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Singapore: Where Affordable Care is a Reality


Efficient health care tied to affordable cost, high quality, and universal access is possible, at least if you’re a country called Singapore. In April, Brookings Press published Affordable Excellencethe first “comprehensive system-level description” of the Singaporean health care system. Tyler Cowen is in Singapore this week, and he’s written a few posts on its health care, pivoting off of the Brookings book and his own conversations in the country:

Yes, the system really is a marvel, and no it is not laissez-faire.  The mix of “private money, public provision” has some marvelous properties for economizing on costs, not the least of which is that private hospitals and doctors and medical device salesmen do not become too strong a lobby.  And the level of conscientiousness in Singapore is high enough that the public hospitals work fine, though they don’t in general have the luxuries of the private hospitals.  Furthermore those public hospitals have to compete against each other for patient loyalty and thus revenue, and so the reliance on private money helps discipline public hospitals […]

In any case let’s start by admitting, and keeping on the table, the notion that the current version of the Singapore system is indeed a poster child of some sort.

One thing that’s not clear to us from what we’ve read so far is if and how Singapore’s system facilitates innovation. We simply cannot solve the global health care crisis without innovations in medical technology and service delivery.

Nevertheless, we do get this feeling that the tone of the debate since Obamacare’s rollout has stagnated. Singapore shows us that there are all sorts of interesting models out there that defy the easy categories of our own domestic discussion. Singapore’s system shifts a lot of costs onto the consumer directly, but it also has single payer for catastrophic insurance and lots of public provision of care. It combines these things that libertarians and conservatives generally like—see this 2012 guest piece talking Singapore up by Avik Roy—with targeted government intervention that goes beyond what American conservatives are generally comfortable with.

With the very important caveat that America is a very different place than a small Asian city-state, or even a medium-sized European country, studying how other countries have gone about solving these problems is probably a very good idea.

[Photo of stethoscope and money courtesy of Shutterstock.]

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  • NCMountainGirl

    I bet tort lawyers aren’t part of the system in Singapore.

    Funny but doctors are far more efficient and less likely to practice defensive medicine than the big regional hospital. I suspect there are two reasons for this. One is the doctors have an equity interest in their practices and are aware of medical economics. The other is that people don’t like to sue doctors who have good beside manners -even when they make a mistake. They are quick to sue institutions such as hospitals and drug companies.

  • Anthony

    “No it is not laissez faire” – lets solve U.S. health care conundrum before we venture into “global health care crisis”.

    As mentioned before on Via Meadia, policy discussion needs to turn to how health care is sold domestically; that is, true health care reform that not only expands coverage but also halts escalating cost begins with how its delivered (sold) going forward. Government provided health care as well as private health insurance (with tax deductibility) give incentives to sellers of health care. Health care providers are making a bundle of money and have every incentive to continue on $$ laden path.

    Hospitals in America do not get paid more money if they do great work. they get paid a lot more more money for patients and chronic illnesses. Time to examine the reimbursement system that appears to be leveraged towards the sellers of health care (while acknowledging that health care spending is most efficient when that spending is done by individual patients and not third parties).

    • Kavanna

      One thing is clear: ObamaCare is not reform. It’s just doubling down on a baroque system of medical financing that’s slowly bankrupting the country.

      Many countries have moved toward a market-oriented (but far from “laissez-faire”) system based on tax-free insurance. In developed world, most systems are converging on a mix of universal, government-sponsored basic care and tax-advantaged supplemental private insurance. Canada moved in that direction in the last decade, while much of northern Europe went there in the 90s, as did Australia, New Zealand, and Israel.

      The countries that reformed their socialized systems in the last 25 years or so (and there are many) were usually forced to do so by impending or actual bankruptcy. The major unreformed delinquents remain France, Italy, … and the US, heading ever faster in the wrong direction. I suppose change will take having our backs to the wall, as Canada went through in the 90s.

      Anyone interested in this should look at the work of Laurence Kotlikoff of Boston University.

      • Anthony

        I’m sorry but my comment was posted in August and it is now October…

  • wigwag

    Singapore mandates that all citizens regardless of age procure health insurance. That’s right Professor Mead, Singapore has, in your ridiculous parlance declared “war on the young.” There’s not a Democrat in the United States who wouldn’t favor adopting the Singaporean system in a flash; there’s not a Republican in the country who wouldn’t have a hissy fit if Congress adopted that system.

    In terms of government control of health care, Singapore’s system is Obama-Romney care on steroids including direct price setting by Singapore’s government.

    Professor Mead, your posts on health care are becoming increasingly schizophrenic and incoherent.

  • AndrewL

    Question: How much of Singapore’s health care success is due to the lifestyle of its people? Compared to American diet, East Asian diet consists of more rice and less meat. Due to the high population density, East Asians rely more on public transportation, which would involve more walking than driving solo. It would be interesting to know the incidence of heart disease, stroke, diabetes among Singaporeans. If the incidence is a lot lower than America’s, then we shouldn’t expect much benefit emulating Singapore’s model.

  • Kavanna

    Indeed, the US has 5% of the world’s population, but far more than that of the world’s lawyers. It will take years, even with the current crisis in law education and legal employment, to de-lawyer-ize our society and undo some of the damage done over the last 30 or 40 years since the law revolution of the 1970s.

    And will people stop with the “laissez-faire” nonsense about health care? We don’t have a laissez-faire system now and haven’t had one for many decades, since the 1930s (if you start with the rise of regulated private insurance) or the 1910s (if you start with the rise of state and federal regulation and professionalization).

    More than half of health care spending in the US is already government-based. Most of the rest is strongly shaped by government-subsidized and regulated private insurance.

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