
What Makes Singapore’s Health Care So Cheap? - sndean
https://www.nytimes.com/2017/10/02/upshot/what-makes-singapores-health-care-so-cheap.html
======
hitekker
Personal anecdote:

My Singaporean Uncle got stage IV nose-cancer two years ago. He has two kids,
a stay-at-home wife and a job that pays only middle income. After a year of
constant, weekly treatment by an assortment of doctors, he went into remission
and paid in total less than one thousand dollars.

My Singaporean ex-girlfriend had systemic organ issues over her life, that
have alternately caused her seizures and blackouts. She was hospitalized for
years at a time. Again, middle income family, with three kids and a stay-at-
home-wife. Her family paid virtually nothing for 15+ years of treatment, and
then the government paid for her university. Full-ride. Oh and they also paid
her directly to attend classes. About S$1500 per semester, last time I
checked.

I have so many other great stories about my mother's country.

For now, my sentiment is that Singapore's society, government and people, on
balance, cares about each other. Not a power-hungry "all glory to the nation"
care, or a brainless "let's give everyone everything for free" care, but a
"these people are people like you and I. If I put on their shoes, how would I
like to be treated?" care.

In the United States, that basic, human empathy is in question.

~~~
ValentineC
> _Her family paid virtually nothing for 15+ years of treatment, and then the
> government paid for her university. Full-ride. Oh and they also paid her
> directly to attend classes. About S$1500 per semester, last time I checked._

Singaporean here. How does one enjoy such education benefits? I haven't heard
of them.

> _My Singaporean Uncle got stage IV nose-cancer two years ago. […] After a
> year of constant, weekly treatment by an assortment of doctors, he went into
> remission and paid in total less than one thousand dollars._

An MRI here will cost between 700 to 1,000 dollars, even at subsidised
hospitals [1]. I fail to see how a year's worth of cancer treatment would be
that cheap.

We have mandatory hospitalisation and surgical insurance (MediShield Life
[2]), but with the various co-payments and deductibles, a procedure would
still cost anywhere between $2,000 to $4,000.

[1]
[https://www.moh.gov.sg/content/moh_web/home/pressRoom/pressR...](https://www.moh.gov.sg/content/moh_web/home/pressRoom/pressRoomItemRelease/2005/radiology_charges_in_singapore.html)

[2] [https://www.medishieldlife.sg](https://www.medishieldlife.sg)

~~~
hitekker
She went into NIE, did the two-year program, got the diploma, and then went on
to do the four-year program to get the full degree.

Mind you, it isn't all sunshine and roses, since in return for the government
paying for basically everything, she has to work more than a few years in the
MOE public school system. Although they do get paid, you make much more money
as a private tutor with credentials so people fresh from the degree program
are always eager to get on out.

Regarding my Uncle, this is what he told me when I asked at the last CNY, but
I can accept if he was off by a few thousand.

~~~
ValentineC
> _Mind you, it isn 't all sunshine and roses, since in return for the
> government paying for basically everything, she has to work more than a few
> years in the MOE public school system._

It should be noted that such "full-ride" scholarships are generally reserved
for the top students in a cohort (scoring at least, I believe, AAB at A
Level), and are not available to all citizens (as compared to EU citizens who
enjoy heavily-subsidised tuition and student loans).

On the other hand, Singapore has a tuition grant available for all
international students who are admitted into a public university [1], with the
stipulation that they work for a Singapore company for at least three years
after they graduate. (This is aimed at trying to get "smart" people to settle
down in Singapore.)

Singapore's system heavily favours strong academic potential (the government's
idea of "meritocracy" — which is starting to show its cracks [2]) over
egalitarianism.

There are sadly no "student loan" schemes to allow for independent living.

[1]
[https://tgonline.moe.gov.sg/tgis/normal/studentViewTuitionGr...](https://tgonline.moe.gov.sg/tgis/normal/studentViewTuitionGrantSubsidyInfo.action)

[2] [https://www.theonlinecitizen.com/2017/09/28/dr-chee-soon-
jua...](https://www.theonlinecitizen.com/2017/09/28/dr-chee-soon-juan-the-pap-
failing-elitist-model/)

~~~
smallnamespace
It's a bit funny that meritocracy has such generally positive connotations
today, even though the term was first used and then mercilessly satirized in
_The Rise of the Meritocracy_ [1].

When different people want different things, who do we decide who is in
charge? Should it be based on family and birth, like monarchy and aristocracy?
Should it be based on who can seize power by force? What about ethnic and
national identity? Or should we have a competitive testing system and metrics
that select out an elite? Or maybe we should all vote on a person?

Or why even have a person at all who's in a charge? Maybe we should all
collectively vote for every decision without any intermediaries? Or maybe we
just give an equal portion of resources to every person, and let them
individually decide what to do with it.

None of these systems are perfect. They all have deficiencies and can be gamed
one way or another. Question is which one is the best for the particular
situation.

[1]
[https://en.wikipedia.org/wiki/The_Rise_of_the_Meritocracy](https://en.wikipedia.org/wiki/The_Rise_of_the_Meritocracy)

~~~
abritinthebay
Outside of certain tech and alt-right circles it certainly does not have a
positive connotation

~~~
mandijut
Unfortunately, it also has a positive connotation in certain finance circles.

~~~
smallnamespace
Why is it unfortunate? Because of what meritocracy attempts or purports to do
(give power and status to those who deserve it, e.g. because they did a good
job in the past), or because of imperfections in practice?

------
kuwze
Why is there never a comparison to Japan? They are 1/2 the size of the USA,
have a privatized health system, and it's pretty damn awesome. They also have
price controls which make things a lot easier to comprehend.

~~~
doh
Spot on. Noah Smith made the comparison couple of months ago [0].

[0] [https://www.bloomberg.com/view/articles/2017-09-19/want-a-
be...](https://www.bloomberg.com/view/articles/2017-09-19/want-a-better-
health-care-system-check-out-japan)

~~~
em3rgent0rdr
sounds like that isn't fully privatised but is rather a hybrid.

------
hellofunk
Incidentally, almost half of Singapore's population are foreigners. And if you
are not a citizen, you do not get proper health insurance there that covers
things like pre-existing conditions. This is in stark contrast to many other
nations in the world where legal residents, whether citizens or not, get the
same care and treatment.

~~~
baybal2
Blue card (edit: permanent resident card) holders have full coverage, and have
to pay for it fully

~~~
hellofunk
Im not sure what Blue card means. Do you mean PR? If so that's basically
citizenship. I'm talking about all the people who are there for work.

~~~
int_19h
By the same token, "in stark contrast to many other nations in the world where
legal residents, whether citizens or not, get the same care and treatment"
above also generally does not apply to temporary workers, but does apply to
permanent residents, in those other nations.

~~~
hellofunk
Europe grants you those rights even for a temporary work visa.

------
narrator
A health minister who makes $1.3 million dollars a year so he is bribed
directly by the people to represent their interests and not by health care
lobbyists who are just looking for ways to increase costs and make more money.

~~~
ValentineC
I think Singapore's cabinet ministers are overpaid for the "value" they offer.

The previous health minister (who's currently the transport minister) is a
joke among Singaporeans, since he took credit for managing the SARS incident
that happened before his stint as health minister [1], and couldn't manage to
fix rising house prices _or_ the failing public transport system in his
subsequent portfolios.

[1]
[https://en.wikipedia.org/wiki/Khaw_Boon_Wan#Minister_for_Hea...](https://en.wikipedia.org/wiki/Khaw_Boon_Wan#Minister_for_Health)

~~~
jnaina
Singaporean here. 'Failing" Public Transport System? Sure the SMRT has issues,
but it is still one of the best run train systems in the world. Second only to
HK MTR. Having used the BART, UK and NY Train services, the Singapore MRT
system is far more cheaper and efficient. Not to mention cleaner, safer , etc.
Yes, it is fashionable to criticize the PAP fatcats. But having lived in an
assortment of first world and other Asian countries, Singapore is haven,
albeit a "Gated Community" with a benevolent and paternalistic government.
Given the chaos I seen in some of the late-stage-capitlisitic democracies,
Singapore gives you safety and stability, at the expense of giving away some
freedom and rights. Price that I'm willing to pay and I'm sure the majority of
Singaporeans also do. And yes, I'm OK to fund and support the PAP "fatcats" as
long as they deliver the goods. Their salary is peanuts compared to the waste,
corruption and chaos that I see in the regional Asian countries due to corrupt
kakistocracies in power. Case in point, up north from Singapore.

------
hellofunk
Singapore's medical community scares me a little bit. Despite having implanted
metal in my body, an orthopedic surgeon wanted to give me an MRI anyway. It's
completely absurd, I got a second opinion and fortunately found a doctor who
agreed that would be extremely dangerous. It's true that the first doctor did
not cost that much; it's also true I got what I paid for.

~~~
acchow
Can you get metal implants which are safe for MRIs?

~~~
tormeh
Anything that's not affected by magnets, I suppose. Titanium should do it.

~~~
namelost
Also it's pretty easy to detect if someone has a large piece of ferromagnetic
metal inside them or not.

------
Lxr
From my observation living in Singapore lifestyle is an important factor.
People are generally active and there seems to be little obesity. Among young
guys at least, national service and the associated mandatory fitness
requirements seem to play a part in setting long term habits early.

~~~
inferiorhuman
See also: Trim and Fit. Obesity is a thing in Singapore.

~~~
seanmcdirmid
Ya, isn't it really hot and humid there? That would make exercise a bit
harder.

~~~
eesmith
Singapore has the nickname "The Air-conditioned Nation".

More to the point, the climate hasn't changed but the percentage of obese
people there, like in most countries, is increasing. You therefore can't
attribute that recent increase to heat and humidity.

~~~
seanmcdirmid
Ya, that makes sense. Also, if it's like southern china, people are probably
pretty active outside at night when its cooler (e.g. Night square dancing,
night markets, etc...).

Rising obesity rates can be related to the weather even if it hasn't changed
if there is pressure on lifestyle from other areas (e.g. Work/life balance).
E.g. People in the south USA are not increasingly obese even though the
weather stays the same, life style pressure plus hot and humid climate combine
to create the problem; climate makes the problem more difficult to fix once it
appears.

~~~
inferiorhuman
From my experience, it's still hot as balls at night. The only deliberate
activity I did outside in SG at any time of day was to go find air
conditioning inside. Of course I'm American, not Singaporean.

~~~
eru
I found Singaporean nights quite nice and mild. I'm German and used to much
colder temperatures, but the 25 degrees Celsius at night and a mild breeze
where quite bearable for leisurely strolls and even working out.

~~~
inferiorhuman
My experience was closer to 30 degrees by 9pm which when combined with that
humidity was just awful. After a rain it gets pretty nice at night though.

The Singaporeans and Malaysians I know mostly tend to be heavier than Asian
friends and acquaintances from other countries. Dunno if the stats bear that
out or if I'm just an outlier. Likewise, I don't think that the climate is so
different than other nearby countries, but the food is. Tons of fried, oily,
greasy carbs. It's absolutely delicious, but you can feel your arteries
slamming shut just looking at half of the things you'd get in a hawker centre.

~~~
eru
I love hawker centre food. Especially the uber greasy char kway teow. I mostly
hung out with locals, and they didn't seem to be on the chubbier side. But I
didn't make formal statistical comparisons with people from elsewhere in south
east asia.

Once the sun's down, I didn't mind the weather one bit. I just avoided going
out during the day.

It's a great place for barefoot running, and midnight shopping.

------
crdoconnor
They somehow failed to mention price controls, except obliquely. That's
impressive.

------
peteretep
Comparison with the NHS seems a little unfair given relative population
densities.

    
    
        > what makes it beloved among many
        > conservative policy analysts, is its
        > reliance on health savings accounts.
        > All workers are mandated to put a
        > decent percentage of their earnings
        > into savings for the future
    

If you tried this in America you'd have anti-Communism riots on the street
with Ann Coulter and Sarah Palin talking about how FEMA were using the money
to set up death camps before taking their guns.

~~~
eru
> Comparison with the NHS seems a little unfair given relative population
> densities.

London needs to become a city state, then. Why subsidise those hillbillies?

------
Iv
Low corruption. Competent leadership. Efficient administration.

With these, any healthcare system will work well.

~~~
tormeh
That's like saying a company will always be successful as long as it executes
well. Good execution is absolutely necessary, and can compensate for mediocre
strategy, but it can't fix a truly broken model.

------
tuna-piano
The article touches on this:

"But when hospitals competed, they did so by... paying more for doctors..."

"Singapore heavily regulates the number of physicians, and it has some control
over salaries as well."

What makes price controls for doctors wages different than failures with price
controls in other industries?

~~~
adventured
> What makes price controls for doctors wages different than failures with
> price controls in other industries?

It's not different conceptually, there are numerous negative consequences for
the market and the doctors. It's different in terms of what's morally
tolerated on the basis that healthcare is now viewed, very widely, as a right.
Even in the US that's increasingly becoming the public view, which is why the
Republicans (with the Presidency + both houses of Congress) couldn't get close
to fully removing the ACA (eg the protections around existing conditions is
overwhelmingly popular even for the majority of Republican voters).

If healthcare is a right, then the people working in healthcare are what
exactly? You have a right to N healthcare, that must be provided by the labor
of someone else. There are two common answers to that, based on what one
believes ideologically: those workers are either economic slaves, or they're
knowingly accepting a social contract of sorts by choosing to be in the field.

~~~
tim333
Price caps on most things produce shortages. Doctors on the other hand are
generally not that money motivated - I doubt many would drop out of medical
college because the salary was $80k rather than $120k say. Though there are
limits - I know some people drop out of the UK NHS.

------
korginator
It's doable because Singapore is a small city-state, easily regulated,
strongly controlled and managed. The largest hospitals are public, and the
smaller ones private, i.e., the government has positioned itself to be the
main healthcare provider, ergo, their strong ability to manage and control
healthcare costs is all but guaranteed.

In doing so, they have blocked profiteering, collusion and exploitation by
vested interests, but this can be challenging to impossible to achieve in
other countries due to the obvious reasons.

------
tormeh
The YouTube channel Health Care Triage has a series on different countries
health care systems. Super interesting how different the systems are.

------
tim333
Not that it'd happen but it would be an interesting experiment if you could
try changing to the Singapore system in some part of the US. Say Hawaii or
Puerto Rico. It would be an upheaval but at ~1/3 the cost and longer life
expectancy it could be worth trying. Assuming the locals were up for it.

------
baybal2
I spent 2 years of my life in Singapore as an excange student 10 years ago.

>What Makes Singapore’s Health Care So Cheap?

I think they missed the most obvious reason: China

Singapore's public health system does not shy away from purchasing a lion
share of pharmaceuticals, disposables, and medical equipment from China.

And about C class, the 'conveyorised' healthcare is one of biggest cost cavers
when Singapore's medical specialist salary is approaching Western levels.
Doctors focus on throughput. The goal is to fix the person and kick him out of
hospital as fast as possible, and not to make everything possible to extend
his stay as '5 star hotel hospitals' do in USA

~~~
yardie
I think no one but a few moderately rich Canadians consider US hospitals
5-star. In my experience, most US hospitals, as soon as they find out you have
a little money try to do services add. The ambulance ride, nurse, specialist,
radiologist, MRI, bed, CATV, telephone, and meals all add up on that bill.

And once they've exhausted your insurance or personal finances then they kick
you out.

~~~
mywittyname
He's referring to the fact that insurance companies have shifted towards a
system where "patient satisfaction" is a key driver of payment. This has
caused a bit of a crisis in hospitals as executives push BS programs intended
to improve these scores and they often come at the expense of actual care.

It's becoming a huge issue in US hospitals

~~~
moduspol
It's not too surprising. The patient doesn't care what's being charged!

We'd see the same thing in other industries if market interference led to the
customer not being price sensitive. Like higher ed.

~~~
mywittyname
My understanding is that it's really just one more way insurance companies try
to avoid paying for hospital bills. My partner works in revenue recovery for a
regional hospital and it's staggering how awful insurance companies are.

I've heard many stories where waiting for insurance authorizations would have
literally cost people their lives, but the insurance has grounds to refuse
payment without it, so the hospital ends up eating the entire cost of the
person's care.

The system is so incredibly fucked up. Far beyond what most people think.

That being said, maternity wards are apparently the college campus of the
hospital world, which is why you see so many of them being built in rich
areas. They are insanely profitable.

------
CryptoPunk
>>But when hospitals competed, they did so by buying new technology, offering
expensive services, paying more for doctors, decreasing services to lower-
class wards, and focusing more on A-class wards. This led to increased
spending.

>>In other words, Singapore discovered that, as we’ve seen many times before,
the market sometimes fails in health care.

Why is increased spending on buying new technology deemed a failure? Maybe the
optimal healthcare spending level is far higher than what's spent now.

------
ygdrasil
Having worked in both Singapore and US, I find the key difference in
healthcare and other societal issues is the ideology. US: left or right,
liberal or conservative. Singapore: whatever works. After all Singapore is one
of the few living city states and less than 60 years old. Running a 200+ year
old huge nation state means complexity and challenges on an exponentially
different scale.

------
fiokoden
The key idea I see here is that instead of dumping money into insurers, you
have your own government mandated "health savings account".

People would be far less likely to overuse health services if they felt they
were paying personally.

That's a powerful idea.

~~~
m1sta_
Is there any good data on health service overuse?

~~~
fiokoden
My understanding is that overuse is one of the primary reasons health spending
is so high in most countries.

No data to back it up, might be wrong.

I can tell you I absolutely loathe pouring money into health insurers to prop
up an overused and wasteful system. I'd much rather something like this
personal account idea.

------
ausjke
Before I dive in, I want to say "size matters". Singapore is the size of a
city in US, whatever works for them does not apply to US as a whole.

~~~
ausjke
No,my point is that as a small country especially like Singapore, it is
easier/more-flexible to optimize healthcare etc comparing to US, it is not as
diversified as US population and thus much simpler to
manage/plan/organize/control etc. While it definitely is a good example, many
scheme there might not work at a large scale.

~~~
tormeh
Politically, I guess it does. Half of the US would rebell if you tried to
simply transplant the Singapore health care system to the US. The US is also
more attractive for lobbyists because of its size.

But economically it's obviously nonsense.

~~~
greeneggs
There are economic reasons why size matters. For example, Singapore is small
enough that you can get to any hospital from anywhere. In many areas of the
US, there are fewer accessible healthcare providers. (For example, less dense
regions, or urban areas in which all the competing hospitals have merged.)
Perhaps this doesn't matter if you want to set broad price controls or
nationalize the entire industry. But under Obamacare, it has made insurers'
lives more difficult.

