When it comes to the never-ending debate on America’s health care system, international comparisons abound. The usual point of reference is, naturally, our neighbor to the north, although France, Switzerland, and the U.K. are sometimes invoked as well (the French in particular have been consistently recognized by the WHO as having the best health care in the world).
However, there is no shortage of countries with universal health care systems of some form or another, so why not broaden the scope of these comparative analyses to see what else we can learn? New York Times columnist Ross Douthat did just that with a piece that examines the incredible success and efficiency of the Singaporean model.
Singaporeans pay for much of their own care out of their own pockets, and their major insurance program is designed to cover long-term illnesses and prolonged hospitalizations, not routine care. The combination has produced genuinely extraordinary results: The island state has excellent health outcomes while spending, as of 2014, just 5 percent of G.D.P. on health care. (By comparison, a typical Western European country that year spent around 10 percent; the United States spent 17 percent.)
This sounds like something government-adverse Americans can get behind — except that despite the emphasis on personal responsibility and private spending, Singaporeans also rely heavily on state-mandated paternalism.
First, Singaporeans do not spend money voluntarily saved in health-savings accounts. Under their Medisave program, they spend money saved in mandatory health-savings accounts, to which employers contribute as well. Second, their catastrophic insurance doesn’t come from a bevy of competing health insurance companies, but from a government-run single-payer system, MediShield. And then the government maintains a further safety net, Medifund, for patients who can’t cover their bills, while topping off Medisave accounts for poorer, older Singaporeans, and maintaining other supplemental programs as well.
So the Singaporean structure does not necessarily minimize state involvement or redistribution. It minimizes direct public spending and third-party payments, while maximizing people’s exposure to what treatments actually cost. And the results are, again, extremely impressive: By forcing its citizens to save and manage their own spending, the Singaporean system seems to free up an awful lot of money to spend on goods besides health care over the longer haul of life.
In other words, the Singaporean approach seems to combine the best (or depending on your perspective, worst) of both worlds: there is government coercion and management, but it goes towards forcing people within their means to save money and benefit from direct treatment rather than the confusing hodgepodge of middlemen that separate most Americans from their actual health care professionals.
Granted, as Douthat points out, there are key cultural and socioeconomic differences between the two nations: Singapore is a city-state of 5.4 million people ruled by a de facto authoritarian government for nearly four decades. But this doesn’t mean that there aren’t some general principles and policies that can be applied. Realistically, any universal service or system requires some degree of state coercion, but Singapore’s approach at least moderates this to a certain degree, while also applying it in a free market way.
In fact, this is pretty much what is already on the table:
What’s more, the federalist health care compromise floated recently by Senators Bill Cassidy and Susan Collins is a little closer to Singapore than many Republican plans to date. The senators propose that states be allowed to experiment with an Obamacare alternative that would 1) auto-enroll the uninsured in catastrophic coverage and 2) directly fund health savings accounts for the working class and poor. The first isn’t MediShield (there’s no public option) and the second isn’t Medisave (no mandatory saving). But together, they’re more Singaporean than what RyanCare does and doesn’t do, and better for it.
Of course they’re also a bigger compromise with paternalism than the Republican Party’s True Conservatives are currently willing to accept. They have their principles, and making America Singapore is simply a non-starter.
I just hope those principles are a comfort to them when the next wave of liberalism delivers us to a much more plausible health insurance destination than Singapore: Straightforward single-payer, in the form of Medicaid for almost all.
What are your thoughts?