• Backed into a corner

    I was walking to the office while reading today’s Wonkbook, and I was struck by this:

    Conservative elites had two options when Democrats began to adopt their policy ideas: Declare victory or declare war. Key figures like Gingrich could’ve stepped before the cameras and chortled about Democrats giving up on single payer and slinking towards conservative solutions. For Hillary Clinton to run in 2008 with Bob Dole’s health-care plan was an amazing moment in American politics. For Barack Obama to reverse himself on the individual mandate and embrace the Heritage Foundation’s approach to personal responsibility was further proof that Democrats had lost the war of ideas here. Republicans could have declared victory and, by engaging constructively, pushed the final product further towards their ideal.

    They chose war instead. And that meant eradicating any trace of support for the policies they had come up with.

    That effort was extraordinarily successful. Republicans quickly convinced themselves they had always been at war with Oceania — excuse me, the individual mandate. But plausible health-care plans are hard to come by. Even the plans that weren’t exactly like Obamacare were too similar to Obamacare for comfort. And so, five years later, even leading Republicans haven’t really come by another one. There’s a gaping hole where the party’s health-care plan is supposed to go. Of course the public doesn’t trust Republicans on the issue. Republicans don’t even know what they’d do.

    I am sure there will be an outcry from conservative wonks about how there is, there really is, some secret Republican health care plan. But a health care plan that gets a couple more people insurance, or allows people to buy insurance – but at a massively huge premium, or that does nothing to increase access isn’t a comprehensive health care reform plan. Sorry.

    The biggest problem, and one that few Obamacare opposers will confront, is that the ACA is a relatively conservative solution. It’s not a government system, like the VA or the UK’s. It’s not a single-payer system, like Medicare or Canada’s. It’s not even a universal public system with a private overlay, like France’s. It’s a massive expansion of private insurance and Medicaid with an individual mandate and subsidies. It’s Romneycare writ large. It’s right out of Heritage Foundation’s playbook.

    By eliminating that as anything even remotely acceptable, conservatives have eliminated almost anything that might work. This isn’t magic. Contrary to the pundits who like to say over and over that we have no idea what we’re doing, we have massive amounts of data on how different health care systems work. There are tons of different systems all over the world. The one thing we do know is that our system leads to the highest costs, one of the lowest levels of coverage in the developed world, and shockingly middling quality.

    But where to go now? Evidently, a new plan is “on the horizon”. We’ll see; we’ve heard this before. But with one of the most promising workable conservative solutions rendered radioactive, there’s not much left.

    That’s how you get conservatives advocating for a decoupling of insurance from employment. Guess what? Liberals like that too. There’s enough of a consensus around that to have created the Wyden-Bennett plan, which had massive bipartisan support, before mandates, exchanges, and subsidies became tyranny. That support cost Senator Bennett his job.

    That’s how you get conservatives advocating for “SwissCare”, while ignoring that Switzerland has an individual mandate, more regulations, price fixing, and lower caps on out of pocket spending.

    That’s how you get conservatives advocating for Singapore’s health care system without any real understanding of it. Singapore’s system has massive subsidies for nursing homes, rehabilitation care, and home-based care. It requires mandatory savings – 36% of wages spread over various accounts. The government also provides a basic level of care that’s heavily, heavily subsidized. And here’s the kicker – it relies on tons of government intervention in the market to keep costs down. They use centrally planned and fixed budgets, they control the acquisition of new technology, they regulate the number of students and physicians, they use purchasing power to buy drugs more cheaply, they have an employer mandate for foreign workers,and  they have a national EHR. They’re also not the most open society in the world.

    Here’s the thing. I bet you could find lots of liberal wonks, and lots of Democrats, who would be fine with much of the above. You want Swisscare? Great. You want Singapore? OK. The problem is that’s not what’s offered. It’s Swisscare, but without a mandate. Guess what? That’s doesn’t work – that’s why Swisscare has a mandate! They suggest Singapore, but without the mandatory savings, public hospitals, and government management. That doesn’t work – that’s why Singapore has those aspects.

    It’s the three-legged stool writ large. These systems all function because they contain stuff people like and stuff they don’t. It’s part of making a working health care system. You can’t have guaranteed issue and community ratings without some sort of means to nudge healthy people into the pool (mandate) and some sort of means to help people at the lower end of the socio-economic spectrum afford care (subsidies). The Heritage Foundation knows it, Governor Romney knows it, and Speaker Gingrich knows it.

    If you’ve destroyed the tools available to make a system function, you can’t expect it to work. Prove me wrong.

    @aaronecarroll

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    • “If you’ve destroyed the tools available to make a system function, you can’t expect it to work.”

      It depends on what you mean by “work.” If you mean a system that provides good healthcare to the entire population at a reasonable price, then your statement is correct. If, however, your goals are to produce a political rallying cry and a low cost group of workers for the benefit of economic elites (a safety net would give workers more bargaining power and would raise costs for the 1%), then the GOP plan is working very well.

      “I was walking to the office while reading today’s Wonkbook” Is it really wise to walk and read at the same time?

      • Insightful. However this argument has one great big flaw.

        It assumes that Obamacare works. It doesn’t.

        This fact is being proved by the administration’s dismantling of the rollout.
        Public opinion has consistently been against it and supports a full repeal. But it is proponents who are backing us into a corner, not those who are against it.

        Cynics believe the following argument: Obama won’t and can’t undo his signature piece of legislation. The implementation is (by design) going to eliminate alternatives to Obamacare. We may like it but we will be stuck with it. The fact that it won’t work anytime will cynically prove Sen Reid correct by propelling us toward single payer. Ironically, the opponents of Obamacare will institutionalize single payer.

        I am an optimist. Heritage is correct. There is still time to salvage the great healthcare we have. My view is that we need to do more than defund Obamacare. We must defeat it. You need ideas to defeat ideas. To those of us who are willing to fight, let us commit to winning the argument and earning the support of the American people.

        • Obamacare is working very well in Massachusetts.

          So far it seems to be working well nationwide. The main problem with the rollout is lack of necessary funding and a massive misinformation campaign.

          “I am an optimist. Heritage is correct.”

          They were some of the originators of the ideas underlying Obamacare

          “There is still time to salvage the great healthcare we have.”

          By just about any reasonable statistical measure, our healthcare system is middling at best when compared to other rich industrial nations.

        • “There is still time to salvage the great healthcare we have.”

          Aaron and Austin have written extensively on this site about the quality of US medical care. It is mediocre. When you look at our ROI for what we spend on our care, it is awful. I would suggest you start reading health care policy/economics on a regular basis.

          Steve

        • “There is still time to salvage the great healthcare we have.”

          By all quantitative metrics, you are wrong

        • You just want Obamacare defeated because of ideology.

        • “the great health care we have”? Surely you jest. Great health care for whom? not the 45 million without insurance. not the 50 million with essentially bogus insurance. You obviously haven’t read any of the international comparative studies on nation by nation health outcomes. Here’s a hint, most of the U.S. numbers are closer to third world outcomes than first6 world.. It’s more than embarrassing, it’s immoral. The U.S. so-called health care non-system: expensive, inefficient, ineffective.

    • Feel better?

      I think that is two rants on the same general topic in two days…

      Not all conservatives are opposed to some of what is in Obamacare – there are some pretty basic things that could have been done and probably should have been debated and discussed.

      But I sit in a different place and see an arrogant President who was able to force through without significant discussion and debate a piece of legislation that is not fair and not sustainable.

      The broad scope of coverage – including a wide range of benefits that go far beyond what I want – or consider basic health care makes it both expensive and open to fraud and abuse.

      Failing to force drug prices down by using the negotiating power of Medicare./Medicaid is a way of transferring a large amount of money to the pharmas at the expense of the rate payer.

      The blame for failure of this poorly designed, bad policy when it comes, should fall on both the “conservatives” who did not articulate alternatives very well aAND “progressives” who arrogantly over reached.

      • “who was able to force through without significant discussion and debate a piece of legislation that is not fair and not sustainable.”

        The topic dominated the news and public discussion for months. The basic proposal was pushed for years by conservatives (e.g., Heritage) and was extensively debated.

        “Failing to force drug prices down by using the negotiating power of Medicare./Medicaid is a way of transferring a large amount of money to the pharmas at the expense of the rate payer.”

        Yep. Unfortunately, it was necessary to get their support, especially in the face of united GOP opposition to what had been their own proposal.

      • “But I sit in a different place and see an arrogant President who was able to force through without significant discussion and debate a piece of legislation that is not fair and not sustainable.”

        I recall the discussion and debate taking up a good chunk of 2009; am I mis-remembering? It’s when I found Wonkblog and this blog, both of which covered the discussion and debate quite well. Experts disagree on sustainability; I don’t have the expertise to proclaim any subgroup of these experts right or wrong, so I will just have to wait & see on sustainability. But “fair” is in the eye of the beholder I think. Like it or not, a majority of our representatives in Congress voted for PPACA.

        “Failing to force drug prices down by using the negotiating power of Medicare./Medicaid is a way of transferring a large amount of money to the pharmas at the expense of the rate payer.”

        Totally agree with you there.

        “The blame for failure of this poorly designed, bad policy when it comes, should fall on both the “conservatives” who did not articulate alternatives very well AND “progressives” who arrogantly over reached.”

        So working to a compromise that a majority of the Senate and House could agree upon is now “arrogantly overreaching”?

      • Did you read the through all of the article? Your statement of “some of what is in Obamacare” suggests you may have missed the point of this excellent post.

        • “But I sit in a different place and see an arrogant President who was able to force through without significant discussion and debate”

          It took 13 months to pass. The move by the GOP to delay reform with the Gang of 6 was tactically brilliant, as it allowed them to have a shot at the Massachusetts election, which they won. The big delay almost stopped the bill.

          If the ACA fails, I would agree that both Dems and the GOP should share the blame. However, that should be done while acknowledging that the GOP has been actively trying to sabotage the bill. If it works, meaning a lot more people get covered, it should be hailed as one of the best bills ever as it was able to overcome active sabotage.

          Steve

          • I don’t recall hearing any REAL debate on specifics – what would be included and what would not be included – and why. The mandate and the exchanges and the public option were what I recall occupying the space. Rightly or wrongly nobody wanted talk about each of the messy little details. I do blame the lack of such a debate on the GOP – but I also know that the way the “sausage gets made” did none of us any real service. Adding substance abuse therapy bought a block of votes. Adding contraceptive services bought another. Docs and hospitals loved the addition of “wellness” and “preventive screening”. Insurers got on board in return for access to a market that arguably might have been easier or better served by expanding existing service – Medicaid and Medicare. Heck even tech companies loved the records part.

            So we end up with a system too large – too complex – too expensive with some real basic problems being ignored. See this post from Tyler Cowen

            http://marginalrevolution.com/marginalrevolution/2013/08/what-explains-regional-variation-in-health-care-spending.html

            And the following “fact” is not only scary today – but gets even scarier in an Obamacare world…

            “36 percent of end-of-life spending, and 17 percent of U.S. health care spending, are associated with physician beliefs unsupported by clinical evidence”.

            - See more at: http://marginalrevolution.com/#sthash.yWpf8KP6.dpuf

            That simple statement is actually pretty frightening…

            The spending that is done without evidence is not without consequences – it often causes pain and suffering – on patients and families. It can lead to lower quality of life and even shorter life spans.

            Fixing the basics should have been a priority – not creating a Rube Goldberg contraption that will cause the loss of jobs and increase the deficit and not leave us any better – it may leave us worse off than we are/were.

            • 1) You are right that a lot of the debate was not public. The Gang of 6 went off for a few months and talked in private. I had hoped that they would come out in support of Wyden-Bennett, but there were already rumors that Bennett would be under pressure for not being conservative enough, his name being on a bill with Wyden being one of his faults. So, there were plenty of opportunities, and lots of debate, but no GOP senator wanted to risk being primaried.

              2) Austin and Aaron have written quite a bit about varying regional demand, and provider induced demand (PID). One (among many) of the issues is the inability of insurers to not pay for care that they know does not work, like knee arthroscopies and back surgery. It was Gawande who popularized the discrepancy in regional utilization, though the Dartmouth group has probably done most of the heavy lifting. All of this exists now. With the ACA, we at least have the potential to address these issues. Not saying we will, but we can.

              Steve

            • And you also don’t recall any *true* Scotsmen involved in that discussion, do you?

            • The cry of “death panels” put paid to stopping ineffective treatments.

            • “36 percent of end-of-life spending, and 17 percent of U.S. health care spending, are associated with physician beliefs unsupported by clinical evidence”.

              This is what led to all of the screaming about death panels. You are right that this should be discussed, but look at how the right became completely unglued at even the most basic attempt to control these costs. How are we supposed to believe that the debate would go any differently this time?

      • “But I sit in a different place and see an arrogant President who was able to force through without significant discussion and debate a piece of legislation that is not fair and not sustainable.”

        When has there ever been an non-arrogant President? By definition, the only people running for the job are certain they know what is best for the country. If you agree with them, they’re showing leadership. If you disagree, they’re demonstrating arrogance.

      • ‘The blame for failure of this poorly designed, bad policy when it comes, should fall on both the “conservatives” who did not articulate alternatives very well aAND “progressives” who arrogantly over reached.’

        What progressives wanted — still want! — was Medicare for All, and we’re all for allowing Medicare to negotiate drug prices down. MfA was never allowed on the table, Obama never even mentioned it.

        Conservatives had articulated alternatives to MfA or a VA/NHS: that alternative was Obamacare. Make insurers take everyone at standard rates, require everyone to get insurance, never suggest that insurers should be non-profit or even subsumed by the government.

    • Another point about the Swiss system (I live in Switzerland) is that major providers like hospitals are owned and managed by the Cantonal governments. There are some privately owned clinics (mostly church-affiliated), but insurance doesn’t cover them unless they agree to charge the same rates as the government-run facilities.

      There’s lots more regulation. Its not single-payer, but we definitely have all-payer pricing for treatments and medications. The minimum package for mandated insurance is comprehensive in some ways (most any evidence-based treatment is covered), but pretty skimpy in others (if you have the base policy, you stay in a ward with 8 or more patients, and have to accept the hospital-employed physicians for your care).

      I actually think the model works pretty well. It certainly isn’t the cheapest, but the quality of care is excellent.

      The biggest difference I see is salary expectations for physicians. They make more than a high-school teacher, but not much more. Not paying for that Mercedes S-class takes a lot of time pressure off appointments.

      • Mercedes S class ? I’m graduating medical school with around 200,000 in debt. Interest alone is nearly 5 figures a year. My residency pays approximately 45000 a year.

        Take from that what you will, but if I made a teachers salary I would literally NEVER be out of debt

        • I think one of the salient features of many countries (I don’t know the details on Switzerland, though) is that university education is heavily subsidized and doctors don’t begin their careers with 5 figure debts. This probably makes doctors more willing to work for lower salaries than they do here where school debt is a very real issue (though not just for medical graduates).

          • Typo: I meant to write 6-figure debts, not 5-figure. I’m sure many medical students would gladly trade 6-figures in for 5-figures!

        • @Will – yes, because as we all know, doctors have to service that $200K of debt with a lifetime fixed income of only $45K. It doesn’t get any easier for them to service that debt between residency and retirement, thus they never get rich enough to drive around in luxury cars. Somehow though, they manage to earn more than 99% of all Americans… it must be tough up there in the 1%.

          • You think Will realizes that 50k is about the average teacher salary? Not to mention what happens in physician earnings post residency…

        • “I’m graduating medical school with around 200,000 in debt. Interest alone is nearly 5 figures a year. My residency pays approximately 45000 a year”

          Teachers will likely never make more than so 50% above what you make. You START at $45k, maybe, but will be making well into the 6 figures. Which everyone (including you) knows perfectly well.

          “Here’s an overview of physicians’ compensation in 2011:

          Radiology: $315,000
          Orthopedics: $315,000
          Cardiology: $314,000
          Plastic surgery: $270,000
          General surgery: $265,000
          Obstetrics/Gynecology: $220,000
          Psychiatry: $170,000
          Pediatrics: $156,000″

          Read more: http://healthland.time.com/2012/04/27/doctors-salaries-who-earns-the-most-and-the-least/#ixzz2cXj0gLxj

          This handy link shows not only what doctors make in the US, but what they make in other countries. Low and behold, post the “entry level phase” they make 3X the median wage or more even in Canada and Europe:

          http://www.healthcare-salaries.com/physicians/medical-doctor-salary-md

          • While I don’t doubt your general claims, I think I’d treat the healthcare-salaries web site with some suspicion. Unless I’m grotesquely misunderstanding what the numbers are supposed to represent, they don’t make any sense.

            For example “An average hourly wage for an MD physician based in Australia is around AU$13 per hour whereas an average annual salary is around AU$189,500 per annum.”

            If that was really true it suggests that Australian doctors are working 280 hours per week.

            • I wouldn’t want to give the impression I think that website is accurate, but you’ve misread the line about Australia. It clearly says that MD’s that are paid hourly recieve AU$13 an hour as compared to the group of MDs that are paid an annual salary, who earn AU$189,500.

              This clearly refers to two different populations of MDs.

            • o_O
              The Australian *minimum wage* is AUS$15/hour.

        • The gauntlet that Gov. licensing forces one o run to become an MDs is ridiculous. That needs to be fixed but the ACA does not address this. IMO you should be able to graduate med school in 5 years (like a pharmacist) and then apprentice. Government is crazy.

      • Also living in Switzerland. Our mandate has lots more teeth as well. If you do not enroll in a plan, you will be assigned to one and your wages garnished. I understand that you may also be denied treatment, but I’m not sure if that actually happens.

        One funny thing, our insurance is good in other countries for up 2x the cost of care in Switzerland. To travel to the US, they recommend you get supplemental insurance.

      • My understanding of Swiss health insurance and the medical system in general is that the government requires that it be not for profit. Insurance and services are also heavily regulated. Switzerland usually runs second behind the U.S. for most expensive health care as a % of GDP.
        I might add that the health insurance offered in Hawaii is not for profit. Hawaii also requires that part time employees be covered by health insurance. The result in Hawaii is that the state has the second lowest insurance costs after North Dakota and the second highest rate of covered citizens after Massachusetts. Maybe Obamacare should have looked more like the Hawaii system.

    • Why don’t republicans stop focussing on repealing the past and fix the future. If there are so many great “mysteries” and “inconsistencies” in ObamaCare why don’t they come up with a solution other than repealing it. Repealing the bill with do NOTHING.

      I have worked in healthcare my entire career and no matter what anyone says about America having the best of the best, we don’t. There is so much waste in our healthcare system is laughable; and no the private sector isn’t going to fix it all because if they have, it would be much more cost effective than it is today.

      ObamaCare is a mechanism to try and provide a framework for the future; no one ever said it was a perfect fix. Get over yourselves, accept your loss from 2008 and come up more additions to make the bill and our healthcare system better.

      Hint: There isn’t one correct way to deliver healthcare; no nation has the single best system (not even the USA)

    • You are correct pharmacist, but their political cliff dive is not complete, they don’t have any truth in their pockets, but they have plenty of lies and hyperbole to spread before they kick the already cooked goose…

    • Pharma,

      I really don’t get this argument – repealing a law – delaying or defunding a law that will do enormous damage is not only a good idea – it is the first step towards trying to get to a much more effective health care system. The basic premise that you and those like you seem willing to accept is that government needs to “manage” our health care…

      I – and others like me reject that premise. I want to manage my health and my health care.

      I do think government can play a role – but that role is in providing a system that allows for informed choices by consumers on how to best take care of their health care needs. Some basic principles.

      1. Transparency in pricing – posting a price schedule for basic services that is easily accessible – online and at the office. This would extend to specific procedures – before going to the hospital I would be given an estimate that would make it clear what I will be spending – and I should be able to easily get competitive quotes from other possible providers.

      2. Taking down drug prices – allowing Canadian/european competitors to sell in the US – making it clear when generic drugs exist and what the price differences are – permitting those who want to use branded drugs to do so – but at THEIR OWN EXPENSE.

      3. Requiring full disclosure of cross ownership – If a doctor has an ownership interest in a clinic or lab where I am being sent for a service I should know about it.

      4. Open markets across state lines – allowing insurers to offer a wide range of plans that meet specific needs – some would include contraceptive care – others would not. Some would be high deductible catastrophic care plans – others would cover first dollar spent. Put they would priced in the market. And yes, I would be willing to design these as guaranteed issue with some form of community rating – probably less restrictive than 3:1 age bands – but that would be negotiable.

      5. Remove a lot of the regulatory crap that protects Doctors and their income – allowing a Pharmacist to do a lot of the kind of things that they are very capable of doing without having a doc sign off on it – allowing a nurse to do things like give shots – monitor diabletes and hypertension. In short increase SUPPLY!

      There are probably more – but these would be good start…

      • I don’t want to spend my energy when I am sick or in need of health care trying to penny pinch. That is crazy and inefficient. Let the experts do it on a system-wide basis so we, when we are seeking medical care, can ask the one most important question: what is the best MEDICAL treatment to get?

        Not even talking about when we are in need of emergency health care. My mom argued with the ambulance driver over which hospital due to insurance. STUPID system.

        Let’s design a systematic approach that removes the stress of cost from individual patients facing a crisis and turns it into a regular insurance payment into a regulated market. A market where all the myriad market failures have been thought about systematically.

        And you might not want contraceptive care but insurance covers a whole bunch of male health needs that I will never need. Comprehensive coverage saves us all money and time and leads to better health outcomes. Which ought to be the point.

      • First of all, as an aside I’m not sure how much you know about healthcare but giving shots is one of the main jobs of a nurse.

        But anyways a lot of your ideas are sound and most of them I agree with. But do you also realize that compared to the status quo ObamaCare is the first step toward many of these ideas; our past system wasn’t. It’s funny, take the insurance across state lines argument, that was one of the main topics of the healthcare debate in 2008 proposed by the administration but they gave into the conservative base and watered it down…

        Again the point is ObamaCare isn’t perfect but it’s a start…

      • On number 4, we have some evidence now on how that works out.

        “A new law that allows Georgians to buy health insurance plans approved by other states was envisioned as free-market solution that would lower prices and increase choices. So far, the law has failed to produce results: Not a single insurer is offering a policy under the new law.”
        No out-of-state insurers offer plans in Georgia
        Monday, April 30, 2012
        Atlanta Journal-Constitution

        “To understand the impact of across state lines proposals on the availability of health insurance and the competitiveness of state health insurance markets, we analyzed legislation that has been enacted in six states—Georgia, Kentucky, Maine, Rhode Island, Washington and Wyoming—to require, encourage or study the feasibilityof allowing the sale of health insurance across state lines or the formation of interstate health insurance compacts…

        “The two states that have implemented across state lines laws, Georgia and Wyoming, reported similar challenges. No out-of- state insurers have entered either of these markets or indicated their intent to do so as a result of the states’ across state lines legislation.
        Maine officials reported that no out-of-state insurers have yet indicated their intent to enter the market under Maine’s new across state lines law…”
        Selling Health Insurance Across State Lines: An Assessment of State Laws and Implications for Improving Choice and Affordability of Coverage
        Center on Health Insurance Reforms – Georgetown University
        October 2012

      • LonelyLibertarian: “And yes, I would be willing to design these as guaranteed issue with some form of community rating – probably less restrictive than 3:1 age bands – but that would be negotiable.”

        Well, that’s where the proposal falls apart. You can’t have guaranteed issue without some kind of a mandate, because otherwise people will buy insurance only when they get sick and prices will spiral upwards. And a mandate requires real insurance, not just a plan that provides two Tylenol a month at a cheap price and is called “insurance,” so there has to be federal regulation to provide a floor–otherwise states will de-regulate into a “race to the bottom.”

        Other suggestions may help bring prices down a bit. But guaranteed issue with community rating without some kind of mandate will blow up premiums. New York has guaranteed issue but no mandate, and it looks like Obamacare will reduce premiums by up to 50% because of the mandate.

        As the article points out, you can’t just knock out an element that’s essential to make the system work and expect it to work. And guaranteed issue + community rating requires a mandate, or a very long lock-out period for those refusing to get insurance, to work.

    • The employer mandates were/are very bad also mandating things like birth control pill coverage are very bad and very political. Failure to address licensing and regulation problems created at the state level and unwillingness to refuse to pay for unhelpful care these are all very bad things. This stuff is really bad and maybe the Republicans are worse but is this the best we can expect from politicians, I am afraid so but we should all be attacking the politicians and the ACA continually.

    • Aaron Carroll wrote:
      “That’s how you get conservatives advocating for Singapore’s health care system without any real understanding of it. … It requires mandatory savings – 36% of wages spread over various accounts.”

      Your statement is highly misleading. That 36% “spread over various accounts” is mostly non-health care accounts, such as retirement savings accounts. The mandatory saving for Medisave is 7.0-9.5% of wages depending on age. To quote the Singapore Ministry of Health:

      “Under the scheme, every employee contributes 7% – 9.5% (depending on age group) of his monthly salary to a personal Medisave account. The savings can be withdrawn to pay the hospital bills of the account holder and his immediate family members.”

      Source: http://www.moh.gov.sg/content/moh_web/home/costs_and_financing/schemes_subsidies/medisave.html