc.)
              Government decision on whether services/facilities are needed (Certificate of Need)

              Do any of those sound like a free market? And that isn’t even getting to the massive distortion of the market caused by the tax preference for employer-provided insurance.

              So yes, I’d call the dominant paradigm central planning, at least closer to that than a free market.

          • Isn’t the simpler point that those who can’t afford it can be subsidized in some way by those who can? I’ve said this before and I’ll say it again: the big divide isn’t so much the delivery of health care as it is whether there should be some basic level of coverage/care and what it should be. But anyway, I’ve long wondered why, at least for very basic stuff, we can’t give everyone a basic amount of money, adjusted for natural differences (those born with diseases/disabilities) and inflation, every year? Those with more money could top off an HSA up to a point, basically like they can with an IRA now.

            • Well, apparently the reason you can’t just give people a basic amount of money and allow them to use it to pay for care is because that would mean people are, you know, shopping for care, and that’s just not possible. I mean, it is possible in the very narrow sense that people are actually doing it in the real world right now, but in theory it just doesn’t work. Everybody knows that.

      • @ Sean:

        How can you argue that a “lesson that can be drawn from Singapore is that HSA-style accounts, with patients responsible for participating in the market as buyers as opposed to passive objects, can work” when the Singapore system involves a heavy Gov’t hand in the marketplace?

        You can’t know how much effect the HSA/Patient-as-buyer is affecting prices and how much the Singaporean Gov’t's controls are affecting prices.

        This is exactly what Aaron is complaining about, drawing a lesson from the part of Singapore’s system you like and ignoring the rest.

        Because the fundamental issue with patients participating in the market as buyers is whether people who are sick and/or in pain and don’t know why (ie a majority of the more expensive interfaces with medical care) can effectively negotiate prices with providers.

        • My point wasn’t that the government of Singapore doesn’t involve itself in the market, it’s that patients can be ‘buyers’ in the market. Whether those are ‘real’ prices is aside from that particular point. And people don’t need to ‘negotiate’ prices with hospitals or doctors any more than they ‘negotiate’ with Best Buy on the biggest, baddest plasma in the store. Providers are perfectly capable of setting prices, and consumers are perfectly able to accept or reject those prices – IF they have to. Self-pay patients here in the U.S. do it all the time, as do the providers that serve them.

          • Right. Self-pay patients choose to accept or reject prices for LASIK, for a check-up, for a flu vaccine. They don’t find it easy to get quotes for and reject prices for more complex problems — one as simple as a broken leg.

            I’ll give you an example: My daughter hurt her leg. I thought it was a sprain and took her to a walk-in clinic at a hospital because I was on vacation. You could say I was walking into Best Buy to buy a small radio. The walk-in clinic (which is supposed to provide affordable, convenient care) doesn’t do x-rays, they sent us to the ER at the same hospital. It’s getting late, my daughter refuses to put weight on her foot, it’s not clear if we drive to another walk-in clinic that they will be open or do x-rays. So, we go down the hall to the ER. We’re now in Needless Markup, not Best Buy.

            Had we been buying a radio, we’d have gone home, had dinner, done some research on stores and gone back tomorrow. But my daughter’s in pain, she won’t put weight on her leg and stuff like using the toilet is a nightmare (try doing it balancing on one leg).

            It turned out, she had a fracture. Not only that, but the doctor thought there could be growth plate involvement and if there was, he’d need to do surgery to pin the bone in place, because damage to the growth plate will mean the bone won’t grow properly and my daughter could be limping for life. She needs a CAT scan to examine the fracture more closely and see if she needs surgery or just a cast (answer: just a cast).

            You could say, we’re now being asked to pay a hefty consultation fee to find out if we need to buy a big, bad-ass plasma TV or a gold-plated, big, bad-ass TV.

            I have a high deductible; I’m educated about supracondylar fractures (ie ones with possible growth plate involvement) thanks to my son’s broken elbow; and I considered my options.

            So, I’m a savvy shopper who cares about prices, but I essentially walked into Best Buy to buy a small radio and ended up in Needless Markup buying a big-ass plasma TV for 10 times as much as I expected to spend.

            So, no, I don’t agree that shopping for a plasma TV at Best Buy has anything in common with shopping for healthcare and I wish people would stop pretending it does.

            • I agree the thrid-party payment system doesn’t make it easy to find prices. That said, they can be found, and once you know where to look (I’m a big fan of the Healthcare Blue Book myself), it really isn’t that complicated. Yes, urgent and emergency care are a little different. Aside from those things, however (which are a relatively small part of health care costs), there really isn’t that much of a barrier to someone going into the marketplace to obtain the goods and services they need.

            • @Sean:

              I’d really like to see a source for your claim that urgent and emergency care are a relatively small part of healthcare costs. Or are you assuming that chronic disease never produces emergencies or urgent needs?

      • “And one possible lesson that can be drawn from Singapore is that HSA-style accounts, with patients responsible for participating in the market as buyers as opposed to passive objects, can work.”

        Wrong.

        What we can learn ” is that ***MANDATED*** HSA-style accounts, with patients responsible for participating in the market as buyers as opposed to passive objects, can work, IN CONJUCTION WITH ALL KINDS OF OTHER FACTORS, INCLUDING SIGNFICANT GOVERNMENT INVOLVEMENT.”

        • Ken: that’s certainly one plausible interpretation. But the point I’m trying to make is, people are capable of shopping for care – it may not be in a pure free-market system (although what I’m seeing here in the U.S. with self-pay patients seems to suggest it works there too), but an individual does not HAVE to present themselves to the health care bureaucracy and become the passive recipient of whatever services their betters decide to allow them, unburdened of having to make any sort of economic decision. There are alternatives, as Singapore suggests.

          • Sean- AS Haseltine points out in his book, it is far, far more than HSAs. It is govt run hospitals. A single payer catastrophic plan for everyone. Forced savings, run by the govt. Limits set upon how much physicians can earn. This is nothing like how HSAs are managed in the US. There is no study of an HSA model in the US that I am aware of that is not free of bias. I would support a large scale, randomized (in some manner) study, and think it could be done at the state level, but no state appears to want to do this.

            Query- You want to focus on HSAs. Why shouldnt we focus on something like capping physician salaries or having the govt run the hospitals?

            • Steve: try to figure out what point I am actually making, then address that.

              I am not saying Singapore operates in a free market environment. It does not. I am saying that there is, in fact, a market of some sort in Singapore (heavily shaped by government), and that the people of Singapore have funds that they use to obtain health care services in that market.

              I think that is interesting. I believe it provides insight to the question “can individuals operate in a market environment to obtain medical services.” I personally prefer a market to what I see as the dominant paradigm, wherein individuals are expected to present themselves to the medical system and abdicate any further involvement in their healthcare other than compliance, and where there are no real prices.

              You are of course free to think otherwise. I remember a conversation I had years ago where every time I suggested that individuals might have a role in, say, choosing the doctor they wish to see, or deciding among different treatment options, would shriek loudly “medical decisions are to be made by trained medical professionals!” So I am not unfamiliar with that paradigm.

              My focus on HSAs isn’t because I think they’re the be-all, end-all of health care policy. But they do work, if you accept the definition of work that I adopt here, which is, providing a source of funds for individuals to pay for health care. If you have some other definition, then no, perhaps they don’t measure up to that standard.

        • I’m not sure if its too late to comment, but as a Singaporean nurse who works in the system, you foreigners simply DON”T understand what our system is.

          Instead of relying upon foreign analysis, or Professor Haseltine rose tinted glasses, how about one written by a Singaporean doctor who’s currently a healthcare policy wonk?
          http://insightshealthassociates.wordpress.com/2013/08/14/myth-or-magic-the-singapore-healthcare-system-out-next-month/

          The myth that HSAs, or MSA, or Medisave has any impact on healthcare costs is exactly that, a myth. Our own healthcare ministers have never subscribed to it. Not one. They DO subscribe to the policy of individual responsibility, of rugged individualism, but that is a philosophical point. Medisave does not allow individuals to be ‘buyers’ in the marketplace. If so, the government would not have restricted healthcare options, imposed yearly limits, indeed, our Minister would not be moaning about how they had to worry liberalizing use of Medisave for chronic disease management would deplete the savings account faster. For ANYONE, ANYONE who believe that Singapore Medisave increase patient choices, responsibility and stuff? Please, please, PLEASE. Go read up on what it actually is and the speeches actually made by our politicians and health ministers. Medisave is essentially a huge rationing scheme, because it forcibly removes money from citizens, then restricts and RATIONS out healthcare dollar spending.

          Its also annoying to see claims that Singapore is moving towards an ACA system. Really? No thank you. I already have a government public option in Medishield. There’s no need to weaken my healthcare by removing that in favour for insurance companies bidding for my health dollar, I already have that with my Medishield plans, of which, the closest US equivalent would be Medicare Advantage. And of course, beside, more than 90% of Singaporeans have healthcare insurance in addition to the public option thanks to employee provided health insurance benefits, and no thank you, we already started the portable insurance benefits years ago. Well, we are strengthening portable insurance, but given that the ACA failed to pass that……

          But……… But……… we ARE moving towards more government intervention in our system, but we’re aren’t moving towards the US public option either, which is Medicare/Medicaid expansion. Medishield life is in no way comparable to Medicaid expansion. The comparison is nonsense.
          The US government is paying for healthcare for seniors as well as the poor. We AREN”T. That is WHY Medishield Life is needed, That is WHY our ‘public option’ is being revamped this August. Because we don’t have Medicare, our ‘public option’, which is a castrophic basic insurance, of which the expansion would NOT be towards ACA style comprehensive private insurance but rather towards removing the opt out options, while we increase its utility by making coverage for life.

      • Sean, we can discard the lesson of patients as active buyers being good. Prior to 1984, Singapore’s health care largely looked like the UK, where hospitals were all government-owned and services were paid for out of tax revenues. Health care expenses were growing by double digits. The government assumed, like you did, that people were overusing health care because it didn’t really cost them anything other than their taxes. That’s what led them to converting to basically the closest any developed country has come to a free-market health care system. Unfortunately, health care inflation actually INCREASED under this system, largely because hospitals competed on available services rather than prices. A 1993 white paper concluded bluntly: “Market forces alone will not suffice to hold
        down medical costs to the minimum. The health care system is an example of market failure. The government has to intervene directly
        to structure and regulate the health system.”

        • Got a link to that paper and/or data to support the health spending trajectory you describe?

        • If the highest purpose of health care is to save money – well, OK, that’s a reasonable argument. I happen to value providing health care services as a goal of a health care market/system of at least equal value to saving money. If saving money were the highest value, the simple answer would be to just de-fund Medicare and Medicaid, no?

          I don’t know too many people who really argue anymore that basic economic incentives drive a great deal of our current system, including overconsumption driven by third-party payment (what I’d call suppression of natural market forces). The questions of late have revolved around how best to address things like overconsumption driven by giving patients a price closer to zero than what the service would cost in a real market. Perhaps there are holdouts though who still pine for no-copay, no-coinsurance, and no-deductible health care, i.e. the type of system that has been rejected by every major industrialized country in the world except for Canada and the U.K.?

          • Doh! the above should read:

            “I don’t know too many people who really argue anymore that basic economic incentives DON’T drive a great deal of our current system, including overconsumption driven by third-party payment…

            • @Sean Parnell.

              “The point is that the healthcare providers can provide a price and the healthcare consumers can take it or reject it.”

              Jeebus Christ – did you not read the post?!?!??!

              Prof. Carroll explicitly pointed out that the government “heavy-handedly” imposes cost controls!

              It is indeed OK to take limited lessons from the general experience of a given nation’s policy system and all that, but the way you’re doing it IS NOT the way to do it.

              It would be like talking about how we can learn a lot about making tasty croissants from the French while denying that lots of butter has anything to do with it.

              The point is that the various features of Singapore’s system are not separable parts that you can mix and match, take and discard, without consequence – they are all interrelated, meaning that there are real trade-offs here.

              The denial of the “bad parts” of Singapore’s healthcare system (meaning government involvement/regulation) while pointing to some probably insignificant part which most likely depends on the “bad government” part is disingenuousness of the highest order.

          • So, if I read you right; the 87 year old middle class/poor person no longer gets his/her operation. This is assuming of course that you would want the elderly under the same system as everyone else. (If not, then why not Medicare for all? If it is good enough for the elderly, it is good enough for the rest of us. No?) The neo-natal kid simply dies as his/her poor/middle class parents have no HSA and catastrophic care only covers so much, right? In essence- no money = no treatment.

            Yes, I realize I have chosen heart-breaking examples but that is the point; under your system people will die and not be treated. It is not a bug, it is a feature of your systems. Someone has to get less treatment and/or someone has to make less money. We know the rich are not going to suffer. Do you really think the medical industrial complex is going to allow itself to be paid less? Real people are going to die under your pay for services system. Not numbers, real people.

            What do you say to those people and their families? Sorry, but in the richest country in the history of the world some people have to die for lack of health care. My response would be: why? Why do you advocate for that?

            I will say it again and you still haven’t answered the point: we have enough money to pay for health care for all. We choose not to do so. What would you advocate to change such a system? Do we leave the war department funded as is while people die? That is your solution?

            And you have to look at that 5 percent who are the real drivers of our health care costs. That figure is well-documented and has been repeated here on this blog forever. What do you propose to do with them? Ignoring them won’t make them go away.

            I am not going to apologize for being angry about this- we all should be furious that we are choosing to have a society where people die from lack of basic medical/dental care when we spend so much on weapons of death and destruction. This is a MORAL decision; not an economic one.

            The economics are easy to fix if your priorities are moral. We have enough money.

            • I’ve no idea where you’re getting the idea that an 87-year old poor person, or a neo-nate, wouldn’t get care under the general system I’d prefer to operate under. I favor a safety net. I don’t believe I’ve ever suggested that an HSA, funded entirely by one’s own resources, would be sufficient.

              The 5% that drive most health care spending – I kind of thought it should be obvious that a catastrophic insurance policy would be what funds those costs.

          • What’s the probability that you’re going to wake up tomorrow morning and decide to over-consume some free medical service? In my case and I would guess in the case of most Canadians, the answer is zero probability. There are only two medical services I can access tomorrow – my or a family doctor and the Emergency Department. In both cases, I have to answer “I don’t feel well.” with unspecified symptoms. My doctor would send the invoice to the medical plan for $35 and tell me to come back in 6 months. The ER would have me wait 6 hours to see a nurse before telling me to go home. With a gate-keeper I can’t order a CT or MRI or major surgery. (There’s the whole issue of the inconvenience of packing up the 7 children, getting time off work, finding parking, etc.)

            The reality is that reducing medical costs is one way that I as a taxpayer can reduce government spending with my family doctor as the only “loser” in the process (he’ll be fully booked whether I show up or not).

            You’re worried about overuse only because the U.S. has a huge rationing program which denies access to basic medical services for something like 50 million people, kills 50,000 people per year by rationing their life-saving surgical/cancer care, and makes untold millions more choose between the health and lives of their family and personal bankruptcy.

            • Yeah, but, freedom isn’t free, and markets, and…?

              Elboku gets it–the real question in this debate is a moral one: Do we value the lives and well-being of our poorer/sicker fellow citizens enought that we, the healthier and wealthier, are willing to suffer a little discomfort (through slightly higher taxes or insurance premiums) to provide universal access to healthcare, regardless of ability to pay? The US political system has repeatedly answered this question with a resounding NO, though the ACA is a small step in that direction. Perhaps this is why the law has engendering such animosity from certain segments of the commentariat–they simply value their marginal tax dollars more than the marginally valuable lives of the underclasses?

              The rest of the civilized world answers this moral question with a firm YES. And lo’ and behold, by taking the moral high ground they’ve also managed to build more effective and less costly health systems, all with varying (but greater than US) degrees of that dreaded “central planning.” None have done it using “free markets,” a flimsy concept at best and easily appropriated by all manner of charlatan and scoundrel as an excuse to treat others as second-class citizens. If you truly “want to provide a safety net” then there are plenty of examples of how to build an effective one, for less money, using “central planning.” But I’ve spent enough time reading libertarian blogs to know that “safety net” is little more than a rhetorical concession used to mask the author’s contempt for the unwashed masses.

    • Frakt had an exchange with David Goldhill about the latter’s idea for mandatory savings accounts as an alternative to health insurance, an exchange in which Goldhill took offense. Goldhill’s plan is similar to Singapore’s in that the individual’s contributions to her account could qualify for government subsidies. An especially intriguing feature to Goldhill’s plan is that the individual could access the funds in her account for non-health care spending if the balance in the account exceeded the actuarial value (my terminology) of the individual’s expected future health care expenses. As for Singapore, my good friend and client visited Singapore recently, and he was astonished by the level of affluence and conspicuous consumption, which he said exceeded that of any wealthy city he has visited.

    • “But many of the same people who “love Singapore” would see this as incentives for those on welfare to have kids to get money, no?”

      This is why people criticize you for being partisan. Ignoring the fact that expanding the child tax credit is popular on the right, there was no point in writing that sentence other than to make a partisan point.

      • Only you are framing this in terms of politics. My libertarian friends, and conservative as well, would view this policy as a government incentive to have children as opposed to working. How is that partisan?

        Also, thanks for the unsolicited advice, but I’m not that worried about what every person thinks of me.

    • I don’t think anybody on the right thinks Singapore has the ideal system. It’s used in debates as an alternative to single-payer. Doth protest too much…

      As for the recent reforms, as Cowen notes from his conversations with Singapore officials, it may have more to do with political expediency than fiscal necessity.

    • I finally managed to finish the Haseltine book tonight. I am shocked that he would conclude that it is free market competition holding costs down. He actually notes what Hsiao cited in the Paper Mike above cites. When competition was introduced, costs rose. Singapore then controlled the number of doctors, controlled the hospitals, cut down on expensive tech, and costs dropped. How this is free market competition I dont know. Did I mention they limit advertising for fatty foods? Again, free market?

      Maybe most of all, I dont really know how you claim Medisave is private. It is forced saving by the govt, run by the govt.

      Last of all, I think Singapore’s median age keeps getting ignored. They have a median age of 33.6. It is 37 in the US and in the 40s for most of Western Europe. Throw in an obesity rate of just 10% and I think we can understand part of the reason there absolute spending is low.

      Steve

      • Competition is not a policy, its a slogan to enable “free market” policies. What often gets lost is that competition need not revolve around quality and price. Not to beat a dead horse, but that kind of information is not readily available, and even when it is, it may be unreliable or otherwise go unused (most of all by the truly sick and/or poor, who are presumably the big spenders anyway). As an employee of a large midwestern provider, I can tell you that we largely compete on gadgets, amenities, and marketing–and I suspect that our market isn’t much different in that regard from others in similar sized cities. The goal is not to provide best care at the lowest price, the goal is to provide the most cutting-edge care through fear-based marketing and constant upgrades to plant and equipment, dominate the market by advertising this advantage, and extract the highest prices possible from commercial (mainly large employer) plans. Doing so enables us to also fulfill a vital safety net function formally provided by the City and State (both of which have extricated themselves from this responsibility with gusto). Of course, fulfilling this role is a financial liability, so we also compete with other providers to shirk these responsibilities as much as the law permits. The winners are the providers’ executives and upper-level administrators (and they are numerous), the politicians that curry our favor (and vice versa); the large employers who pass all the costs along to their employees, while locking them into jobs they may not like much otherwise; and the insurance companies and their investors who are laughing all the way to bank while railing against our “centrally planned” economy and the socialist in the White House. The losers are of course working stiffs and their families, who have no recourse except to pray and play the lottery.

    • Reading through Aaron’s recent posts on Singapore and the comments, it’s almost a perfect demonstration of the communications misalignment that Arnold Kling wrote about in the book Austin linked to a couple months back. In person, I’ve seen exceptional discussions of Singapore by policy experts of both sides, but on blog comments (even on exceptionally good blogs like this one), issues like this quickly devolve into tribalism and signaling.

    • @ SAO:

      http://meps.ahrq.gov/mepsweb/data_stats/tables_compendia_hh_interactive.jsp?_SERVICE=MEPSSocket0&_PROGRAM=MEPSPGM.TC.SAS&File=HCFY2010&Table=HCFY2010_CNDXP_C&_Debug=

      Traumatic care = $82b in 2010.

      You will also see a column specific to each condition that reports on where care related to it. was delivered. So the first line, heart conditions, shows total 2010 spending at about $107 billion, of which 5.3 percent was for ER visits. Likewise if you go down a bit, you’ll see hypertension, total 2010 spending about $43 billion, of which 2 percent was for ER visits related to that condition. The highest percentage of care received in an ER setting for any condition was 14.4 percent for Otitis media (ear infection).

      • Money is irrelevant. If we agree that health care is a fundamental right then once one is born one is given a medical card that covers all medical/dental costs from birth. (People ignore dental care at their own peril and it is critical for health.)

        If we say health care is an earned right; you only get what you pay for; then cost becomes critical. If you but catastrophic as an 80 year old and your 500k limit is reached you die. We won’t even address how much such a policy would cost and what insurance company would be insane enough to agree to cover an 80 year old. (Again, I assume you want the 80 year old to have the same system as the rest of us and Medicare will be abolished; otherwise it is hard to argue both morally and economically why the 80 year old gets Medicare and the rest of us don’t.) The neo-natal million dollar baby dies because one, no one realistically buys a catastrophic policy for a new born. If you agree to cover all the costs of the 5 percent burning through health care dollars, you cannot realistically save money by fine-tuning the other 95 percent of us. So, in a cost conscious policy, they must be cut-off from care and die; the specter of soylent green is not far-fetched.

        We save money and lose our soul.

        But this doesn’t affect the wealthy. They will prosper and get the care they need. They have the money and any honest discussion of this problem must acknowledge that the money is there for the rest of us. We choose as SB in STL and I have pointed out before not to provide care.

        I wil end where I began: you know we have enough money. You just don’t want to re-allocate it because you do not see health care as a human right. At least be honest in your belief that money trumps morality.

    • I think that conservatives like the incentives to save that exist in the Singapore system, they are suspicious of Government inputs.

    • As I am not American, I don’t really want to comment on your politics, except to thank you for pointing out the (deliberately?) mis-guided libertarians who look at Singapore and react as if they have found heaven, without realising the huge hand of the state which hovers over almost all aspects of life here. I’m not sure if it is all just a pretext for attempting to adopt a system with a repuation for low tax rates, but as you note, forced savings are an essential part of the system – something which our libertarian friends seem to wilfully overlook.

      One point which is often not mentioned is that healthcare – like many things in Singapore – is actually a thinly disguised source of revenue for the government. In response to a parliamentary question a few years ago, it was revealed that from 2001 to 2010, MediShield (one of the key components of the system) received 2 billion in premiums but paid out 1.3 billion in claims. As for the difference no one knows what happened. Presumably it is being “managed” by one of the sovereign wealth funds – either the one run by the PM himself (GIC), or more likely the one run by his apparently unqualified wife (TH).