Subsidy and other Preoccupations 9

Another letter on the subject of means testing in the ST Forum today:


Means testing: Allow less well-off to pay less

WHILE I agree fully with the intention of means testing to bring about a more equitable health-care system, the operationalisation of the aim should not be to make the better-off pay more but to allow the less well-off to pay less.

The Health Ministry's decision to stick with the former indicates that health care is a zero-sum game.

All indicators point towards economic prosperity, so why the need to cut costs now instead of just boosting subsidies from the bottom?

Means testing for long stayers in hospital seems to be based on the following assumptions:

• Patients with more money are not spending as they should on health care.
• They are able to spend but they choose not to for reasons which the ministry feels are invalid.
• These patients deprive the more needy of their subsidies.
• Patients' ability to pay for health care correlates positively to their family income.

Although affordability is an important consideration when deciding on nursing homes versus hospitals or A-class versus C-class wards, I find it rather presumptuous to assume that elderly patients who can afford much better would choose a hospital over a nursing home with a better environment. For the elderly who have lived out a large portion of their lives, costs would probably be a lesser factor over environment and comfort, especially if they can well afford it.

Another debatable assumption in means testing seems to be definite familial support for the patient. Family income alone is not a good indicator of how well a patient is able to afford his hospital bill. A family that willingly supports an elderly patient would necessarily give him the best health care and comfort within its means. However, immediate family members have their own family units to take care of.

Furthermore, not all families follow the 'seniors first' rule. In the event of having to choose between paying for one's child and one's parent, many would choose to support the child.

Health care is an essentiality which no one should be deprived of, regardless of the patient's supposed ability to afford higher fees. Policies should not be made based on assumptions of familial support or dubious claims that high-income patients choose to stay in a poor man's ward.

Fang Shihan (Ms)


Ms Fang makes some valid points, but angry doc thinks some of her assumptions are wrong.

"Although affordability is an important consideration when deciding on nursing homes versus hospitals or A-class versus C-class wards, I find it rather presumptuous to assume that elderly patients who can afford much better would choose a hospital over a nursing home with a better environment."

It makes sense to think that a patient who does not need to stay in a hospital would choose to go to a nursing home instead, but in practice patients resist this as it actually costs less to stay in a C-class ward in a hospital than in a nursing home if one fails the means test. This is in fact one of the reasons given for extending the means test to hospitals (see item 13.).

"For the elderly who have lived out a large portion of their lives, costs would probably be a lesser factor over environment and comfort, especially if they can well afford it."

Again, it makes sense, but in angry doc's own experience this is not always true. In fact, many of the elderly patients he has met are obsessively thrifty when it comes to healthcare expenditure. Patients have asked for 'standby' medication to be added to their subsidised prescription for their overseas trip to China or Korea (thus helping them save a few dollars for a trip that costs them a few thousand dollars).

"Health care is an essentiality which no one should be deprived of, regardless of the patient's supposed ability to afford higher fees."

angry doc would once again like to state that he is not a fan of means testing in its current proposed form, but he nevertheless thinks that we should as far as possible be precise and accurate when we discuss this issue. Means testing in its current proposed form does not "deprive" anyone of healthcare. It does not even "deprive" anyone of subsidy, but just reduces the amount of subsidy they receive. If we misrepresent means testing in an effort to discredit it, we stand to lose credibility ourselves.

"Policies should not be made based on assumptions of familial support or dubious claims that high-income patients choose to stay in a poor man's ward."

Here angry doc agrees with Ms Fang. angry doc would like to know how much we stand to 'save' if means testing was implemented. Perhaps there should be a data-gathering phase where patients who stay for more than 5 days in the C-class ward are subjected to the proposed means test questionnaire. Perhaps it is already being planned or implemented.