MediShield Life is the next milestone in a complex, complicated and confusing healthcare journey. A committee has been appointed to make recommendations. Here, Dr Paul Tambyah, a professor at NUH and one of those who authored the Singapore Democratic Party’s national healthcare plan, answers questions on the new initiative.
What are the critical issues the committee must tackle to make this a success?
The critical issues are affordability and sustainability. A fundamental shift has to take place in that healthcare has to be viewed as a basic human right. Most people do not choose to get sick; as such, we should take care of those who are unfortunate enough to fall sick despite their best efforts to stay healthy. Once that premise has been accepted, I think that we can begin to talk about the details of a sustainable affordable healthcare plan.
One big issue is to make sure everybody is covered but to keep premiums affordable. Is this kind of balancing act possible?
Certainly! The current system is too complex and depends too much on out-of-pocket and employer funded healthcare which is bad for people and bad for business. The proposed SDP health plan would do away with the 3Ms and mandate a $600 contribution from all citizens ($700 for PRs and subsidized rates for those earning less than $1500 a month and children). Together with a government share of health expenditure comparable to what it used to be like in Singapore in the 1980s, this would adequately cover the costs of health expenditure.
Another is getting Singaporeans to pay higher premiums when they are younger and lower premiums when they age. How to make sure that the young will bite?
Singaporeans have in general accepted the principle that the needy should be subsidised regardless of age. Under the SDP plan, the amounts that young people would pay would in fact be lower than current Medisave contributions. As statistician Leong Sze Hian has been repeating, there is no real need to increase premiums when Medishield is already the world’s most profitable public insurance scheme and the total amount of Medisave contributions every year exceeds the Government health expenditure! As President Obama has recognised, a mandate is the only way that a universal health insurance scheme is going to be sustainable.
What role should government play in making sure that Medishield Life will leave no cracks behind?
Ideally, the government should take over Medishield and make it a truly universal single payer insurance scheme. Co-payments must be capped rather than pay-outs (there is currently a lifetime limit on Medishield pay-outs). Mandates can be included to ensure that all people are covered with the government paying the premiums for those who cannot afford them. Co-payments must be limited and targeted. As the World Health Organization’s Director-General, Dr Margaret Chan, pointed out: “Direct out-of-pocket payments at the time of care are identified as the single biggest barrier to universal coverage. While user fees have been promoted as a way to reduce the overuse of services, this is not what happens.
“User fees punish the poor. They are inefficient. They encourage people to delay seeking care until a condition is far advanced, and far more difficult and expensive to treat. And when people do pay out of pocket for care, financial ruin can be the result.
Are you satisfied with the composition of the committee?
I think that an attempt has been made to have some diversity in the committee but it would have been good to have some general practitioners or healthcare workers who actually look after patients in Singapore. The committee appears to be dominated by corporate leaders. This is a little disconcerting for ordinary Singaporeans.