A few notes on Singaporean (and other) health care systems

This is oversimplifying of course, but you can think of the Singaporean system as “2/3 private money, 4/5 public provision,” with private hospitals on the side.

You can think of the UK system as “public money, public provision.”  Again with some private supply on the side.

The US system is “lots of public money, lots of private money, mostly private provision.”

Many other systems are “public money, private provision.”  In all cases there are various complexities piled on top.

Singapore now is making some changes, outlined in brief here.  For the most part, Singapore is adding on some public money, but in targeted fashion (one of the changes is for people over 90 years old, another is for people over 60).

Here’s from The Straits Times (gated, I write from the paper copy) from Saturday:

The first [priority] is to keep government subsidies targeted at those who most need them, rather than commit to benefits for all.  Universal benefits are “wasteful and inequitable”, and hard to take away once given, he [the Finance Minister] said.

That’s exactly the liberaltarian line and sometimes the conservative line as well.  It is a principle I strongly agree with.

I am grateful to have had a lengthy dinner with several of the civil servants who run the Singaporean health care system (I don’t need to tell you about the food).  I had the liberty to “ask away” for several hours and I learned a lot.

Yes, the system really is a marvel, and no it is not laissez-faire.  The mix of “private money, public provision” has some marvelous properties for economizing on costs, not the least of which is that private hospitals and doctors and medical device salesmen do not become too strong a lobby.  And the level of conscientiousness in Singapore is high enough that the public hospitals work fine, though they don’t in general have the luxuries of the private hospitals.  Furthermore those public hospitals have to compete against each other for patient loyalty and thus revenue, and so the reliance on private money helps discipline public hospitals.

Whether those public hospitals would work fine everywhere in the world is a debatable proposition.  It’s easier to monitor quality in a small, Confucian city-state with high levels of expected discipline.  (Oddly, Krugman, who thinks the VA model in the U.S. could be generalized to a national scale, should be especially sympathetic toward a Singapore-like system.  An alternative is that the public hospitals are run at city, county, and state levels.)

In any case let’s start by admitting, and keeping on the table, the notion that the current version of the Singapore system is indeed a poster child of some sort.  And it is not being modified because somehow it has started spewing out unacceptable health care outcomes.  It is being modified because, for better or worse, Singaporean politics is changing.

Now enter Aaron Carroll, who tries to argue Singapore is moving in an ACA-like direction.  His post has been cited numerous times, but it is not insightful nor does it show much curiosity about the new changes in Singapore.  It is mostly a polemic against Republicans.  In any case the new Singaporean emphasis on taking care of the elderly isn’t well understood by a comparison with ACA.

For an additional and important point, here is a good comment by Chris Conover on just how limited Singaporean coverage can be.  This ain’t your grandfather’s ACA, though with some luck it may be your grandson’s.  Even if the Singapore model is not fully generalizable to larger, more chaotic countries, it shows that government health care coverage and finance, no matter what exact form they take, should and indeed can be quite limited and you still can end up with excellent outcomes, including better cost control.

I also should add that quite a few intelligent, non-ideological Singaporean economists and civil servants believe the new changes to be bad ones, driven primarily by the demands of citizens for goodies rather than by the quest for the best technocratic policy.  The alternative view is that Singapore is now a wealthy place and it can afford to spend extra on these health care services and indeed should do so to limit inequality and also for reasons of political popularity and stability.

The Singaporean health care system is not done changing.


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