*Affordable Excellence*

The author is William A. Haseltine, the subtitle is The Singapore Health System, and the Kindle edition is itself an…affordable excellence at $0.00.

This book is a clear first choice on the Singapore health system and everyone interested in health care economics, or Singapore, should read it.  It is short, clear, and to the point.  And anyone interested in public policy or fiscal policy must, these days, be interested in health care economics.

Singaporeans have some of the best health care outcomes in the world and yet the system consumes only four (!) percent of gdp.  Here is one short bit:

Private expenditure in Singapore amounted to around 65 percent of the total national expense (2008).  Note that this includes payments out of the government-run MediShield scheme and related insurance schemes, MediSave accounts, and other private insurance schemes or employer-provided medical benefits.  The figure for the United States is 52 percent, 17 percent for the United Kingdom, and 18 percent Japan.  Singapore’s relatively high private expenditure is a direct result of the government’s efforts to shift more of the cost burden to consumers than do most other countries.

Before you pure libertarians get too happy, however, note that public sector hospitals account for about 80% of all patient hours and there is a single payer system for catastrophic expenditures.

Definitely recommended, at this price or even the paperback for $20.00.

By the way, here are some changes they likely will be making to the Singaporean health care system, moving it closer to traditional welfare state policies (for better or worse).


Before you pure libertarians get too happy, however, note that public sector hospitals account for about 80% of all patient hours and there is a single payer system for catastrophic expenditures

Doesn't that make the most sense, consumers generally handle the routine stuff that can't be feasibly socialized and a fiscally sound government covers the serious casualties? Hopefully we can stop with all the public 'preventive medicine' fairy tales at this point, unless somebody's offering to underwrite my home gym and paleo diet.

I'm guessing most libertarians could live with the government spending 1-1.5% of GDP on healthcare, which is apparently what Singapore is spending.

Libertarians have a tough enough time living with a government-run postal service. How would a virtual government monopoly on health insurance (you are only allowed to purchase private supplementary insurance in Singapore after you pay into the government's insurance scheme) combined with a system of government-run hospitals appease ideologues?

Such choices are not offered in the real world, so extrapolating the response of ideologues based on how they have responded to the policy debates we actually have is a fool's errand.

Note, however, that spending 1-1.5% of GDP on healthcare would be a massive reduction in the size of government even while the value of the services being provided by government increased equally massively. If this were possible (and real assurance could be provided that the system would work), how many would really turn it down?

Also, Americans are already contributing to mandatory government schemes to fund healthcare. I don't think the contributions would go up if American costs could match Singapore.

"Libertarians have a tough enough time living with a government-run postal service. "

What the F are you talking about? Getting to make fun of the post office and other government services adds greatly to my life?

And if you think the post office isn't ridiculous I get to make fun of you too!

@Andrew', that too. Why is an agency, 99.9999% of whose functionality either has been made obsolete by the internet or is already being done better by private companies, the stock example of a government program that nobody should reasonably object to?

It's like saying pacifists are so anti-military that they even oppose dropping nuclear bombs.

I literally can't remember the last time something made it from the mailbox all the way into the house. Partly because my memory is bad, but not only for that reason.

If you from the Constitutionalist wing of libertarians, the post office is great, since it is actually authorized in the Constitution.

I'm always baffled by the opposition to the Post Office.

Is this opposition based in the principle that customers must be denied service based on profit maximization through inherent geographic monopoly?

The Post Office lost money every year until 1913-14. Given government needed a means to communicate, clearly some means that was secure for government communication was required, this First Class provided the secure communication between government and government and citizens. Is the objection that this service which would have operated at a cost no matter what was also provided to citizens for communicating to other citizens securely?

Why do you think that your ability to communicate with the government or other citizens be restricted by the interests of for profit businesses. Do you think a for profit business should be able to control your communication? After all, if you are sending a petition to your government which the for profit mail carrier opposed, wouldn't that mail be discarded, or otherwise stopped? Note mail like freight until recently, was always COD, so your petition to the government could have had postage imposed of ten thousand dollars if the for profit mail carrier opposed it.

The Post Office only maintained a monopoly on First Class. But Congress in promoting the 1st amendment directly and explicitly subsidized news and book delivery services. Yet news boys were common from the beginning - the Post Office served to deliver news to distant customers, subsidized by Congress, but not for a lower price than new boys.

But package delivery was not done by the Post Office, which only accepted First Class to 11 ounces, and only handled packages internationally under the postal union treaties.

Package delivery services were begun early in the 19th century. For example, American Express, Wells Fargo, Adams Express, and dozens of others. When the railroads covered the far reaches, they operated extensively over railroads out of depots, especially Adams Express, which in WWII split off the package and freight part into Railway Express Agency - Adams exists today as an investment fund, so the package and freight business was very profitable if well managed, which most weren't. None of the 19th century package and freight companies made it to 1913 when the Post Office began Parcel Post service, covering more customers than any of the private sector companies ever attempted.

Farmers, especially through the Grange had long lobbied the Republican Party to provide mail delivery, including packages, to their rural addresses. The Congress pressured the Post Office to test rural delivery, and it did in the late 19th century, and then began implementing universal RFD service in 1896. Prior to that point, private delivery services would deliver the mail, but the cost was higher than most could afford, and it wasn't universal. Congress authorized $36 million in funding in 1910. But the Post Office was still not providing Parcel Post service.

So, the argument that the Post Office monopoly on First Class prevented the private sector from delivering First Class cheaper and better than government was clearly disproved. The private sector failed to respond to the organized demand for efficient rural delivery of the mails. Instead, the private sector sought to maximize profits instead of maximizing service.

But you say, the Post Office proved that rural delivery was unprofitable because of the high costs. Yet in 1913 when the Post Office added Parcel Post, the explosion in package shipments in total was so great that the Post Office became profitable for the first time in its history.

Why hadn't a private package delivery service provided universal First Class mail delivery used that to sell package delivery service efficiently enough to generate high volumes of profitable business. This is the standard operating model of most of the Internet businesses - free mail service or similar as a means of gaining access for selling goods and services for greater profit which more than pays for "free".

And Congress always used the Post Office as a means of creating private sector businesses that competed with each other. The Post Office contracted with private companies like Overland Express and Pony Express, and used the rail scheduled service extensively. And it was Post Office contracts ordered by Congress that established the first schedule air route services. The Post Office has always contracted with the UPS and FedEx companies and others when possible.

And today, thanks to Rep Issa leading the way to block higher rates by USPS, it has by edict the lowest last mile delivery prices, and both UPS and FedEx have bought companies that use the postal service to do most of their deliveries - in high density areas, they will deliver by their trucks, but 90% of the country is handled via USPS.

Mail and package delivery have the same properties as delivery of medical care. The "free market" carves out about 50% of the customers as not generating high enough profit margins, so they leave them for the government to serve. But in doing so, they fail to serve enough to achieve the network effect that makes them essential for all, and thus reach sufficient scale to reach the maximum economy of scale.

Given what is either blind opposition to the Post Office without understanding the history of the business and the total failure of "the market" to serve the citizens who act through their government to get essential services, or a well informed policy position of denying essential services to 50% of citizens in a principle of "us" v "them".

The Internet is a government solution dictated by Congress because of the failure of the market to reach the network effect and thus scale. Was the decade plus that the Internet could not be used for commercial use to give the free market the opportunity to delivering a cheaper and superior solution not long enough?

Do you think AOL, or MSN, or Sprint, IBM, AT&T, and a dozen others would have produced one winner by the year 2000 that had more customers, better service, and lower costs than the work of the Clinton administration to build the universal service model of the Internet with private companies providing the services according to Federal government rules?

My guess is network service would have been as fragmented and inefficient as package delivery was in 1912.

The medical delivery system is as comprehensive as it is because employers provided medical services via medical benefits to prevent being taxed to pay for a national health service like in the rest of the industrial world. The result is a fragmented and inefficient system just like package delivery in 1912.

@mulp, there may have been a pretty good case for the post office to exist in, say, 1900. But I am talking about now. Letters are no longer essential for communication, since the internet exists.

Your claims about only serving 50% of customers and "total failure of the market" are bizarre, since private companies already offer delivery to all addresses in America--as well as to remote locations around the world. You have misunderstood the partnerships with the postal service--they are additional services that don't replace the companies' existing service. FedEx, for example, still operates delivery to every home address. They just also offer a cheaper, slower service that uses the postal service.

Why would I fear relying on a private company because it is "for profit"? They make profit by offering the best delivery service possible. FedEx and UPS have long been known to provide faster, more reliable, more secure service than USPS. I have never heard of delivery being refused for ideological reasons. While that is possible, it is just as possible that government would refuse a service for such reasons (see the recent IRS scandal).

You have greatly exaggerated the role of government in rolling out internet access in the US. This was mainly driven by private companies, with the government as a bit player. In any case, there is no basis for claiming internet access would not be universal without government support. Cable TV, which has similar infrastructure requirements to internet, became nearly-universally available without government help (in fact, the government's main contribution was imposing regulatory burdens on cable companies, on behalf of local stations that didn't want the competition). With satellite service (a technology also used to deliver internet), coverage is now 100%.

The historical case for the post office is stronger, but there is no 21st century case for the government to be in the delivery business. If USPS ceased to exist, the only thing that would stop is junk mail (note: why is it that junk mail, a wasteful and universally-hated service, comes only via the government?).

@dan, please write about what you know. You misunderstood the private public partnership for delivery of goods, misunderstood the history of the Internet, misunderstand the current penetration of cable TV. Your whole reply is off.

Private companies invest heavily in high density areas and neglect sparsely populated areas. Electricity worked this way, transportation worked this way, the phone worked this way, the Internet works this way. We have one of the worse Internet penetration in the developed world and you seem to think it's at 100%. Wow.

Your understanding of companies' business models and how a business makes a profit is a fantasy. Businesses make a profit by offering the best service possible? I'm surprised there are still people who believe that.

"Doesn’t that make the most sense, consumers generally handle the routine stuff that can’t be feasibly socialized and a fiscally sound government covers the serious casualties? Hopefully we can stop with all the public ‘preventive medicine’ fairy tales at this point, unless somebody’s offering to underwrite my home gym and paleo diet."

Absolutely makes sense to rational people. However, these views get denounced as Liberaltarian!

Moving what is covered by ACA plans in a Singaporean direction is quite feasible. In 2009 we had two big health care problems, too many people did not have health insurance coverage and too much was being spent for too little outcome. Unfortunately solving problem one was so controversial that Congress could do little to address problem two. If something like the Singaporean plan or the Swiss plan had been championed by President Bush, I think Democrats would have gone along.

Is the health system one of the reasons why Singapore has such a low birth rate right now. Some measurements are showing they are having less than 1 baby than 15 -45 year old women. Although immigration keeps them from Japanese depopulation right now, what can be done to increase the birth rate?

That's a question. What % of the total healthcare expenditure in other countries goes to prenatal checkups, deliveries and pediatry? These expenses are low in Singapore.

As far as I can tell (including from personal experience), the answer is no. People have fewer babies because (a) the earlier drive to have them "stop at two" in the 70s (because of over-population concerns) were to a degree quite successful*, (b) the normal thing as societies become more developed, woman become more educated, etc., and perhaps (c) some other set of factors (but not the healthcare system itself).

*The population policy has completely reversed since the 80s. Now they give you tax rebates, cash bonuses and co-savings in an education account for having kids. The more kids, the more the bonuses. See http://en.wikipedia.org/wiki/Baby_bonus#Singapore

From a demographics class in college I remember that it is less development or education per se but urbanization. I would expect Singapore to have an extraordinarily low fecundity. Also, I am reminded of Tyler or someone else saying last year that Singapore seems like a great place to be really rich or really poor but that it was stifling and limited for everyone else.

Believable. Maybe this http://www.themoneyillusion.com/?p=17809?

High housing costs and small apartments also have a good deal to do with it.

Yes, cost of housing has gone up. But at the same time, I wonder if the interaction with rising expectations regarding quality of life have a lot to do with the trends as well. People were much more ready to live with less sq m per person than that are today. Speaking from personal experience--I spent my childhood in a 'three room flat', probably around 60+ sq m; that's mom and dad and three boys. And for part of that time, plus one unmarried uncle. But I suspect that many people will find the 90-100+ sq m of a contemporary 'four room' apartment still too cramped for the same number of people. But again, this seems to be part of the normal effects of economic development: rising expectations.

Wow,at 0 zero price the book's price is equal to its marginal cost!

In this vein, may as well ask if anyone else has good free non-fiction eBooks to recommend.

And worth every penny!

Brisk, professional. I have good experiences with Singapore hospitals.

Several years ago I was in Canada and came down with a very painful condition. After 8 hours in emergency the doctor said I needed surgery. I was scheduled for a specialist in 3 months with the surgery to be months later still.

I flew to Singapore, saw a specialist the next day and had an operation the morning after that. Total cost S$900.

The nature of the Canadian single payer system is that you are forbidden from paying for non essential care other than through your taxes.

Then you stand in line.

In the U.S., you'd be dead. Libertarians have no place in this discussion, nor any discussion.

Factually incorrect: In the US emergencies, and only emergencies, get taken car of, and somebody else pays.

Libertarians have a place in every discussion, and Liberaltarians even more so, for we are right.

It really depends--we don't know what this condition was. If it was truly an emergency, he probably would not have been told to wait 3 months in Canada. He would probably also been advised against making a trans-Pacific flight. Most US hospitals would likely _not_ pony up for a major surgery if it was something that could wait.

If it was extremely urgent, however, they would have first tried to bill his insurance (including Medicaid, which most men do not qualify for), then tried to ascertain the his ability to pay for himself, then if he was considered indigent he may have been considered for free care. In Texas, to qualify for county-supported indigent care one must have less than $2000 in total resources.

If he had more than $2,000 then he could pay for his surgery

That's what the Texas government thinks! I believe they forgot how much surgeries cost, unfortunately.

If you have emergency room care and you don't have health insurance, you'll be billed. If you don't pay the bill, bill collectors will come after you. If you still don't pay, credit rating agencies will be contacted and your credit rating will take a hit.

The bill will be enormous if you don't have insurance. Read Steven Brill's article in Time Magazine or a recent series in the NYTimes to see how large.

Of all the stupid things conservatives believe, the notion that you get free medical care in an emergency room is about the dumbest.

That liberals believe that is what conservatives think is not even their dumbest idea.

w, fuck off.

That's right. Because in the US, if you have a very painful condition, we just take you out back and shoot you with one of our numerous guns. I have personally shot dead over 100 people with very painful conditions.

Every day, I drive my car to work over the corpses of people who died trying to find a doctor within walking distance. My undercarriage is a mess!

July 2008, New York: Woman dies in an emergency waiting room after waiting for 24 hours.

I went to a nearby private hospital emergency room after experiencing blood in my stool over several days, they gave me a preliminary diagnosis, and since my insurance had recently lapsed along with my job, they pointed me in the direction of a large regional county hospital, where after many hours in the emergency room, which prioritized admissions based on urgency, I was admitted. After three days of full scans, tests, blood work and a colonoscopy, two malignant tumors were discovered, one in my colon and one on my right kidney, surgery was scheduled and within two months both tumors were removed, and a chemo regimen was started. I have spent allot of time in waiting rooms, and witnessed many facilities that were well past there prime, BUT were perfectly functional, and with excellent medical staff. I'll repeat that, the staff were excellent from nursing through to surgical consults etc.

When the bill finally arrived AFTER it was all over, it was a little over two hundred thousand dollars, at which point county social workers sat me down and went through my income, assets and resources to determine how much I would contribute, and how much was going to be socialized. Several years later, fully recovered, and newly flush with resources due to a successful business, I'm beginning to try and reimburse the county for the more than 80% of my bills they picked up. It's actually surprisingly difficult to do, as the county medical payment machinery is not set up to receive money from former patients, but rather pay it out. But were working on it. Not sure what all the different takeaways are, but the notion that Americans are dying for lack of care does not reflect what i witnessed. The one thing though is that it's all expensive.

"The one thing though is that it’s all expensive."

It is expensive in part because of all the price discrimination happening. Can we rename price discrimination to pricefare?

A damning datum, to be sure. Is it your contention that within the Canadian healthcare system there have been literally *zero* preventable deaths at any point in the past five years? Because if so, I am moving to Canada tomorrow.

No you wouldn't. You are too biased against things that are not like you to do so. If finding out that another country does something better than yours is enough to make you move, you would have done so already. There's plenty of things we do worse than others like K-12 education, Internet access, college costs, etc...

Preventable deaths occur everywhere in the world but it's about degrees of recklessness. what happens in our healthcare system is more reminiscent of third world country than anything else. I remember the republican presidential primaries where Ron Paul asked "what are you supposed to do, let them die?" And the crowd cheered "yeah!" That's us.

No, you are forced to suffer until life threatening, then you declare bankruptcy when the cost of the medical care is so high.

The U.S. doesn't have the luxury of imitating the health care systems of city-states. We're still the preeminent nation on the medical technological frontier, we can't follow a flying geese paradigm like Singapore.

It's great to see the liberals use all the arguments that conservatives used for why we can't be like Switzerland.

And neither side experiences any cognitive dissonance at this.

Some comments:

1. The private system will never be removed - the money from medical tourism is just too good. It serves as a release valve for the often over-worked public system.

2. The effect of National Service. I think there is more or less a beneficial effect of forcing most male citizens to maintain their physical fitness. Certainly, I think a comparison of our males under 40 to other countries should show some striking differences.

Not so sure about the national service - overall Singaporeans seemed to be rather on the fat side for SE Asia... Considering what your average hawker sells for food, that is not all that surprising.

Really? One of the lowest obesity rates in SE Asia, half that of the American title-holders, and it's not good enough? Considering most Singaporeans are in sedentary, non-physical occupations....

We can't all be supermodels, you know.

I'd like to add that in the Acknowledgements Mr. Haseltine writes the following

"I am grateful to support from ACCESS Health International, a not-for-profit operating foundation dedicated to promoting access to high-quality and affordable health worldwide, of which I am Chairman and President. The proceeds from this book will be going in their entirety to supporting its work."

Possibly useful information for those of you considering purchasing the paperback.

I'd like to humbly thank myself for the awesome work I do, and will be paying myself accordingly.

Are there any data on how developing new medicines and procedures relates to the overall healthcare expenditure? For medicines, US patients pay top dollar to get the newest experimental drugs. Other countries get them later, or in single payer systems they have bargaining power to push the costs way down. The FDA also does all the trials, so foreign governments don't have to spend as much on safety.

New procedures developed at US medical universities, often at great expense, are easily taught to foreign doctors. The foreign hospital essentially gets the procedure for free. But no one is going to reasonably argue that these techniques are national secrets that can't be shared with foreigners

So what can the US do to better share this cost with foreigners? Strong patent and export restriction laws on medicines? Then the US gets accused of killing the sick in other countries. Forbid US doctors from teaching procedures to foreigners? Again, not possible.

I don't see a good way to manage this at all. I guess you could tell big pharma to stop making new medicines, so foreign countries will invest more in R&D to develop new drugs. Or you could put price controls on medicine, which would again stunt R&D domestically. Obviously there are pharmaceutical companies and research hospitals abroad, but not at the same level as the US medical industry. I don't see any way to force other countries to share more of the medical research burden. So the Singapores of the world get to free-ride in large part due to massive health expenditures in the US.

The Singaporeans may belong to the free-ride crowd, but so does Canada and the UK and everyone else. Regardless of this, Singaporean quality of healthcare exceeds that of Canada and almost everyone else.

So they must be doing something right anyway.

I think it's partly due to the culture of management. I've been treated in the UK, Japan, Canada and Singapore among others.

I've found the UK has really declined in quality of personnel. When my son was born in London there was only one nurse who didn't spend most of her time chatting at the front desk. I cleaned my wife's room every day. When she passed out from internal bleeding they couldn't find the electronic blood pressure machine and when they went with the manual device, a nurse put it on backwards. Most of the nurses were from Africa and I really don't think they had much training.

In Singapore over numerous visits for births, pneumonia, a broken arm and others, I've never had a nurse or doctor who wasn't serious, professional and punctual.

Many of these personnel were immigrants as well, but the standards and culture are completely different from the UK.

I suspect they're probably paid less than in the NHS. But the standards are much higher. Why? It's complicated but I think a culture of excellence versus a culture of entitlement and indifference plays a part.

1. Singapore purchases medical stuff at international prices. Even though there is bulk purchasing, the market is too small for the government to have any bargaining power to push costs down.

2. As far as the public sector hospitals are concerned, they are not allowed to just introduce the latest (and most expensive) procedures and drugs. (Yes, it's a highly regulated system at that end.) Cost for the locals is partly being controlled that way.

3. Pharmaceuticals research and manufacturing is big in Singapore. (There is a lot of government money in it as well.) GlaxoSmithKline, Pfizer and Merck & Co. all have major operations here. Obviously, it won't ever be as big as in the US, but it's a significant proportion of the economy (something like 8% of the country's manufacturing production).

"Are there any data on how developing new medicines and procedures relates to the overall healthcare expenditure?" I ask the same question. I always assumed what is discussed is the cost and access to medical services as well as medicine when talking about the healthcare expenditure. New medicine is great but it has nothing to do with access to doctors' advice or MRIs or X-rays.

There seems to be an assumption that healthcare means drug taking. That's erroneous. There's a lot more that goes into healthcare than pill popping. Otherwise, why do we need doctors and nurses at all? We should just contact the customer service departments of the pharmaceutical companies, explain our symptoms and be told what pills to take.

There seems to be an assumption that new drugs equal new cures. That's erroneous. We are not curing new diseases with all the new drugs we're producing. In fact, that other countries do just fine with old drugs should be a clue that drug companies are producing new drugs to enjoy the profits from local monopoly. Our current patent and healthcare laws encourage companies to produce new drugs that add no value and they make obscene profits while preventing us from seeking competitive prices and products.

To claim that other nations are just benefitting from U.S. innovation, one must first show the value of said innovation. That we have 15 variations of aspirin with the same acting agent is hardly an example of innovation. The second thing one must show is that it's the drug that makes others healthy. This discounts the value of good doctors and nurses, good access to them and good habits, none of which have anything to do with pills. And that argument is further weakened by the acknowledgement that other countries don't even bother using the newest drugs in the first place.

Rather than trying to figure out how to make other countries pay, which seems about increasing the profits of drug companies, we should instead concentrate our efforts on figuring out why healthcare is so expensive here, so inaccessible and so ineffective. What we need is a change of paradigm, away from the stale idea that the only way to improve anything is to give a handful of companies a bunch of money. We should get scientists to cooperate, something they're willing to do for little money. We should get crowdsourcing of ideas and even research, something that's already starting to happen. We should dis-incentivize profiteering in the healthcare industry.

Singapore is doing a lot of things right in this area but things are not what it used to be.

"Before you pure libertarians get too happy"

You worry too much.

The problem here is that while one could plausibly argue that the Singapore system is more market friendly and uses elements of consumer choice to control cost (at which it does seem remarkably successful), the notion that it is not a centrally planned system is laughable. It is more libertarian in the sense that Chipotle is more high end dining than McDonalds.

As for the plausibility of implementing something like it in this country, got news for you, all those MDs that vote Republican won't be too thrilled about it either ....

Krugman has an interesting post on all this conservative euphoria for Singapore's healthcare system.

here is that while one could plausibly argue that the Singapore system is more market friendly and uses elements of consumer choice to control cost (at which it does seem remarkably successful), the notion that it is not a centrally planned system is laughable. It is more liberta - See more at: http://marginalrevolution.com/marginalrevolution/2013/08/affordable-excellence.html#comments

here is that while one could plausibly argue that the Singapore system is more market friendly and uses elements of consumer choice to control cost (at which it does seem remarkably successful), the notion that it is not a centrally planned system is laughable. It is more liberta - See more at: http://marginalrevolution.com/marginalrevolution/2013/08/affordable-excellence.html#comments cym plus kısırlık tedavisiinde kulanlan bitkisel hap

It's very nice to know that a number of insurance provider companies are available that offer different insurance services at affordable rate, some even at no amount. People surely will be get benefited with this move. Only thing to be kept in mind is that one should be aware of the fraud cases and fraud independent insurance advisors/agents that cheat people.

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