Thursday, April 27, 2017

Singapore Health Care Costs

This is Joseph

Ezra Klein has a very good Vox article on US versus Singaporean health care systems in terms of health care cost control.  The real crux of the issue is here:

According to the World Bank, in 2014 Singapore spent $2,752 per person on health care. America spent $9,403. Given this, it’s worth asking a few questions about what Singapore’s model really has to teach the US.
Are Singaporeans really more exposed to health costs than Americans? The basic argument for the Singaporean system is that Singaporeans, through Medisave and the deductibles in Medishield, pay more of the cost of their care, and so hold costs down. Americans, by contrast, have their care paid for by insurers and employers and the government, and so they have little incentive to act like shoppers and push back on prices. But is that actually true?
I doubt it. The chasm in total spending is the first problem. Health care prices are so much lower in Singapore that Singaporeans would have to pay for three times more of their care to feel as much total expense as Americans do. Given the growing size of deductibles and copays in the US, I doubt that’s true now, if it ever was. (It’s worth noting that, on average, Singaporeans are richer than Americans, so the issue here is not that we have more money to blow on health care.)
According to Singapore’s data, in 2008 cash and Medisave financed a bit less than half of the system’s total costs. Let’s say, generously, that’s $1,200 in annual spending. According to the Kaiser Family Foundation, the average deductible in employer health plans is now $1,478 — and that’s to say nothing of premiums, copays, etc. And of course, average deductibles outside the employer market are much, much higher.
The key issue that Mr. Klein's article rests on is that people in Singapore are wealthier than Americans.  So you can make some pretty good inferences about their health care costs being translated to the United States, as it avoids the issue of whether or not we spend more on health care because we have more to spend.  Americans spend 3.4 times as much on health care as Singapore which means the funding instruments that Singapore uses would need to be scaled up.

So Medisave (between 7 and 9.5% of income) would translate to 24 to 32% of income (maybe more as Americans are poorer so there would still likely be shortfall), and then you would have to pay Medishield premiums (hard to imagine these are less than 10% if they also have to be 3.4 times as large). This is before payroll taxes (say 15%), income taxes and sales taxes, in terms of the total government mandated spending and taxation.  This seems very high and would immediately make the United States a very high tax country (remember Medisave is a government mandate).

The other amazing point in the passage above is that deductibles in the US now exceed total costs in Singapore (by a fair bit).  This gives absolutely no evidence that increasing the amount of  "skin in the game" is going to accomplish anything like a transition to a lower cost system (if the cost to consumers is what matters we already exceed what Singapore spends, and our costs do not appear to be rapidly declining).  We have talked before about how the health care system resists patients bargain shopping (or even identifying real costs in advance) and has a monopoly on many services (like pharmaceutical medications).

If we want to reduce costs then we really need new ideas (government regulation?).  Because just passing costs to the consumer isn't doing much to reduce total costs, relative to other health care systems.  This is not to say that there is nothing to be done, but that increasing costs to consumers increases suffering and is having little effect.  Perhaps the redesign of the ACA (AHCA), as it continues to undergo revision, should grapple with creative ways to improve the affordability of health care in the United States.

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