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