Goldhill and Singapore

The following chain of logic was suggested to me by an email exchange with Tyler Cowen:*

  1. Singapore’s health system works well.
  2. Goldhill’s proposed system is similar to Singapore’s.
  3. Therefore, Goldhill’s system should work well.

Leaving aside whether or not you agree with the premise in 1, if 2 holds, 3, more or less, follows. Of course it all hangs on what “similar” means.

I did a bunch of Googling and Twitter and email outreach, and some reading on Singapore’s system was suggested to me. Cowen also recommended to me someone who knows a great deal about the country’s health system, and I spoke with that individual.

Without going into a lot of detail, there seem to be at least two big differences between what Goldhill has proposed and the Singapore system:

  1. The deductible for Singapore’s “catastrophic” plan (MediShield) is lower than what Goldhill proposes (TruCat). MediShield deductibles are as low as $1,500 per year (that’s Singapore dollars, which, converts to about $1,200 per year U.S.). If Goldhill pinned down TruCat’s deductible, I don’t recall the annual figure, but I do remember it was supposed to be on the order of $500,000 per lifetime. Singapore’s MediShield doesn’t sound very catastrophic to me.
  2. Singapore’s deductible is low enough that there isn’t a need for loans to people who can’t pay it. Not so of Goldhill’s system. There, if one can’t pay the deductible, one can get a loan, the balance of which is forgiven if it grows higher than what could be paid off in 10 years or upon death. In Singapore, the safety net is MediFund, which sounds akin to U.S. Medicaid.

All in all, I agree with Cowen’s view that Goldhill’s system is a lot like Singapore’s but with differences in scale. I think another way to say it, though, is that Singapore’s system is a lot like universal, mid-range deductible Medicare with a mandatory health savings account (HSA) plus Medicaid for the poor. By the way, in Singapore, the government dictates what health services you can and cannot use your HSA funds for.

I wonder, though, if one believes Singapore’s system is working well, why advocate a system at a different scale? One reason is that U.S. health care prices are a lot higher. On the other hand U.S. per capita income is lower. Do those facts warrant a dramatic change in scale?

I am neither disparaging nor praising Singapore’s system. I will say this much, though, I cannot imagine a Congress that would pass anything like universal Medicare, even if it was mid- to high-deductible. We can’t even agree whether all poor people should get Medicaid! That issue is settled in Singapore.

* I am not putting words in Cowen’s mouth. He didn’t write out this chain of logic in this way.


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