I finally paid attention on his third attempt, by which time he had written a piece for The Online Citizen about his many observations. I'm not going to dwell on most of them, but only the bit about Medifund, which serves as the take-off point for this essay.

First, however, I need to describe Singapore's four funding pillars for healthcare costs:

Medisave -- this is a compulsory savings scheme for medical expenses. One can use the money from there to pay for most kinds of hospital treatments and some kinds of outpatient treatments, subject to a complex set of limits. [2]

Medishield -- this is an opt-out insurance scheme. Basically it covers 80 – 90% of hospital treatments for catastrophic illnesses, after the patient has paid the first $1,500 in each year ("the deductible") [3]. The patient can pay the deductible with his cash or his Medisave. Premiums for the Medishield scheme are paid through deductions from the Medisave accounts. Since 1 December 2007, all newborns are covered (opt-out basis) by Medishield with a premium of just S$30 per year. The scheme will be expanded to cover other young children progressively.

Medifund -- an endowment fund set up by the government since 1993 that acts like a charity giving out money to those who are too broke to pay for medical treatment. The government utilises interest income from the capital sum, which currently stands at S$1.48 billion, to finance the needy. [4]

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:

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,

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.

© Yawning Bread