The American humorist Will Rogers once said, “I am not a member of any organized [political] party. I am a Democrat.” Likewise, today’s Americans could say they don’t have an organized, logical or practical healthcare system: they have Obamacare.
Except not everyone has Obamacare, more properly called the Patient Protection and Affordable Care Act. The United States does not have any form of universal healthcare, but instead a hybrid patchwork of private insurance (employer-provided and individually purchased) and government-provided (social insurance such as Medicare and social welfare such as Medicaid).
US Opposition to ACA and Single-Payer
The ACA itself wasn’t a healthcare plan per se, but a series of compromise consensus reforms, designed to extend insurance to the uninsured and the under-insured (those who couldn’t afford or didn’t want the expense of insurance, as well as those who were kept out of the market because of expensive-to-treat pre-existing conditions) through a series of carrot-and-stick reforms. Its eventual goal was universal health coverage for every American, though not necessarily under one plan or system.
Single-payer – as is the norm in Canada, the United Kingdom and Australia – was a non-starter due to the perceived expense. Actually, healthcare in the US cost nearly 18% of Gross Domestic Product (GDP) in 2015 (almost $10,000 per capita) compared to the cost in single-payer nations such as Canada (10.2% or $4,351) and the United Kingdom (less than 10% or about $4,000). Another concern is the fear that single-payer would lead to Socialism. (Why that is such a fear is tied up in anti-Communist hysteria dating back to before the Russian Revolution that no sane nation is expected to understand.)
The ACA has faced similar criticism, but now that it is faced with potential repeal and replacement by the ruling Republican majorities in the US Congress and the sitting president, it is becoming more popular. The fact that nonpartisan estimates of the costs of both proposed replacement plans left many more people uninsured while reducing taxes on the wealthiest Americans has not gone unnoticed either.
Considering the Singapore Scheme
Now that the two plans are stalled, possibly dead, members of both mainstream political parties are considering other options, including seeing what other countries do to deliver better healthcare at less cost. One nation’s healthcare system that some analysts have said the US would do well to emulate, at least in part, is Singapore.
Last year Sean Masaki Flynn, an associate professor of economics at Scripps College wrote that Singapore is in the top-five for several categories – infant mortality, maternal mortality, life expectancy – and (according to Business Week metrics) the healthiest country in the world. Singapore spends 4.9% of its GDP on health care, or about $381.
Earlier this year Conservative New York Times columnist Ross Douthat argued that the Singapore model would be a better and more conservative healthcare plan than any the Republican leadership has proposed but predicted they would never accept it because they would consider it too paternalistic and statist.
How Singapore Manages Healthcare
Singapore seems to operate midway between a single-payer system like in the UK and the total free market favoured by the US Republicans. In Singapore:
- Insurance only covers catastrophic health problems.
- Patients fund it through mandatory health savings accounts – 8-10.5% of income, based on age – held and invested by the government, but tax-free, interest bearing and inheritable.
- The government supplements the accounts as needed, up to 80% of the total bill.
- Prescriptions and doctor visits for ordinary ailments are ordinarily paid for by the patient out of pocket.
- The vast majority (80%) of hospitals are publicly run.
- The government strictly controls costs, including prescriptions, devices and surgeries.
Health Savings Accounts
The health savings account (HSA) also is an important element of Republican ACA replacements, though a voluntary one. Though they exist already, taxpayers would be encouraged to place money, tax-free, in a HSA to pay for their medical expenses. The idea is that they will be more careful with spending on health care if it’s their own money. If they don’t spend the money, they get to keep it and spend it on whatever they want.
Unfortunately, many Americans have trouble saving money in traditional savings accounts, so the notion that they will be able to save money in a dedicated health savings account seems slim. It doesn’t seem likely US Republican lawmakers would endorse mandatory deposits – how is this different from a tax? – when the ACA’s individual mandate that all citizens must purchase health insurance is anathema to them.
What about Substance Abuse Treatment?
One thing that the Singapore healthcare plan doesn’t cover (though that could be modified if the US adopted it) is most substance abuse treatment. That’s because Singapore has some of the most draconian anti-drug laws in the world. Dealing in drugs is a death sentence, and illegal drug alone results in mandatory treatment and rehabilitation, including cold turkey detox, paramilitary style training and incarceration.
Dr. Muni Winslow, an addiction specialist, recalls that when he went to work for the Singapore health service, only nicotine and alcohol addictions were to be treated (though for the best alcohol rehab centers Singaporeans often leave the city-state). All other drug users were criminals, and that “the police and prisons are there to treat the drug users”. He got around this, to some degree at least, by recognizing that addiction is usually comorbid with a mental illness, and putatively treating them for the co-occurring disorder of their dual diagnosis.
US Is Not Singapore
But the main problem with the US adopting a Singapore-style healthcare plan may be that the US is not Singapore. There are behavioural differences that lead to worse health outcomes in the US, and so greater health expenses, such as car and gun ownership, and more alcohol and drug use. Far fewer Singaporeans drive, drink or use drugs, and gun ownership is prohibited.
Also, Singapore trusts its government – the same party has ruled since independence in 1965 – and is comfortable with what US conservative Republicans would call a “nanny state”. They considered the more modest ACA a government takeover of healthcare although it left the private health insurance markets intact.
The US probably can’t implement the Singapore scheme, but it can certainly improve its healthcare delivery and better control costs. Canada, the UK and other single-payer nations are better models to emulate.
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