L e a d e r s h i p , r e s o u r c i n g a n d g o v e r n a n c e government’s response was essentially positive, and similarly acknowledged that ‘a balance will need to be struck between the enhanced benefits and higher premiums, to ensure that the scheme remains sustainable and affordable for Singaporeans, and to guard against inadvertent over-consumption or over-provision of health care services’ (MoH, 2014). The inclusion of those formerly uninsured, including those with pre-existing conditions, indicated that the government was prepared to take on a share of the cost, on the premise that ‘all of us can shoulder a small part as a society to support and include this group’ (ibid), and help vulnerable groups with their premiums. On 5 June 2014 preliminary proposals were put forward as formal recommendations of the MLRC. Following their acceptance by the government, the main essence of these recommendations is now embodied in legislation. Higher claim limits will be established for the national health insurance system, while co-payments will be lowered. In order to keep premiums affordable, co-payment could not be completely removed and no change has been proposed to deductibles. The annual claim limit has been raised and the lifetime limit on medical claims will be removed. Substantial increases in claim limits for cancer treatments (including chemotherapy) have also been proposed. In addition, coverage will be widened to cover the medical claims of an insured person throughout the entire course of their life (subject to an annual limit). Coverage will extend to all eligible citizens and permanent residents who are not members of MediShield, and will include those who are already sick. Certain adjustments to premium settings will also be made. Premiums will be comparatively high among those who are young and healthy, as part of the contributions will be used to offset the even higher premiums that they will need to pay when they get older. This offset is currently taken to commence when an insured person reaches 70 years of age, and ranges from $30 to $449 a year, based on age of entry into the insurance plan. The MLRC has recommended for the offset age to be brought forward to 65 years, when most people would have stopped working. A critical inclusion not addressed by the MLRC has been the extension of MediShield Life coverage to HIV carriers and AIDS patients. Currently, these individuals are unable to get insurance coverage, while those already insured fear that their insurance policies will be voided if they make a claim. The financial cost of including those with pre-existing conditions (including HIV carriers) into MediShield Life is expected to be high, as they are likely to make claims from the moment they enter the insurance plan. Consequently, it would be fair for these individuals to pay a higher premium, which the MLRC proposes to be an additional 30 per cent on top of the premiums for their age group for a period of ten years. The added financial burden on existing members of the plan should not exceed three per cent of their current premiums. Even with this cost sharing, the MLRC was of the view that the increased collection will not cover even half the estimated cost of the widened coverage and the additional financial burden will have to be underwritten by the government. The government has announced that two-thirds of insured households with per capita family income of up to $2,600 a month will be provided with (possibly permanent) premium subsidies. A separate set of ‘transient’ subsidies over a period of four years will be applicable to all insured. Those aged 65–79 years will get some subsidy for their premiums, regardless of income level. Medisave top-ups have already been announced for the ‘Pioneer Generation’ (or those aged 65 years and older in 2014) over the entire course of their lives in recognition of their significant contributions to nation building as Singapore celebrates its 50th year of independence in August 2015.3 Other benefits include Medisave top-ups, cash assistance for those with moderate to severe disabilities, MediShield Life premium subsidy and subsidies for outpatient treatment for the indigent. To facilitate the transition from MediShield to MediShield Life, the maximum coverage age has been extended from 75 to 92 years of age, from March 2014. Similar top-ups over a period of five years have also been announced for those aged 55–64 years in 2014. The premiums of those who are aged 80 years and over will be entirely paid for by the government through subsidies and Medisave top-ups. Ethical lessons from Singapore’s experience Lincoln Chen and Kai-Hong Phua indicate that ‘the major lesson from Singapore is the need to constantly rebalance failures of both the market and the state’ (Chen and Phua, 2013: p. 931). One may perhaps extrapolate from this view to a more general proposition that a health system like Singapore’s should not be defined exclusively by a single principle. Clearly, solidarity needs to Distributive justice The importance of fairness becomes evident in the challenge of maintaining a collaborative social cohesion over a long period of time. More specifically, the extent of contributions and distribution of benefits must be fair, and should be in a manner that maximises utility for all. Fairness and equity have been recognised as having a focal role in the context of UHC (WHO, 2014: p. 7). As an initiative led by the World Health Organization, UHC has the goal of increasing affordable access to a wide range of health and preventive services, especially to the worse off in a given population. While centrally concerned with financing, UHC relates to coverage in general and hence, all barriers to coverage. In working towards UHC, all countries are encouraged to expand priority services, include more people and reduce outof pocket payments. Policies that are enacted to achieve these goals should be optimal both from the perspectives of fairness and benefit maximisation. Drawing from an essentially Rawlsian framework of distributive justice, fairness (taken to be synonymous with equity) gives emphasis to pro-poor policies, in terms of both distribution and contribution. Similar in effect to solidarity, fair distribution requires coverage and use of services to be based on need, and priority should be given to policies benefiting the worse-off groups. In contrast, fair contributions to the health system should be based on ability to pay and not by need (ibid: p. 8). 120 Commonwealth Health Partnerships 2015
Commonwealth Health Partnerships 2015
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