Angry Doctor

Friday, April 13, 2007

Subsidy and other Preoccupations 6

As expected, a letter on the ST Forum on means testing.

Mr Chang sounds angry, and his letter looks a little disorganised (and angry doc had to rearrange a couple of paragraphs to make his commentary below). He uses many arguments that people use when faced with the prospect of paying more for healthcare. Let's have a look at them together, shall we?

"I STRONGLY disagree with the plan to introduce means testing in public hospitals ('Means testing in hospitals within a year'; The Sunday Times, April 8).

Why are Singaporeans paying more in income tax, based on earnings, and getting less or no subsidies in hospitals? Isn't this a double whammy? Middle-income earners are likely to be the hardest hit again.

What is the justification for taking away subsidies because of a heavier patient load in hospitals? The heavier load should be managed through beefing up health-care staff and more funding from the Government. This is especially so in the face of an ageing population."

At first glance Mr Chang's argument makes sense: why should one tax-payer receive less subsidy compared to another tax-payer who has a lower income, since he, by virtue of the fact that he has higher income, pays more taxes? Let the government government rather than tax-payers pay for the required funding and staffing, he argues.

Now assuming that the other government expenditure remain static, any increase in government funding in healthcare will necessarily come from taxation. And if we assume that this taxation will come from income tax with the same exemption for people who do not make the minimal taxable income, such a system will benefit the lower-income group, and 'penalise' the middle income group who do pay income tax, and also all tax-payers who do not utilise the subsidised healthcare system.

So at the end of the day, unfortunately, a middle-income earner will still have to pay for his healthcare, either out of his pocket or through his taxes.

(If you are interested, angry doc has previously tried to estimate how much increase in taxation a fully funded healthcare system will mean.)

"Hospitals already have a first-line check. The minimum entry level is B2 class. Downgrading to C class involves much red tape, which prevents people from abusing the system."

angry doc is not sure that the minimum entry level is B2 class, but downgrading to C class is difficult, although there are ways to beat the system...

"Having a child with a critical long-term medical condition means having to visit the hospital on average once a week, be it inpatient or outpatient.

The Government has been encouraging young parents to have more children but its actions are not in sync with this drive."

One can in fact utilise the same argument to argue against an increase in the cost of almost everything: petrol prices because children need to go to school, food prices because children need to eat, property prices because they need a place to sleep, and so on. O! won't somebody please think of the children?

To be fair the government does provide many things in the form of free healthcare for children, such as free immunisation and free screening by the School Health Service Division, and until recently free weight reduction programme in the form of the TAF Programme.

"As a Singaporean and a taxpayer, I would expect to be taken care of and not have to compromise on health care because of uncertain financial support.


Medical subsidy should not be given on a case-by-case basis. It should be an entitlement of the Singaporean taxpayer, who should not have to 'beg' for it during trying times.

Chang Kiang Meng"

These two paragraphs give the two key obstacles to the implementation of means testing: that it offends our sense of entitlement, and that it can be demeaning.

angry doc believes that most Singaporeans do view healthcare subsidy as an entitlement - something they earned just by being a citizen and a tax-payer - and so it seems like a perversion of justice when those who pay more taxes should be denied benefits from the very system they have contributed towards.

angry doc is no fan of means testing, but he nevertheless thinks he might need to re-examine this sense of entitlement. Means testing in its current form does not deny one subsidy altogether - it merely reduces the amount of subsidy one receives - nor does it deny one affordable healthcare. If we all make the connection that the subsidy being given comes from the taxes we pay ourselves, perhaps the idea of means testing will become more acceptable?

The final sentence in Mr Chang's letter tells us the other reason for resistance to the implementation of means testing: people do not like to beg.

Being subjected to means testing can be a demeaning experience. One is required to provide proof of one's poverty, as it were.

angry doc has seen some patients who would rather give up on their applying for financial assistance than to turn up for the interview and provide the required income data. Perhaps they didn't really need the financial assistance or would not have made the cut. Perhaps their per capita household income was too high, but their family did not give them enough money to see the doctor. Perhaps their pride did not allow them to go through the whole process.

Whatever the case, angry doc imagines that the means test is one test that a patient wouldn't feel good about whether he passes or fails it.

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  • Well, the entitlement mentality increasingly pervading society must be stopped at some point, and I guess means testing is a step in that direction. Though some people will object to it, you have to admit it is a double-edged sword - it helps some purposes just as it hinders others.

    Did that make sense? Maybe I've been revising too much...time for me to shut up and toodle back to the library.

    By Blogger The Angry Medic, At April 14, 2007 7:43 am  

  • I accept that government healthcare funds needs to be rationed, but I am not sure rationing by income-level is an ethical way of doing things.

    I believe in rationing by need of treatment, but in practice this can be difficult to implement, takes moral courage on the part of the government and healthcare workers, and is of course politically unpopular.

    By Blogger angry doc, At April 14, 2007 6:37 pm  

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