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Notes -
Singapore has a new prime minister, marking the end of the political dynasty founded by Lee Kuan Yew. I don't know much about this new guy, but it will be interesting to see for how much longer the People's Action Party can maintain its current level of centralized control with less charismatic leaders. Given the popularity of Lee around these parts, I figured others may have something to add about the stability of the current system or the future of everyone's favorite Southeast Asian city-state (no offense to Brunei).
One of my crazier ideas is that the US should pay the government of Singapore to run our health care system.
How does SG’s healthcare work?
If there’s ever a country I’d expect to have the dreaded “death panels”, it’d be this one, I guess.
The core financing system is savings-based - everyone in Singapore contributes 37% of their income (some of this is formally an employer contribution, but the incidence is on the employee) into a forced-savings fund. There is a complex formula which determines how much of that is allocated to the HSA "pot" (Medisave) but the effect is that most people end up with $1 less in their retirement pot for each $1 they spend on healthcare. This is backstopped by a government-subsidized catastrophic insurance fund (Medishield) and an indigent fund which is made deliberately unpleasant to claim from (Medifund).
But it looks like the secret sauce of how the system works is on the provider side - most Singapore hospitals are State-owned but commercially managed, and the Singapore government generally runs State-owned enterprises well. There is also a very deliberate class system - if a Singapore citizen stays in a class C ward (nightingale wards with no facilities and deliberately inferior food) the government picks up 65-80% of the bill and if they use a class B2 ward (similar but with 6-bed bays) the government picks up 50-65%. Class B1 patients get 4-bed bays, decent food, and phones and TV at the bedside and get 20% subsidy. Class A patients get a private room and pay full freight (including an extra $200 a night or so on top of class B1 to cover the room itself). Medisave and Medishield only cover the class B2 fees so you have to pay cash for B1 or A.
These seem like facially reasonable approaches that nonetheless would be politically untenable in the U.S.
Assuming quality of care was comparable, it shouldn't be controversial for the government to maintain lower standards for amenities at the facilities they're paying more for, and people willing to pay for the nicer stay are in contrast agreeing to foot more of the bill.
Now, in practice this is basically how Medicaid works for long term care, and I think we're going to see some massive birfurcation in end-of-life treatment between people who are reliant on Medicaid and people who actually saved up enough to cover cushier facilities. But it seems likely that U.S. citizens would flip their lid if the government declared that was exactly how the system was supposed to work, right on the tin.
I mean, the US is also not going to collect 37% of income either.
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