Hope no one has posted this article:
http://www.yawningbread.org/index2.htm
Yawning Bread. 4 January 2008
The healthcare funding gap
.....................
What piqued Leong's interest were the discrepancies in various
numbers reported in the Straits Times.
On 4 December 2007, the headline of a story said "Record 301,000
needy patients get help from Medifund". It reported that a total of
"307,500 Singaporeans applied to Medifund" in 2006, of which only
6,500 or 2.1% were turned down.
It also reported that Medifund gave out a total of S$39.6 million
in 2006.
Leong's quick calculation revealed that on average each beneficiary
received only S$132. His point was that this was not only
remarkably stingy on a per capita basis, but looks even worse
compared to 2001 pay-out of S$174 per head. (I don't know what his
source was for the 2001 figure.) This, especially as healthcare
costs have been climbing more rapidly than inflation.
He also seized on another fact reported by the Straits Times: the
figure of 6,500 people turned down was a 30-fold increase over the
number disappointed in 2005. More proof of stinginess?
Then on 27 December, another story appeared in the Straits Times,
which threw the above figures into doubt. This story led with the
decision by Dover Road Hospice to leave the Medifund scheme,
because the hospice didn't think it was any use to them or their
patients.
When the hospice joined the scheme in 2004, it did not know the
extent of what was needed for patients to apply successfully for
aid.
They typically have to produce documentation to show that they and
their family members have little or no money left in their Medisave
and bank accounts.
The hospice's practice, however, has always been to subsidise needy
patients from its coffers before they reach such dire straits, Dr
Chan said, so Medifund has never come into the picture.
Furthermore, it did not want dying patients and their families to
be stressed by exhausting their savings, and having to prove
it.
-- Straits Times, 27 Dec 2007,
Hospice pulls out of Medifund
What was interesting was that buried within that story was the
mention that
The hospice's withdrawal came to light this month when the Health
Ministry released its annual report on Medifund [5], the
Government's safety net for those who cannot pay their medical
bills. Last year, a record $39.6 million from Medifund was given to
20,000 to 30,000 patients, who made a record 301,126 successful
applications.
-- ibid
As you can see, there weren't 301,126 beneficiaries as earlier
reported, but only 20,000 30,000 patients (now why is the figure
so vague?), who each made an average of 10 15 applications in
2006.
20,000 30,000 is much more believable. It's about 10% of
approximately 300,000 hospital admissions a year (based on the
Health Ministry's statistic of 91 admissions per 1,000 population
in 2005).
It also works out to a Medifund pay-out of S$1,300 to S$2,000 per
patient instead of $132.
But this now begs the question: How many people were behind the
6,500 Medifund rejections in 2006? Was there really a 30-fold
increase in rejections compared to 2005?
Leong believes that the number of people rejected would be close to
6,500, because if you're rejected once, are you going to continue
doing paperwork to apply again? If his theory is right, then 20
25% of patients are turned away by Medifund.
* * * * *
What this all shows is this:
1. We don't really know the facts.
2. People get very suspicious of the government when contradictory
information comes out in dribs and drabs, and this certainly does
the government no favours when healthcare costs are already such a
hot potato.
Conceptually, the 4 pillars -- government subsidies, Medisave,
Medishield and Medifund -- should offer pretty comprehensive
coverage. However, each has so many exclusions that the end result
is hardly comprehensive.
For example,
1. subsidies do not cover HIV medication;
2. Medisave cannot be used for outpatient treatment except for
diabetes, hypertension, blood lipid disorders and stroke, and even
these are subject to a limit of S$300 a year;
3. Medishield insurance does not cover congenital and hereditary
conditions, mental illnesses, HIV and Aids treatments, dental work
due to accidental injuries and so on [6]. And amazingly, Medishield
coverage stops (yes, stops!) when you reach the age of 85 or when
you've spent a maximum amount over a lifetime.
4. Medifund is an entirely discretionary scheme, operated in quite
an opaque manner. Leong Sze Hian had asked in his article for the
eligibility criteria to be made public. I suspect there are no
fixed criteria. It is important to note the statement that Medifund
payments come out of the interest earned from the endowment fund,
so the critical decider is how much money there is, rather than
what your needs are.
The effect of all these exclusions is that there are plenty of
cracks for people to fall through. What if your Medisave account
has been exhausted? What if Medishield does not cover the illness
that hit you? What if Medifund has run out of money for the
year?
It is also very frustrating when you try to navigate the system.
It's like having bought something only to discover later that the
warranty actually doesn't cover this, that and an unknown hundred
other eventualities.
Why is the system like this? you ask. It seems to come out of a
number of ideological impulses. How much you can spend from your
own Medisave is limited because the government wants to save you
from your spendthrift self, as if limiting the amount you spend on
healthcare will make you less sick. Excluding HIV and mental
illnesses is entirely due to irrational moralistic reasons. The
various Medishield exclusions appear to spring from an aversion to
cover costs that aren't easily calculable, even though it claims to
be an insurance scheme.
Going by what Dover Road Hospice said, Medifund requires you and
your family to prove, with documents, that you are destitute before
they -- maybe -- step in to help.
There is a huge gap between what the people consider an acceptable
system and what the government is prepared to deliver. People want
a comprehensive system that is easy to understand and navigate. The
government, ever paranoid about people becoming dependent on the
state and always suspicious about abuses in claims, wants a system
that limits their liability and is abuse-proof. Thus the recent
proposals to add means-testing to all the above exclusions.
For political sell, the government likes to claim that they have a
well-thought out, comprehensive healthcare funding system, but
looking at the details, they appear motivated to do the minimum
they can get away with. When people see that, doubts arise over the
government's sincerity, and this very fundamental distrust bedevils
the debate.
Or, to put it another way, the average person's conception of a
social safety net is to have a set of clear entitlements and
guarantees that assure them that, come what may, basic medical care
will be available and paid for by the state. Such an idea alarms
the government; they see it as entitlement -- in the People's
Action Party's eyes, one of the worst mistakes any state can
make.
So ultimately, to the people's question, "Is there a basic
guarantee of a safety net?" the short answer, despite the
government's spinmeisters talking around the issue, is "No." And in
that gap is a fatal moral problem.
