Means Testing (3)

"Means Testing" is assessing a person's income to decide whether they are poor enough to receive government benefit programmes. Most welfare programmes are means tested; you can only receive a benefit if your income is below a particular level. Sometimes a banding system is used so that the amount of benefit you receive is more closely related to the level of income you have. Some benefits, however, are universal benefits paid to individuals regardless of their income or wealth. The mix of universal and means tested benefits varies from country to country, and is often politically sensitive.

Is means testing the most effective way of redistributing wealth to the poor?

Is means testing more efficient approach than universal programs?

Will means testing help reduce corruption and fraud?

Are there ways to get around the potential problems of a dependency culture and means testing?

Is means testing better than universal access?

Means Testing (2)

Straits Times, 14 Jan 2008

Debate on means testing should go beyond cost

MOST of the arguments concerning means testing have dwelt on cost issues. While not unimportant, perhaps the debate should catalyse a broader rethink on how we conceive the health-care system.

Firstly, to all the bargain hunters out there: there is no free lunch. If people regularly expect to pay less for a medical consult than a hairdo, we have a serious reality distortion field in place.

Secondly, health is good to have, but it is not a right. And when it falters, it often takes more than grandma's advice to put things right.The sooner people, led by unrealistic expectations, stop playing a game of emotional blackmail with the Government, the more likely we will have a sustainable health- care system that can scale what it delivers to reflect advances in delivery methodology and our ability to pay.

Maintaining a consistent level of quality right through the care chain is vital, but it costs. If you do not know what this means, have an accident in any nearby country and see if out of 100 times, you end up as well as you would if it had occurred in Singapore.

Thirdly, more Singaporeans have to think about allocating some of their assets to health insurance, meaning, in addition to money, time and mindset.

It is a fallacy to equate wealth with health, though the converse is probably true. Insurance is also about doing what one can to reduce the risk of illness.

If someone invests foolishly and incurs loss, we accept it as a personal problem. If someone gets sick because he did not bother to maintain a healthy lifestyle, the prevailing populist view is that it is still the Government's responsibility to bail him out. Does this make sense?

Fourthly, for all its supposed warts, the health-care system is as compassionate and as caring for the poor as they come. It really is not a trivial thing to say because it is not so in much of the world.

Many people worry that they will be left out, but in reality, how many hard-luck cases are turned down? Delays, nuisances and irritations there will always be, but what counts is the final outcome.

Means testing is long overdue and will benefit the populace in the long run. The timing is right and in time to come, people will look back and say, although seemingly tough, it was a measure that allowed public health to scale upwards along a new architecture that befits Singapore's ascendancy into the league of First World nations.

Means Testing (1)

Straits Times, 8 Jan 2008.

Means Testing: Why the health system needs it and how it can work

How can the state allocate health-care resources to those who need them most? Health Minister Khaw Boon Wan pondered the question yesterday and drew a parallel to public housing.

How HDB does it
SINGAPOREANS are familiar with means testing through the public housing system.

What are the options?
From one- and two-room rental flats to three-, four- and five-room owner flats.

Any subsidies?
Yes, for flats bought directly from the HDB, subject to an income ceiling. Buyers of smaller flats get proportionally bigger subsidies as these flats are meant for lower-income buyers.

To qualify for a subsidised flat, applicants cannot earn more than $3,000 a month for a three-room flat, or $8,000 for a five-room flat.

Has it worked?
Yes, most people consider the system fair. This is clear, going by the complaints aired when owners of three-room flats are seen driving Mercedes-Benzes. To their minds, someone who can afford a high-end car should not be depriving a poorer person of a subsidised flat. They are somehow 'getting around the system'.

How MOH does it

THE Health Ministry takes a different approach to giving subsidies.

What are the options?
From Class A to B1, B2 and C. While all patients get good clinical care, wards differ in amenities, access and comfort.

Class C wards have more beds and no air-conditioning. The patients there are treated by doctors on rotation and queue longer to consult specialists.

Class A ward patients have privacy and greater comfort, a choice of doctors and shorter waiting time for consultations.

Any subsidies?
Yes, up to 80 per cent for Class C wards. Patients can choose any class of ward, irrespective of how well-off they are.

Has it worked?
Yes, the system has its merits. Patients have freedom of choice and peace of mind, knowing they can opt for health care they can afford, even for prolonged and expensive hospitalisation.

Those in the middle-income group worry that major complications would wipe out their finances, a concern which is valid and of which the ministry is well aware.

It's not sustainable
TWO questions must be raised about MOH's approach.

Is it fair?
Last year, the Government gave out more than $1.5 billion in health-care subsidies. While this sum can be increased, it cannot be unlimited.

A high-income patient occupying a Class C or B2 bed deprives a low-income patient of that place. While the former can afford an alternative, the latter cannot.

Will access for the poor be further eroded as standards in subsidised wards improve?
In the past, the differences between the private and subsidised wards were stark. Class C wards could have as many as 40 beds each.

But the gap is closing. Class C wards now have about 10 beds each. In the new Khoo Teck Puat Hospital, they will have their own in-ward toilets instead of having to share such facilities with other wards.

Subsidised wards will approach the standards of private wards and yet cost much less. Patients who can afford B1 may then opt for B2 and C instead, which reduces the number of beds available for lower-income patients.

This has happened with polyclinics, which have improved so much that they are better than many neighbourhood general practitioners (GPs). Patients who used to go to GPs to avoid the queues at the polyclinics are now turning to polyclinics for better care for much lower fees.

The result: Overcrowding again at the polyclinics.

A different way

ECONOMISTS have two ways of dealing with demand that exceeds supply.

What are the options?
They either raise the price till demand drops to meet supply, or let the queues for subsidised services sort it out. Those who can afford private treatment and do not want to wait will drop out of the queue.

Is there a better way?
There is a third way:

Firstly, it is clear that all emergency cases should be attended to, regardless of the patient's ability to pay. It is also clear that frills like cosmetic surgery should not be subsidised.

In between is a range of treatments which can be tailored to different needs and abilities to pay. As living standards improve, new and better treatments can be extended to subsidised patients. But these must not unwittingly draw those who can pay but are attracted to the lower fees.

A fair and practical way to share limited resources is to get higher-income patients to co-pay more for the same treatment than lower-income patients. This means that if they opt for subsidised treatment, they will get less subsidy than someone who earns less.

While the principle is sound, implementation is challenging. The aim is to find a fair way of sharing resources which does not impose a burden on patients.

Judge & Jury

Melvin Beaunorus Tolson (February 6, 1898–August 29, 1966)


Who's the judge?
God.

Why is it God?
Because He decides who wins or loses, not my opponent.

Who's your opponent?
He doesn't exists.

Why doesn't he exists?
Because he's a mere dissenting voice to the truth that I speak.

The Public Demands Better

“Director ISD met me and told me that he accepted responsibility for what has happened and apologized. Having known him for many years, I told him that I have full confidence in him and he must carry on.”
- DPM Wong Kan Seng

“I am satisfied that the Ministry has taken the correct remedial and disciplinary action, and that the Minister and top management were not to blamed for what has happened. DPM Wong Kan Seng and the Director of ISD both continue to have my full confidence."
- PM Lee Hsien Loong

The long awaited report into the escape of JI member, and alleged terrorist Mas Selamat Kastari on 21 April 2008, came as no real surprise to many people. As a taxpaying citizen of this country, I am extremely disappointed with the way the report has accounted for the security breach, and the glaring lack of government accountability on this debacle.

With each passing day that this controversy does not have closure that meets the growing expectations of discontented citizens, the window of opportunity for the government to show exemplary integrity, humility and leadership gets more narrow, particularly for the Ministry of Home Affairs as well as our Prime Minister.

Needless to say, this incident has also put the relationship of the government and it's people under further strain, from which the "great affective divide" gets even wider. That is bad for Singapore, and worse for Singaporeans, as our social compact is once again put to the test, with dismal results.

The public demands better. They deserve better, and rightly so. The winds of change have already begun to billow. Dissension has taken root.

“Perhaps nothing in our society is more needed for those in positions of authority than accountability. Too often those with authority are able (and willing) to surround themselves with people who support their decisions without question.”
~ Michael Armstrong, Former CEO of AT&T

“The ancient Romans had a tradition: whenever one of their engineers constructed an arch, as the capstone was hoisted into place, the engineer assumed accountability for his work in the most profound way possible: he stood under the arch.”
~ Michael Armstrong, CEO of AT&T (from his resignation speech in 2002)

Related topics:
1. Winter of Discontent
2. Winds of Change
3. Complacency
4. Change of Tide