• About Singapore…

    UPDATE: When you’re done reading this post, go read this and this.

    Man, this has been a week. Just a few days ago, I wrote about how Singapore has been a go-to for many of my more conservative colleagues, who think it’s a much more market friendly alternative to the ACA. I think that many of them underestimate how much “government” there is in the system. Today, all that is a bit irrelevant, because Singapore announced that however much government is involved, it’s not nearly enough (emphasis mine):

    Singapore’s Prime Minister Lee Hsien Loong announced a number of policy adjustments on Sunday evening in areas such as medical insurance and education, outlining a strategic shift in his approach to nation building.

    Individuals must still do their best, but the community and government must do more to reduce the pressures on individuals, he said at the annual National Day Rally.

    In one of the key changes announced in the evening, Lee said that the government is revamping the country’s medical insurance system to move towards universal and life-long coverage.

    Hoo-boy. What kind of changes can we expect? You don’t think they’ll look anything like Obamacare, do you? Let’s get out our scorecards.

    The coverage of MediShield, a low-cost basic medical insurance scheme, will no longer stop for people who turn 90.

    A “Medicaid expansion”! Check.

    It will also be expanded to include even those with pre-existing illnesses.

    Guaranteed issue! Check.

    The benefits will be increased so patients will pay less out of their own pockets.

    Less cost-sharing! Check.

    There will be no choice to opt out under the scheme, which is to be renamed MediShield Life.

    A stronger mandate! Check.

    The premiums will likely be higher, but Lee said the government will step in to help those who cannot afford it.

    Rate shocks! Increased subsidies! Check and check.

    He also singled out the pioneer generation, in their late 60s and above. The government will create a Pioneer Generation Package to help pay for their MediShield Life premiums.

    A new entitlement program! Check.

    It’s almost as if Singapore doesn’t realize that it’s supposed to eschew all of these things so wonks can point to some system somewhere that hews to a more market-based health system. Don’t they understand what they’re supposed to do?


    • why can’t you write normal prose instead of writing in snark mode? I realize that many of your detractors may decide to write in such a fashion, but as a scholar could you attempt to refrain from it?

      • This is like my tenth post this week. Let me have a little fun.

      • Must a scholar be “scholarly” all the time? Should he be?

        My own view is that, while it’s important that key points ultimately are supported by real scholarly analysis, there are appropriate times for pith and snark.

    • I am constantly amazed by all those that hail Singapore or Switzerland as some kind of health system Mecca when they actually have no idea what the system entails. Does Avik Roy really know how the Swiss or Singapore systems work? Has he lived there and studied these systems?

      I am tired of people trying to pass themselves as experts when they really have no clue what they are talking about. Imagine trying to become an expert on the US system based off of some articles and a couple of books. It would be impossible.

      I respect what Austin said a couple weeks ago in a blog post which is just be honest if you do not know something well enough to provide real academic insight on a topic. So many people want to argue just to argue without knowing what they are talking about. Sorry for the rant and thanks for another great post.

    • Another bastion of capitalism crumbles…

    • MediShield is a mandatory BASIC insurance scheme meant to help patients pay for large bills at the Class B2/C levels. What are Class B2/C wards? Class B2 wards have 6 beds per room, Class C wards have 9. . If stay in a Class A bed in a public hospital or in a private hospital, MediShield only pays the Class B2 rate, so you would have a rather sizable cost difference to make up out of pocket.

      Check out some of these exclusions:

      • Ambulance fee
      • Maternity charges (including Caesarean operations) or abortions
      • Dental work (except due to accidental injuries)
      • Infertility, sub-fertility, assisted conception or any contraceptive operation
      • Mental illness and personality disorders
      • Treatment of any illness, disability, injury or any condition arising from or due to the Acquired Immune Deficiency Syndrome (AIDS) virus
      • Treatment for drug addiction or alcoholism
      • Vaccination

      What? No free contraceptives? No free preventive care? No outpatient MD services? No 10 categories of essential health care services? Obamacare this is not!

      Even after Singapore revamps this package of mandated benefits, I’m pretty sure if Republicans had introduced an amendment proposing to substitute it for the one included in Obamacare, not a single Democrat would have voted in favor. Would you?

      • “Even after Singapore revamps this package of mandated benefits, I’m pretty sure if Republicans had introduced an amendment proposing to substitute it for the one included in Obamacare, not a single Democrat would have voted in favor. Would you?”

        As Aaron points out, it’s hard to see a plan with these features (stronger mandate, lower cost-sharing, etc.) getting many Republican votes either (at least if proposed by a Democrat). Unless all the rhetoric about tyrannical, unconstitutional mandates and government takeovers was deeply insincere, in which case it’s possible they could support such a plan proposed by the GOP. If the GOP does evolve toward supporting this type of plan, it would be very interesting.

        The political inviability of such a plan doesn’t mean it’s not worth discussing (as with the recent AEI proposal), but the line between debating serious alternatives to the ACA and concern trolling is pretty thin these days.

        • Here’s my “concern.” There’s a world of difference–practically a night and day difference–between favoring a mandate for CATASTROPHIC coverage and a mandate for coverage so comprehensive that it even includes contraceptives for Sandra Fluke. Progressives have not facilitated honest debate on this issue by repeatedly (and mendaciously IMHO) conflating the two and accusing Republicans/conservatives of hypocrisy for supporting the first while firmly rejecting the latter. The truth-twisting as it related to Romneycare was particularly egregious. http://www.nationalreview.com/corner/316425/what-really-happened-romneycare-grace-marie-turner

          The reality is that Romney had a principled position as it related to health reform, what got passed in MA did NOT conform to his original vision, and what got implemented by Gov. Patrick made it deviate even further. Romney backed a mandate for catastrophic coverage (and would have allowed people to avoid the requirement by posting a $10K bond, which demonstrates it was focused squarely on the free rider problem rather than conscripting the young to pay for the old as in Obamacare). http://www.forbes.com/sites/theapothecary/2012/04/12/how-deval-patrick-gutted-romneycares-market-oriented-reforms/

          So in light of that sordid history, Aaron’s attempts to make Singapore sound like Obamacare–a willful distortion of reality, in my book–rubbed me the wrong way. I felt compelled to set the record straight. My point about what Democrats would be willing to vote for was simply an effort to demonstrate in an intuitive way (at least I thought so) just how different the two plans are. If they truly were so alike (which seemed to be at least one point in Aaron’s post), then one could easily imagine a majority of Democrats being willing to swap one for the other. My intention wasn’t to imply that such a plan wasn’t worth discussing: it was more to point out that in bringing it to the table, Aaron didn’t appear to be truly suggesting a politically viable alternative to Obamacare that might secure bipartisan support. Instead, he was seizing an opportunity to snarkily bash Republicans.

          Readers can decide for themselves whether either his original post or my response makes a useful contribution to the debate.

          • I call BS.

            Here’s why: the healthcare debate is not just about the comprehensiveness of coverage. If that were the case, there would be some reasonable compromise possible about what not to include as mandatory coverage.

            The heart of the debate is about the mandates. That’s the so-called threat to freedom. That’s where all the calls about “socialism” come from, primarily from residents of states that receive way more tax dollars than they contribute.

            The mendacity about the scope of the program (death panels, etc.) primarily comes from the right. The design is a three-legged stool indeed, and they cannot escape the fact that it has to look the way it does or it won’t work. While Mitt Romney may grouse about the contents of what’s covered, the basic structure of reform is what is being argued about in right wing circles.

            Is the act perfect? No. But it is exactly what was proffered by right wing thinkers as a market based solution back in the 90s. It’s not good enough now, because they cannot take yes for an answer from Democrats.

            I wish this was just about whether or not contraception and Viagra should be covered, instead of straight hypocrisy about freedom and socialism.

          • If the Republicans wanted an honest debate, all they had to do was bring a plan like Singapore’s to the table. Heck, they could still do it by actually repealing AND replacing. Sure, it might not go anywhere, but it would signal a willingness to engage in governing and policy making.

            What you call bashing, others call reality based on prior experience. No matter how much I dislike their ideas, it’s not a good thing when a major party no longer governs.

          • Like Anone, I will have to call BS. Conservatives have opposed every single liberal proposal for national health insurance since the 1940’s. There is not a shred of evidence based on the policy proposals and voting records of leading conservatives in the last 70 years that indicates that this was ever about a technocratic distinction between high-deductible insurance and more traditional insurance. If conservatives had at some point made a good faith proposal for a system like Singapore’s with UNIVERSAL catastrophic insurance and with various other provisions to help those of modest means pay for and access care (and no, HSA’s in isolation don’t count, since the way the GOP proposes them now is essentially as a tax shelter for wealthy people facing high marginal rates), I think many liberals would have jumped at that chance. But this never happened, because the real policy dispute in this country is about whether healthcare is a right of citizenship or just another market good.

            • Also, how many times does Jonathan Gruber have to say that evil, socialist, job-killing ObamaCare, and freedom preserving RomneyCare are “the same %$*&ing bill” before people stop trying to find trivial distinctions between them.

          • “There’s a world of difference–practically a night and day difference–between favoring a mandate for CATASTROPHIC coverage and a mandate for coverage so comprehensive that it even includes contraceptives for Sandra Fluke.”

            One could argue that any difference makes two plans “night and day” or whatever, but besides sounding very disingenuous (as others have described) in this case, there isn’t a significant quantitative difference here, in terms of actuarial value.

            That’s because all that stuff the GOP is so offended by, like birth control, is practically free. Depending on how you account for it, the actuarial cost of birth control ranges from a small positive to a large negative, because it happens to prevent a more costly condition (aka. pregnancy!). Since we’re talking government, we should be including the costs to the Medicaid system, in which case the cost is a large negative.

            Overall, the preventative stuff in ACA is cheap. Most of the costs are for the provisions in the bill that make every insurance policy a catastrophic one at minimum. If that’s what conservatives were really interested in, they’d be celebrating the bronze plans available on exchanges.

            But they aren’t, so again … it looks very disingenuous, because it appears every trivial difference is used as a pretext for imagining substantive differences.

            • Under the previous policy, elderly folks over 90 were dropped from medishield, a catastrophic insurance scheme. There was a sharp uptick in the number of elderly folks who can’t afford to pay their medical bills, and the Government continued to pay for their bills because kicking them out of the hospital would have been a real shitstorm politically.

              The individual mandate was thus imposed, and the previous 90-year-old insurance limitation removed, to make sure that the cost of these bills were shifted away from general revenue, and onto individual taxpayers. Premiums would probably quartupled, but at least it’s not the government’s pasar (problem) anymore. That is the rationale behind the policy change.

              Other features of Singapore’s healthcare system

              – Private savings accounts for individuals, with defined contributions withheld from your paycheck every month.

              – Government clinics for primary care has a price ceiling of $20 per outpatient visit, paid out of pocket. It’s an assembly line system: you go in, see your doctor for 10 mins, and leave. Doctos can come from developing countries like Sri Lanka, Burma, Vietnam, India, whereby they are bonded to serve in such clinics for a period of time to gain accredition. You do have to wait about half a day to see a doctor though.

              Family physicians charge around $40-$50 per visit, too high a price and the price/time tradeoff swings against them.

              – All medical students studying in Singapore are bonded to serve for a period of 5 years.

              – A single buyer (The Ministry of Health) for all medical and pharmaceutical products, and they drive a hard bargain. MOH then redistributes the medicine throughout the public health system.

              – Wards that hold 6 – 8 patients in unwalled premises (think WWII field hospitals) for C class wards. Basically it’s a sprawlling hall with partitions that defining “wards”.

              Nice try, but it’s nothing like Obamacare at all. Check back again when you get rid of the millstone around the neck of American healthcare policy – Medisave.

            • * Apologies, I meant to say Medicare.

          • “So in light of that sordid history, Aaron’s attempts to make Singapore sound like Obamacare–a willful distortion of reality, in my book–rubbed me the wrong way. I felt compelled to set the record straight.” … “Aaron didn’t appear to be truly suggesting a politically viable alternative to Obamacare that might secure bipartisan support. Instead, he was seizing an opportunity to snarkily bash Republicans.”

            This posting is one of the best demonstrations of the problem faced by those that are serious thinkers with regard to health care. The problem is that this particular discussion will end without resolution only to begin sometime in the future where the presentation will be unchanged. I note that the followup comments criticizing Conover didn’t include a debate revolving around the facts that Conover presented.

            I don’t want the Singapore system, the Candian system, the German system, etc.etc. I want an American system based upon American values where the free market has made America the strongest nation in the world. Thus what is good for Singapore may not be good for America no matter how well or bad the system works in Singapore.

            Conover’s response is a keeper for serious thinkers.

      • Many basic health services that aren’t covered by insurance can be had inexpensively, thanks to government subsidies and direct government provision of many services in the public clinic system. The polyclinic (government clinic, roughly equivalent to one of our community health centers, except that the practitioners there are directly employed by the Singapore government).

        My reading of your comment is that you think we can and should have basic hospital insurance plans similar to Singapore’s available here. But that basic hospital insurance plan assumes that outpatient costs are pretty low and manageable without insurance. That simply is not true here. Singapore’s health system is very differently organized, and the point that Aaron is trying to make (and that I’ve made in comments here) is that you can’t simply transfer the elements you like over to the US and call it a day.

      • Yes?

    • Lots of snark from AC…

      It is a shame that he fails to point out….

      1. Singapore spends about 4% of GDP on healthcare! Roughly a quarter of what we spend!

      2. Singapore has significantly better outcomes than the US.

      I for one would trade their system for ours in a heartbeat!

      Note that in their system if you want a private room or other special treatment you are free to buy it – and pay for it out of your own resources.

      • Stop. I’ve pointed that out many times. Did you even bother to search the blog for “Singapore”? Do so, read all the posts, and then come back.

      • Do you know anything about the SIngapore system? Do you understand what AC is trying to say?

        Singapore is one of the most regulated healthcare systems in the world. The reason why they spend so little is because the government DIRECTLY intervenes with nearly all healthcare decisions. This is a situation that you constantly criticize ObamaCare for. Pick a side…do you want government regulation or not. Because if you want de-regulated healthcare then stop saying Singapore should be the model for our country.

    • So many blogs – so little time 😉

    • The attempt by conservatives to find a poster child for “free market” health care is intriguing. Aaron’s snark aside, I am reminded of Romney’s gaffe in the fall of 2012 when he essentially admitted that Israel was getting healthcare outcomes that were either comparable to or better than those of the US (with all the caveats we’ve seen in the past on this blog about how hard it is to do a cross country outcomes comparison) for a cost of about 8% of GDP. Now, this plays well in the cultural aspects of coalition politics in the US, since many conservatives have decided they like Israel except… I’m not sure that Romney realized that Israel’s health care system is essentially a form of managed competition which conservatives here are supposed to hate given that terms associations with the Clinton proposals of the early 90’s.

      • Taiwan was free market.
        Then they decided that sucked, looked around the world, and implemented Medicare for all in about 9 months. The civil servants wanted longer but the leader wanted it in time for the next election.

        Switzerland had had communal norms, which eroded; when that led to 5% of the population being uninsured, they went Bismarck-style legally, what we’re calling Obamacare these days.

        I think all non-US rich countries now have universal health care, as do an increasing number of poorer ones. Free market is probably in Africa somewhere, or maybe India and China in practice despite alleged programs.

    • Thanks again to Aaron and all the responders here – especially those who called out Conover. This discussion illustrates a key point about our so called health reform debate (and a dead horse that I keep beating – sorry). For one side, this is about policy. For the other, it’s about politics. Two very different things.

    • Please repost the singapore book link. thanks.

    • “Less cost-sharing! Check.”

      Did you not mean more cost-sharing (i.e. less out of pocket)? Or do I not know what the term means?

      • More cost sharing would be more out of pocket.

        • Interesting that when someone pays more of their own expenses we call that “more cost sharing”. Shows how language gets distorted in a political discussion.

        • Aaron,

          Does more cost sharing really mean “more” out of pocket costs. In Singapore 4% of GDP goes to health care – say 25% of what it is in the US…

          So instead of the $5,000 or so I see for individual annual health care spending in the US in Singapore the number would be $1250 per person – probably a bit more since the per capita GDP in Singapore is about 20% higher than the US.

          So unless I am missing something a person in Singapore might spend relatively more – but less in absolute terms vs. a US consumer.

          I know you guys have posted a lot on Singapore – but I think one thing that gets lost is that the per capita health care costs are much lower in an economy with somewhat higher incomes. Affording $1500 to $2000 a year out of a $60,000 annual income is significantly easier to do [and financing] than $5,000 out of $50,000.

          When people hear about the forced savings accounts in Singapore I think they can get caught up and intimidated by the thought of how hard it would be to save $5,000 a year for medical – the challenge differs a lot when the account needs to have ~$2,000 a year for health care.

          • I didn’t say that. I said more cost sharing means more out of pocket spending. Conversely, less cost sharing means less out of pocket spending.

    • Healthcare it the ideal thing to socialize in a democracy.
      This is because it is something everyone wants to have and something that nobody wants to pay what it actually costs.
      If you do not think this is the case here look at the unfunded liability of medicare and medicaid.

      • Actually, the massive and growing unfunded liabilities for M & M are a pretty strong argument AGAINST socializing health care. The fact is, the short-term political interests of politicians militate against responsible financing of such entitlements. Their strong incentive is to front-load the benefits and back-load the costs to arrive long after they have disappeared from the political scene. The unfunded liabilities are living proof of this proposition.

        We also have learned from how SS and Mcare trust funds have been mishandled that we essentially cannot trust politicians to keep their hands off funds accumulated to finance long-term future obligations. If you want to mandate savings because you think people are too irresponsible/short-sighted to save for retirement, then it is far better to force people to save through individually owned accounts (see Singapore) than to pay all that money into a central fund and pray that politicians won’t grab it for another purpose (again, promising to pay it back long after they’ve left office).

        DECENTRALIZED accounts designed to encourage PERSONAL RESPONSIBILITY (read: defined contributions rather than defined benefits for Medicare, for example) are the solution to the entitlements mess. Sadly, this common sense idea is persistently rejected by progressives who stubbornly cling to a social insurance model that is badly outdated (having been invented in Germany more than 125 years ago!).

        So bitterly do progressives cling to their old-fashioned communitarian “we’re all in this together” religion that they are perfectly happy to let GDP shrink by $150K simply to ensure that Medicare bankrolls $350,000 in lifetime benefits for Warren Buffett and his deceased wife when it’s pretty obvious that Warren is perfectly capable of financing his own retiree health benefits. http://www.forbes.com/sites/chrisconover/2012/10/03/debate-over-medicare-health-care-reform/

        That’s crazy, but that’s the system we’re stuck with until/unless progressives stop believing they have a monopoly on the proper role and size of government. If we end up like Greece, it won’t be conservatives who are to blame.

        • ” If you want to mandate savings because you think people are too irresponsible/short-sighted to save for retirement, then it is far better to force people to save through individually owned accounts (see Singapore) than to pay all that money into a central fund and pray that politicians won’t grab it for another purpose”

          Of course as Aaron points out, Singapore found this doesnt work that well. They are expanding to make it work more like the ACA. Also, one just has to appreciate the irony of someone condemning the act of putting money into a central fund, while citing Singapore as his model. (Maybe you were trying to be funny and I just missed it?)

          “DECENTRALIZED accounts designed to encourage PERSONAL RESPONSIBILITY (read: defined contributions rather than defined benefits for Medicare, for example) are the solution to the entitlements mess.”

          Again, there is no evidence that this works very well. It might, we just dont know. What we do know is that private insurance costs are increasing just as fast as Medicare. The central issue is costs.


          • Chris
            Have to agree with steve. I read your link.

            “Market forces” remain speculative at best, and in my eye, the quote is a proxy to mean all things to all people . Maybe yes, or maybe no on the inflationary front of controlling HC costs, but by no means assured.

            You also underestimate the power of congress–GOP and dem– to subsidize Mcare beneficiaries in any funding program in the face of escalating costs. Whether more taxes, or transfers from other entitlement programs, as long as seniors vote, no model will be immune from gamesmanship.


        • I am not arguing that medicine SHOULD be socialized only that an “ideal” sector to sell the standard “something for nothing” line that is usually used in government takeovers of a section of the economy.

          People want health care but they do not want to pay what it costs thus they are vulnerable to something for nothing or the something for a lot less argument. There are only three ways government can do this. 1. Charge someone else (read tax the rich) 2. Be more efficient (those of us who have been involved with both public and private entities know that the use of “government” and “efficient” on the same entity is an oxymoron) 3. Defer paying for something till a later date. (this is the reason for the large unfunded liabilities in Medicare and Medicare).

          Looking at health outcomes vs. spending as a % of GDP is misleading. The best way to stay healthy and live a long life is lifestyle not medical care. Talk to any doctor about how much obesity complicates any medical procedure. Our problem as Americans is that we live unhealthy lifestyles as a rule and then expect modern medicine to fix it for us. This is an expensive and inefficient system. The main reason that our health care is so expensive is not our health care system it is us.

    • We choose to have growing unfunded liabilities for M&M. We choose not to raise taxes. We choose not to permit M&M to bargain with suppliers for lower costs. We choose not to decide what procedures are covered under Medicare. Those are political choices, not some inherent problem with socialized health insurance.

      Greece? Nonsense! You’re watching Fox. We are not part of the Euro zone and Germany doesn’t control our monetary policy. We aren’t particularly indebted — it’s been worse in the past. As the economy picks back up, the deficit has been dropping like a rock. We have the lowest taxes in the industrialized world. If we were to return to Clinton or Reagan or Nixon era tax rates and maybe even trim the Pentagon budget a bit, we’d be back to the pre-Bush years. We just choose not to do so. Dick Cheney said that deficits don’t matter. Had he said that in the short term deficits don’t matter much, he would have been more accurate. As a medium to long term problem, yes, something needs to be done. In the short term, however, interest rates are low and borrowing is cheap. Now is a good time to borrow and invest.

      • Actually you are incorrect in saying that we are not particularly indebted. It depends on what you compare our current debt load to. If you look historically at the USA then our current levels of debt were only matched at the end of WWII. There was great concern at the time that we would be able to borrow what we needed, thus the drive to “buy war bonds”. During that time we knew that there would shortly be a dramatic reduction in government spending on the horizon.

        Today there is no dramatic spending reduction on the horizon. In fact there are large increases on the horizon as the baby boomers begin to claim their retirement benefits. The fact that we can print our own “money” also does not protect us from financial crisis. If you can stand the statistics Reinhart and Rogoff’s book “This time is Different” is well worth the read.

        • Right, because the debt in the post-war period resulted from a terrible recession followed by an enormous two-front war whereas the current debt is the result of two large wars followed by a severe recession which makes the current debt therefore a lot like, um, Greece. I’ve got it now. Of course, one political party has great plans to hamstring the IRS so that the government can stop collecting taxes (like Greece) and slash the number of government employees (like Greece) and then we won’t be like Greece! I think I’ve got it!

          • I have no intention of arguing who is responsible for the debt (I feel both sides have played very important rolls.) The point is that debt is at its highest point by historical standards, particularly if you include the unfunded M&M liabilities. So your statement that we are not particularly indebted in incorrect.

            As for your obsession with Greece, no one can say that the path of the US will be exactly the same but what can be said is that once countries reach a certain debt to GDP ratio the historical result has always been a major financial crisis and this is true whether they print their own currency or not.

            So, yes the US will end up like Greece, or at least similar. If it does not it will be the first time in recorded history that a country with a debt to GDP ratio as high as ours is has not.

      • J.Bean, Though there is small amounts of truth in what you say on the whole you are incorrect.

        Socialized health care systems are inherently politicized.

        Germany doesn’t directly control our monetary policy, but indirectly all countries do and they affect the value of our dollar. The price of oil and gold haven’t just gone up because of scarcity rather they have also gone up because of the amount of money we keep printing.

        You say we have the lowest tax rates in the industrialized world, but that is dependent upon how one calculates the tax rates and how much of those taxes are actually paid. It is too difficult to determine whether or not one country compared to another is taxed greater, but since the topic was on Singapore why not go to Wikipedia and compare the US to Singapore the best you can. Then you can explain the numbers to all of us.

        Deficits don’t matter is something that is true. What matters is how the money is spent that causes those deficits. If spent on wealth producing products then deficit can be repaid. If not one can end up in trouble.

        It is always a good time to invest. The question is what to invest in.

        I won’t comment on the rest.

    • I’ve seen that some Singaporeans have already posted. I’ll give my impression as an American who has lived in Singapore for over a decade (with one major medical event as well).

      As mentioned earlier, basic doctor service (polyclinics serve about 80% of the populace) is relatively cheap because the government regulates what can be charged. There is also a strong tendency towards generics which keeps medicating costs down.

      Additionally the large government hospitals are similarly regulated in their billing. When I had an MRI in the US several years back, it billed at 4-5k. I had it repeated in Singapore for about 600. The eventual treatment was about 10% what it would have been in the US.

      Singapore is a pseudo-single-payer system. For public funded providers there are strict limits on charges. The private providers can charge any amount… but must compete with a very reasonable option.

      Singapore *is* highly pro-market. Everything that can be determined by market forces is – interest rates, car prices, surcharge to drive in CBD, etc. But Singapore is also pro-strong-government from censorship to babybonuses to regulated real-estate etc etc.

    • Utterly drivelous comparison to Obamacare.

      Conover and SqueekyWheel have (roughly) the right end of the stick.