Universal health coverage in Singapore: An ethical reflection On 29 January 2015 Singapore’s parliament passed a law that will introduce universal lifelong health insurance coverage. At present, about seven per cent of the population is uninsured. This figure includes an estimated one in four citizens aged 65 years and over; low-income or unemployed Singaporeans whose insurance coverage has lapsed due to inability to make premium payments; younger Singaporeans or permanent residents who will be covered once they start work; those excluded by pre-existing conditions; and those who have opted out of the health insurance scheme for various reasons. By the end of 2015, however, universal health insurance coverage will be achieved for all Singapore citizens and permanent residents. This article discusses the transformation of Singapore’s national voluntary opt-out insurance for financial protection against catastrophic illnesses (or MediShield) to a compulsory insurance with universal health coverage (UHC) for life (or MediShield Life). This change is important for a number of reasons. Singapore’s health care system is relatively distinctive as a kind of quasi-market system that attempts to promote individual responsibility over one’s health, supported by an enabling state. As the out-of-pocket part of health care expenses is essentially paid for by the individual (through Medisave1, for instance), competition among service providers is relied on to keep costs down, ensure efficiency and enhance quality (Haseltine, 2013). While personal responsibility remains the key characteristic of Singapore’s health care system, the introduction of MediShield Life represents a more explicit recognition of more communal values, like solidarity and fairness. What is clear from the experience of Singapore is that, while individual responsibility was not the only drive to enable universal coverage, it did (together with other relatively more communal principles) create – after 50 years of nation building – the environment for this to be achieved. MediShield The philosophy of self-reliance and individual responsibility evident in Singapore’s health system (see Box: ‘Singapore’s health system’) percolates to Medisave, a mandatory savings account scheme. A working Singaporean contributes seven to 9.5 per cent of their monthly salary into this personal account dependent on age. Savings can be used to meet the health care expenses of the account holder, including hospitalisation, certain vaccinations, health screening and other outpatient services, and home-based hospice services. Responsibility is not limited to the individual, but shared with their family. Accordingly, if an individual is unable to meet the cost of medical care, their family is expected to be the first line of support. On this rationale, a family member is able to draw on their Medisave account to meet the health care expenses of their dependents. 118 Commonwealth Health Partnerships 2015 Along with a legal requirement for adult children to care for their aged parents, some regard these policies as reflective of Confucius’ precepts that are deeply embedded in the predominantly Chinese population of Singapore (Lim, 2012). What is clear from existing arrangements is that health care costs should not be borne exclusively by the state, but must first and foremost be the responsibility of the individual and their family. The private and voluntary sectors also have a role to play in addressing the challenge of escalating health care costs (Lim, 2013: p. 24). For the indigent, Medifund has been set up as a public endowment fund to serve as a safety net for Singaporeans who cannot afford to pay for subsidised bill charges. In addition, a capital sum of S$500 million was set apart as Medifund Silver to provide aid specifically to needy elderly Singaporean patients. Other schemes, such as the Community Health Assist Scheme, are available to enable Singaporeans from lower- and middle-income households to receive subsidies for medical and dental care. Medisave (or Medifund, for the indigent) may also be drawn on to pay the premium for MediShield, which was established in 1990 as a voluntary opt-out national insurance scheme to reduce the financial burden of catastrophic illness. MediShield covers hospitalisation expenses in restructured hospitals and approved outpatient treatments, such as kidney dialysis, chemotherapy and radiotherapy for cancer treatment. More recently, a severe disability insurance known as ElderShield has been introduced to enable those insured to risk-pool against the financial risks of such a condition. Coverage under this scheme is at best supplementary as it is unlikely to be adequate in the light of rising costs and the very real prospect of long-term care extending beyond six years. Calvin Wai Loon Ho Singapore’s health system Singapore’s health system gives emphasis to self-reliance, individual responsibility over one’s own health and collective responsibility in maintaining health care affordability. This is evident in its predominantly private primary health care sector, where private general practitioners (GPs) provide about 80 per cent of primary health care needs. Subsidised primary care services are available at public health care centres (or polyclinics), which provide about 20 per cent of the primary care services to all citizens, with certain groups (such as those under the age of 18 or above the age of 65 years) receiving greater subsidy. To discourage over-consumption, most Singaporeans are expected to pay for their own primary health care needs (with some subsidy from employment insurance, where applicable).
Commonwealth Health Partnerships 2015
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