I spent 2 years of my life in Singapore as an excange student 10 years ago.
>What Makes Singapore’s Health Care So Cheap?
I think they missed the most obvious reason: China
Singapore's public health system does not shy away from purchasing a lion share of pharmaceuticals, disposables, and medical equipment from China.
And about C class, the 'conveyorised' healthcare is one of biggest cost cavers when Singapore's medical specialist salary is approaching Western levels. Doctors focus on throughput. The goal is to fix the person and kick him out of hospital as fast as possible, and not to make everything possible to extend his stay as '5 star hotel hospitals' do in USA
"The goal is to fix the person and kick him out of hospital as fast as possible, and not to make everything possible to extend his stay as '5 star hotel hospitals' do in USA"
From my experience they are happy to kick you out right after surgery while still charging a ton of money. My girlfriend just had a surgery. Took 5 hours from entering the building to leaving the building. Cost was 40k. This is just for the surgery center. The doctors were extra.
>"I spent 2 years of my life in Singapore as an exchange student 10 years ago"
I'm sorry but how does spending two years there as an exchange student a decade ago add any weight to your opinion? As an exchange student weren't you still part of your parents insurance? Also do you think nothing has changed in 10 years?
I think no one but a few moderately rich Canadians consider US hospitals 5-star. In my experience, most US hospitals, as soon as they find out you have a little money try to do services add. The ambulance ride, nurse, specialist, radiologist, MRI, bed, CATV, telephone, and meals all add up on that bill.
And once they've exhausted your insurance or personal finances then they kick you out.
He's referring to the fact that insurance companies have shifted towards a system where "patient satisfaction" is a key driver of payment. This has caused a bit of a crisis in hospitals as executives push BS programs intended to improve these scores and they often come at the expense of actual care.
My understanding is that it's really just one more way insurance companies try to avoid paying for hospital bills. My partner works in revenue recovery for a regional hospital and it's staggering how awful insurance companies are.
I've heard many stories where waiting for insurance authorizations would have literally cost people their lives, but the insurance has grounds to refuse payment without it, so the hospital ends up eating the entire cost of the person's care.
The system is so incredibly fucked up. Far beyond what most people think.
That being said, maternity wards are apparently the college campus of the hospital world, which is why you see so many of them being built in rich areas. They are insanely profitable.
Most of the world does this, here in NZ the government bulk buys most of our medication through an entity known as Pharmac. They often buy off brand medication from India for instance instead of the branded equivalents.
One of the best things about the US removing itself from the TPPA is the fact that one of their conditions of entry was the fact that Pharmac would have had to buy branded pharmaceuticals from US companies rather than the Generics that we usually get which would have increased the cost that the country pays for pharmaceuticals massively.
If you count the city limits proper that would be true. If you count the agglomeration or greater city area which is what you are doing by saying all of Singapore then no, not by a long shot:
> If you count the city limits proper that would be true. If you count the agglomeration or greater city area which is what you are doing by saying all of Singapore then no, not by a long shot:
Yes, if you said “Singapore is of similar size to a large metropolitan area in the U.S.”, rather than “...a city...”, then, yes, the comparison would be to a category where Singapore's population would be reasonably typical, rather than just shy of the biggest.
But when you say “city”, it doesn't communicate something bigger than a city just because the thing you are comparing to a city is, itself, not just a city.
Saying it does't make it true. How about justifying why you think it matters? Because we can talk about any population in terms of percentage which factors out size. I suspect when you try and explain why size matters, you'll run into a better argument to make.
And on the other end of the spectrum we have Canada which has a smaller population spread out over a bigger area. Both extremes are able to to deliver health care for less than the US. Surely there's a lot we can learn from both extremes.
No,my point is that as a small country especially like Singapore, it is easier/more-flexible to optimize healthcare etc comparing to US, it is not as diversified as US population and thus much simpler to manage/plan/organize/control etc. While it definitely is a good example, many scheme there might not work at a large scale.
Politically, I guess it does. Half of the US would rebell if you tried to simply transplant the Singapore health care system to the US. The US is also more attractive for lobbyists because of its size.
There are economic reasons why size matters. For example, Singapore is small enough that you can get to any hospital from anywhere. In many areas of the US, there are fewer accessible healthcare providers. (For example, less dense regions, or urban areas in which all the competing hospitals have merged.) Perhaps this doesn't matter if you want to set broad price controls or nationalize the entire industry. But under Obamacare, it has made insurers' lives more difficult.
The only really valid point there is the culture one, which is actually our problem and the reason we're not already using socialized medicine country wide. It would work fine, everyone would be better off, but half the country would object based on their values regardless of it helping them.
I'm very tired of this argument that alway seems to get trotted out in an attempt to shut down discussion.
I'd love to see a US state try to do some drastic health care reforms. CA has toyed with single-payer options, though it's hampered funding-wise by the federal government, and the fact that, despite popular appearances, CA has a large segment of conservative voters.
Singapore and, say, South Carolina, have similar populations, so you'd expect to be able to implement Singapore-style healthcare on a state level if your only objection is population.
In reality, though, consensus-building and lobbying dollars tend to be the biggest obstacles to US-wide reform.
the downmodding seems a tad unfair, given that the article also made a reference to size being an advantage:
> Singapore is also very small, and the population may be healthier in general than in some other countries. It’s a little easier to run a health care system like that.
but what I don't get is why so many people will simply say this without any further evidence that this is true.
if size is a benefit, will a country with a population of 1 have an extremely efficient healthcare system? how about a country with a population of 10? obviously no. But does it get better at 1m people? 10m? 100m? I think the size of the US is a red herring, and there are so many other reasons why the US doesn't work, like the way the healthcare economy is structured, social contribution, population sprawl, etc that size offers no economies of scale advantage and in fact works against it. Under the right conditions, being larger really should help a healthcare system, not hurt it.
I think the problem is that there are many things that come with size. For example, a larger country is more heterogeneous, thus it's more likely that it'll be harder for people to agree on how to solve a particular issue. Also, I think most of the problems you mentioned would be ameliorated if the US had a smaller population.
It's not the size per se, but rather the political system. If the USA had a federal executive branch as powerful as the equivalent in Singapore then getting people to agree wouldn't be an issue. (I'm not necessarily recommending this since it causes other problems.)
Each US state is a lot smaller than the US. So imagine for a moment each US state individually implements it. That is obviously possible. So following this thinking, that should make you realise that size (in this case) does not matter. Of course the US can implement something like this. Except that the US is a plutocracy and not a democracy => no political will.
You're entirely missing his point; imagine all states implement the exact same system, if that'll work, then it'll work for the nation as a whole, size is irrelevant. Yes, there are other factors at play, but he's addressing the size issue, not the other factors, so your objections are off point.
But some states already have implemented health care much better than the other states next door. We have a natural experiment occurring right now. And yet people don't seem to be flocking to those states.
When you move your legal residence from one state to another you are considered a resident of that state almost immediately.
My understanding is that overuse is one of the primary reasons health spending is so high in most countries.
No data to back it up, might be wrong.
I can tell you I absolutely loathe pouring money into health insurers to prop up an overused and wasteful system. I'd much rather something like this personal account idea.
Further into the article, they also mention that there are a lot of government regulations about proportions of high-class beds to lower-class ones, needing approval to buy expensive medical equipment, and the number of physicians.
From the end of the article:
> [American] Conservatives will point to the Medisave accounts and the emphasis on individual contributions, but ignore the heavy government involvement and regulation. Liberals will point to the public’s ability to hold down costs and achieve quality, but ignore the class system or the system’s reliance on individual decision-making.
The article specifically says this is not the case, and that it actually increased health care spending.
Here's the quote.
In a 1995 paper in Health Affairs, William Hsiao looked at how health spending fared in Singapore before and after the introduction of Medisave. He found that health care spending increased after the introduction of increased cost-sharing, which is not what most proponents of such changes would expect.
Why is there never a comparison to Japan? They are 1/2 the size of the USA, have a privatized health system, and it's pretty damn awesome. They also have price controls which make things a lot easier to comprehend.
It seems like Japans system would just be Medicare, as it is today, for all. That is just take out the line that limits Medicare to those over 65. Medicare still allows for private insurance to cover the gap between what Medicare pays and covers.
As I understand it Bernie’s plan is a bit more than this and would expand Medicare to be a full single player plan.
At this point though it seems we have more than enough comparisons and data telling us to do something. They’re all going to be nearly night and day in terms of comparison to what we have currently.
I think the essential ingredients for controlled healthcare costs is a) the principle of universal healthcare b) government control of procedure and drug costs. No one is as expensive as the US per capita for healthcare. All the other nations beating us have wildly mixed healthcare delivery systems from full public to hybrid public/private - the hybrids are all administered differently. The characteristic they all seem to share in common is those two features. Even the worst of the modern nations systems beats the US cost and universality of coverage, and quality, by a large margin.
Japan seems to have a mixed private/public insurance system, but has government control of the fee schedule.
"The government has well controlled cost over decades by using the nationally uniform fee schedule for reimbursement."
"Fees for all health care services are set every two years by negotiations between the health ministry and physicians. The negotiations determine the fee for every medical procedure and medication, and fees are identical across the country. If physicians attempt to game the system by ordering more procedures to generate income, the government may lower the fees for those procedures at the next round of fee setting"
"Public health insurance covers most citizens/residents and the system pays 70% or more of medical and prescription drug costs with the remainder being covered by the patient (upper limits apply)."
"Singapore has a non-modified universal healthcare system where the government ensures affordability of healthcare within the public health system, largely through a system of compulsory savings, subsidies, and price controls."
Notice the "price controls"... It really doesn't seem to matter strongly exactly what mix of private/public does the actual administration. To capture first order cost savings better than what the US pays you need to control the fees.
The Japanese health system is pretty horrible in my experience.
The good:
* It's cheap
Prices for services are set by the government IIRC. Needed an MRI, was covered by insurance. Asked for copy of data. $25 for a CD with all my MRI data and free open source software included to view it.
* It's easy to use
Go to any doctor you want any time. Just show up at a doctor's office and hand over your insurance card
The bad:
* The doctors are not qualified
I've had many experiences with quack doctors in Japan. First doctor I went to 20 years ago gave me an ultrasound and then declared I had hepatitis.
Another doctor I went to for hives on my forehead just said "I don't know what that is". No referral, nothing.
Another doctor was telling every patient to breath through a respirator for 5 minutes. Every patient was using the same respirator, same mouth piece, no changing of anything.
Many doctor's offices are filthy. Machines are covered in goop (caked on bodily fluids?). Now that I have a smart phone I've started documenting this.
Lots of foreigners complain no matter what the symptoms they're given the same 3 to 6 medicines. Break an arm, get the flu, catch a cold, always the same 3 to 6 medicines.
* Nurses require zero training
To be a nurse just show up. Becoming a nurse in Japan requires no more training than working at fast food.
* If you want to good doctor for surgery you must bribe them
If you need some serious surgery you research who the best doctor is then hand them an envelope with $$$$-$$$$$ and beg them to take your case. This is a common topic on Japanese TV dramas and no, the dramas are not making it up. I have several friends who've needed one kind of surgery or another who paid the bribe.
* Long waits
Went to a major hospital in Kanagawa. Hospitals in Japan are not like Hospitals in the USA. In Japan you can go to the hospital for every day medical issues (colds, flu, etc...). Had to wait 2.5 hours in a room with about 300 other sick people.
I will say I don't know how common that is. Waits that long have only happened to me twice as I've only gone to a hospital for service twice. They're just something I haven't experienced in the USA partly because I don't know a single place in the USA that has a waiting room that big. I did experience similar in the UK, the long waits part not the 300 people. Doctors offices have normal waits (5-10 mins)
I'm not trying to defend the USA's system. It's got lots of problems. I like the good parts of the Japanese system. It's just not all roses. The Japanese have pretty good health but I tend to guess it's genetics+lifestyle+diet and not so much because of health care.
From my observation living in Singapore lifestyle is an important factor. People are generally active and there seems to be little obesity. Among young guys at least, national service and the associated mandatory fitness requirements seem to play a part in setting long term habits early.
Singapore has the nickname "The Air-conditioned Nation".
More to the point, the climate hasn't changed but the percentage of obese people there, like in most countries, is increasing. You therefore can't attribute that recent increase to heat and humidity.
Ya, that makes sense. Also, if it's like southern china, people are probably pretty active outside at night when its cooler (e.g. Night square dancing, night markets, etc...).
Rising obesity rates can be related to the weather even if it hasn't changed if there is pressure on lifestyle from other areas (e.g. Work/life balance). E.g. People in the south USA are not increasingly obese even though the weather stays the same, life style pressure plus hot and humid climate combine to create the problem; climate makes the problem more difficult to fix once it appears.
From my experience, it's still hot as balls at night. The only deliberate activity I did outside in SG at any time of day was to go find air conditioning inside. Of course I'm American, not Singaporean.
I found Singaporean nights quite nice and mild. I'm German and used to much colder temperatures, but the 25 degrees Celsius at night and a mild breeze where quite bearable for leisurely strolls and even working out.
My experience was closer to 30 degrees by 9pm which when combined with that humidity was just awful. After a rain it gets pretty nice at night though.
The Singaporeans and Malaysians I know mostly tend to be heavier than Asian friends and acquaintances from other countries. Dunno if the stats bear that out or if I'm just an outlier. Likewise, I don't think that the climate is so different than other nearby countries, but the food is. Tons of fried, oily, greasy carbs. It's absolutely delicious, but you can feel your arteries slamming shut just looking at half of the things you'd get in a hawker centre.
I love hawker centre food. Especially the uber greasy char kway teow. I mostly hung out with locals, and they didn't seem to be on the chubbier side. But I didn't make formal statistical comparisons with people from elsewhere in south east asia.
Once the sun's down, I didn't mind the weather one bit. I just avoided going out during the day.
It's a great place for barefoot running, and midnight shopping.
Singapore's medical community scares me a little bit. Despite having implanted metal in my body, an orthopedic surgeon wanted to give me an MRI anyway. It's completely absurd, I got a second opinion and fortunately found a doctor who agreed that would be extremely dangerous. It's true that the first doctor did not cost that much; it's also true I got what I paid for.
I believe most surgical steel is fine. I have a permanent retainer in my mouth and have no issues getting an MRI. The only problems would be if I need an MRI of my head, the metal could cause distortions in the image.
With that said, tell your doctor and more importantly tell the MRI tech about all possible metal in your body.
A lot of metal implants(most?) are safe for MRIs so your original doctor who did the implant and was aware of its composition was possibly correct and your second one was possibly just happy to agree with you.
Dude, that is most definitely not true. It is true that implants being done today often contain metal that could be safe for future MRIs, but implants from more than just a few years ago are generally very dangerous. In my case my implant is not at all safe, and the surgeon absolutely should've known that. There is a general sense of ignorance among lots of medical community there for some reason.
It's a standard pacemaker. There's the device itself and then the wires to go to the heart. Any surgeon with half a brain should know you don't go anywhere close to an MRI with that. And for all of his misguided advice that could've threatened my life, I still had to pay him of course. He never did any research or checking on my particular model to even see if there was a danger or not. Turns out, the danger is extreme.
Ah right. Just realized I read your original post wrong. I read it as saying the orthopedic surgeon implanted metal in your body. There isn't much they'd implant that isn't MRI safe.
For a pacemaker in an MRI, it's not being made of metal by itself that's unsafe, it's that the rapidly changing magnetic fields during the scan may cause it to malfunction. But not looking up the MRI conditions under which a device is safe is definitely bad practice. http://www.medtronic.com/us-en/healthcare-professionals/prod...
I may not be understanding how you're categorizing the failure modes of a pacemaker in an MRI. Here's a review that describes a lot of what can go wrong.
I'm not talking about the failure of the device, I'm talking about the dangers of a MRI magnet ripping the metal out of your body. These are very real dangers for nearly all pacemakers, with the exception of those that are being developed now and some that are implanted extremely recently. But most of the pacemakers in use around the world were not installed today.
No surgeon should be casually dismissing these risks to a patient without getting any extra information at all.
Incidentally, almost half of Singapore's population are foreigners. And if you are not a citizen, you do not get proper health insurance there that covers things like pre-existing conditions. This is in stark contrast to many other nations in the world where legal residents, whether citizens or not, get the same care and treatment.
By the same token, "in stark contrast to many other nations in the world where legal residents, whether citizens or not, get the same care and treatment" above also generally does not apply to temporary workers, but does apply to permanent residents, in those other nations.
In canada if your a canadian resident (not a tourist basically) you get healthcare. Many provinces also have a 3 month residency requirement, but some don't even have that.
On top of that, uninsured costs of healthcare are still significantly cheaper.
A health minister who makes $1.3 million dollars a year so he is bribed directly by the people to represent their interests and not by health care lobbyists who are just looking for ways to increase costs and make more money.
I think Singapore's cabinet ministers are overpaid for the "value" they offer.
The previous health minister (who's currently the transport minister) is a joke among Singaporeans, since he took credit for managing the SARS incident that happened before his stint as health minister [1], and couldn't manage to fix rising house prices or the failing public transport system in his subsequent portfolios.
Singaporean here. 'Failing" Public Transport System? Sure the SMRT has issues, but it is still one of the best run train systems in the world. Second only to HK MTR. Having used the BART, UK and NY Train services, the Singapore MRT system is far more cheaper and efficient. Not to mention cleaner, safer , etc. Yes, it is fashionable to criticize the PAP fatcats. But having lived in an assortment of first world and other Asian countries, Singapore is haven, albeit a "Gated Community" with a benevolent and paternalistic government. Given the chaos I seen in some of the late-stage-capitlisitic democracies, Singapore gives you safety and stability, at the expense of giving away some freedom and rights. Price that I'm willing to pay and I'm sure the majority of Singaporeans also do. And yes, I'm OK to fund and support the PAP "fatcats" as long as they deliver the goods. Their salary is peanuts compared to the waste, corruption and chaos that I see in the regional Asian countries due to corrupt kakistocracies in power. Case in point, up north from Singapore.
> What makes price controls for doctors wages different than failures with price controls in other industries?
It's not different conceptually, there are numerous negative consequences for the market and the doctors. It's different in terms of what's morally tolerated on the basis that healthcare is now viewed, very widely, as a right. Even in the US that's increasingly becoming the public view, which is why the Republicans (with the Presidency + both houses of Congress) couldn't get close to fully removing the ACA (eg the protections around existing conditions is overwhelmingly popular even for the majority of Republican voters).
If healthcare is a right, then the people working in healthcare are what exactly? You have a right to N healthcare, that must be provided by the labor of someone else. There are two common answers to that, based on what one believes ideologically: those workers are either economic slaves, or they're knowingly accepting a social contract of sorts by choosing to be in the field.
Price caps on most things produce shortages. Doctors on the other hand are generally not that money motivated - I doubt many would drop out of medical college because the salary was $80k rather than $120k say. Though there are limits - I know some people drop out of the UK NHS.
My Singaporean Uncle got stage IV nose-cancer two years ago. He has two kids, a stay-at-home wife and a job that pays only middle income. After a year of constant, weekly treatment by an assortment of doctors, he went into remission and paid in total less than one thousand dollars.
My Singaporean ex-girlfriend had systemic organ issues over her life, that have alternately caused her seizures and blackouts. She was hospitalized for years at a time. Again, middle income family, with three kids and a stay-at-home-wife. Her family paid virtually nothing for 15+ years of treatment, and then the government paid for her university. Full-ride. Oh and they also paid her directly to attend classes. About S$1500 per semester, last time I checked.
I have so many other great stories about my mother's country.
For now, my sentiment is that Singapore's society, government and people, on balance, cares about each other. Not a power-hungry "all glory to the nation" care, or a brainless "let's give everyone everything for free" care, but a "these people are people like you and I. If I put on their shoes, how would I like to be treated?" care.
In the United States, that basic, human empathy is in question.
It seems to me that it's unfair to compare a relatively small, new and homogeneous country such as Singapore with the states, and come to the conclusion that the USA lacks human empathy.
Not only is two of these completely wrong, what does that have to do with anything anyways? The United States is 50 small countries in one big country, there is no reason why a Singapore system could not be done here.
The age of and diversity of a country have nothing to do with its healthcare system.
> there is no reason why a Singapore system could not be done here.
I'm not saying it's impossible for the US to have a better healthcare system, I'm saying that looking at what Singapour has and then concluding that people in the states lack empathy is not only unfair, but also lacking in perspective.
> The United States is 50 small countries in one big country
Not only are each of the states bigger than Singapour, but they're different to each other and at the same time they're not completely independent of each other.
> The age of and diversity of a country have nothing to do with its healthcare system.
A system that has been in place for a longer period of time, tends to become larger, more complex and harder to change. Moreover, a society that is more heterogeneous will have a harder time agreeing on an issue. Also in a democratic country, the larger the population, the more people you'll have to convince in order to change the status quo.
No idea why your comment has been downvoted. The individual US states do indeed have little independence in the crafting of their healthcare system, given the heavy involvement of the federal government in healthcare. And the federal government is a massively complex beast that is subject to intense special interest lobbying and is far less accountable to its constituents than Singapore's government. There's no comparison between a fractured government presiding over 300 million people and a single party government of 6 million.
When can we stop to being so euphemistic and just call it corruption? I do not have to wear my PhD hat in economics to say that the relatively high cost care in the US pays for both the lobbyists' salaries and the now-even-higher dividends of the companies that choose to contract those lobbyists. Workers pay through the nose, rich folk get richer. Democracy subverted once again.
> The United States is 50 small countries in one big country
I see this sentiment touted a lot, but is there really that much difference between a Connecticuter and Rhode Islander, or a Mississipian and an Alabamian? A North Dakotan and a South Dakotan?
I'd wager that the somewhat arbitrary state divisions and the length of time they've been around have little to no cultural or biologically significant differences. Differences between populations in physical geographies and regions yes, but not because of the political boundaries unless you're referring to things that depend solely on political differences.
> Her family paid virtually nothing for 15+ years of treatment, and then the government paid for her university. Full-ride. Oh and they also paid her directly to attend classes. About S$1500 per semester, last time I checked.
Singaporean here. How does one enjoy such education benefits? I haven't heard of them.
> My Singaporean Uncle got stage IV nose-cancer two years ago. […] After a year of constant, weekly treatment by an assortment of doctors, he went into remission and paid in total less than one thousand dollars.
An MRI here will cost between 700 to 1,000 dollars, even at subsidised hospitals [1]. I fail to see how a year's worth of cancer treatment would be that cheap.
We have mandatory hospitalisation and surgical insurance (MediShield Life [2]), but with the various co-payments and deductibles, a procedure would still cost anywhere between $2,000 to $4,000.
She went into NIE, did the two-year program, got the diploma, and then went on to do the four-year program to get the full degree.
Mind you, it isn't all sunshine and roses, since in return for the government paying for basically everything, she has to work more than a few years in the MOE public school system. Although they do get paid, you make much more money as a private tutor with credentials so people fresh from the degree program are always eager to get on out.
Regarding my Uncle, this is what he told me when I asked at the last CNY, but I can accept if he was off by a few thousand.
> Mind you, it isn't all sunshine and roses, since in return for the government paying for basically everything, she has to work more than a few years in the MOE public school system.
It should be noted that such "full-ride" scholarships are generally reserved for the top students in a cohort (scoring at least, I believe, AAB at A Level), and are not available to all citizens (as compared to EU citizens who enjoy heavily-subsidised tuition and student loans).
On the other hand, Singapore has a tuition grant available for all international students who are admitted into a public university [1], with the stipulation that they work for a Singapore company for at least three years after they graduate. (This is aimed at trying to get "smart" people to settle down in Singapore.)
Singapore's system heavily favours strong academic potential (the government's idea of "meritocracy" — which is starting to show its cracks [2]) over egalitarianism.
There are sadly no "student loan" schemes to allow for independent living.
> It should be noted that such "full-ride" scholarships are generally reserved for the top students in a cohort (scoring at least, I believe, AAB at A Level), and are not available to all citizens (as compared to EU citizens who enjoy heavily-subsidised tuition and student loans).
Makes sense. She was going to go A-Levels after Higher Chinese but her illness threw her off, so she later went to Poly, and then did Primary School prepatory teaching, before going to NIE.
> This is aimed at trying to get "smart" people to settle down in Singapore.
I don't know if the bond is working. My Indian Classmates at NTU wanted to go straight to Silicon Valley, but got stuck at (what they called) the IBM and Amazon sweatshops. They're not happy about it.
> There are sadly no "student loan" schemes to allow for independent living.
The lottery selection on campus definitely makes it worse. My roommate at the time paid one of the lucky ones under the table for a slot but he was somehow exposed and had to move out halfway through the semester. Sad, but I got a two-bed room in the hostel all to myself!
> I don't know if the bond is working. My Indian Classmates at NTU wanted to go straight to Silicon Valley, but got stuck at (what they called) the IBM and Amazon sweatshops. They're not happy about it.
If they were planning to go straight to SV, perhaps they should have given more thought before accepting the tuition grant offered by Singapore?
It's a bit funny that meritocracy has such generally positive connotations today, even though the term was first used and then mercilessly satirized in The Rise of the Meritocracy [1].
When different people want different things, who do we decide who is in charge? Should it be based on family and birth, like monarchy and aristocracy? Should it be based on who can seize power by force? What about ethnic and national identity? Or should we have a competitive testing system and metrics that select out an elite? Or maybe we should all vote on a person?
Or why even have a person at all who's in a charge? Maybe we should all collectively vote for every decision without any intermediaries? Or maybe we just give an equal portion of resources to every person, and let them individually decide what to do with it.
None of these systems are perfect. They all have deficiencies and can be gamed one way or another. Question is which one is the best for the particular situation.
Why is it unfortunate? Because of what meritocracy attempts or purports to do (give power and status to those who deserve it, e.g. because they did a good job in the past), or because of imperfections in practice?
> An MRI here will cost between 700 to 1,000 dollars, even at subsidised hospitals [1]. I fail to see how a year's worth of cancer treatment would be that cheap.
It's not necessary to do MRI for cancer patients. BTW, you just assumed the person who posted this is lying. You should question his uncle not him. He is just telling you what he heard.
The stories are somewhat similar to SG in UK, France, Can, Aus, and NZ. I wouldn't tar the rest of the western world with the US's experience.
David Sedaris talked nearly two decades ago of having a treatment at a French hospital, and finding it hard to get someone to even accept payment. Mind you, he also liked that he could smoke in the hospital.
Speaking as a Southerner, our friendliness is quite temporary, superficial, and cliquish.
Many Southerners are friendly toward 1) visitors, and 2) people in their immediate social circle. When the scope broadens to people of different races, nationalities, or political/sexual orientations, the friendliness quickly fades.
Growing up in a small Mississippi city in the 1980s & 90s, I saw a small but steady influx of transplants from other parts of the country who came to work our booming aluminum siding factory. They were all received warmly at first, and seemed bowled over by the attention. But as soon as they demonstrated their alien-ness by attending the wrong church (or being nonreligious), or heaven forbid, commenting on racial or political issues, the welcome mat was pulled back. They'd last a year or two at most, and then transfer somewhere else. And people would gossip about the funny Yankees after they left. "Andy's wife was a real loony-tunes," they'd say. "Told her Sunday school group she didn't believe abortion was wrong. And you know what they said about her husband. [whispering] That he was a pervert!"
I upvoted you because I think you are asking a good question.
If Americans aren't more selfish than others with better functioning health care, it would support the view that our health system is what is what is suppressing our better natures. I agree to some extent but I when I see "I don't want my money going to $theOther" it's hard not to think that selfishness is part of the problem as well.
> "I don't want my money going to $theOther" it's hard not to think that selfishness is part of the problem as well.
I think the selfishness is just expressed differently.
Where do you think the massive taxes on cigarettes and alcohol in most first world countries comes from? The calls for taxes on fatty foods? Requirements for extra insurance to do certain extreme sports?
It's the way they say we don't want to pay for your life choices.
It’s an extreme lack of empathy and also not a well thought through position (it’s one step away from “I only want to pay for healthcare for healthy people”)
Can you please provide some real-world examples of what you mean, because I can't figure the kind of things you're talking about when you talk about excessive empathy being a problem for others.
People with too much empathy can be easily swayed by a couple of emotionally charged stories without carefully considering the long term consequences or the data.
Going off topic but gun control is a great example. There is a small group of Americans who want to take away the right to private ownership of firearms. It's a small group and not a real concern.
The problem is there is a decent chunk of Americans who are very empathy driven and you show them the picture of a little girl who was shot dead and reason goes out the window.
So what does the other side do? Push their own emotionally charged propaganda to combat it. And refuse to compromise even when they agree.
That's like saying a company will always be successful as long as it executes well. Good execution is absolutely necessary, and can compensate for mediocre strategy, but it can't fix a truly broken model.
Having worked in both Singapore and US, I find the key difference in healthcare and other societal issues is the ideology. US: left or right, liberal or conservative. Singapore: whatever works.
After all Singapore is one of the few living city states and less than 60 years old. Running a 200+ year old huge nation state means complexity and challenges on an exponentially different scale.
>>But when hospitals competed, they did so by buying new technology, offering expensive services, paying more for doctors, decreasing services to lower-class wards, and focusing more on A-class wards. This led to increased spending.
>>In other words, Singapore discovered that, as we’ve seen many times before, the market sometimes fails in health care.
Why is increased spending on buying new technology deemed a failure? Maybe the optimal healthcare spending level is far higher than what's spent now.
Comparison with the NHS seems a little unfair given relative population densities.
> what makes it beloved among many
> conservative policy analysts, is its
> reliance on health savings accounts.
> All workers are mandated to put a
> decent percentage of their earnings
> into savings for the future
If you tried this in America you'd have anti-Communism riots on the street with Ann Coulter and Sarah Palin talking about how FEMA were using the money to set up death camps before taking their guns.
Not that it'd happen but it would be an interesting experiment if you could try changing to the Singapore system in some part of the US. Say Hawaii or Puerto Rico. It would be an upheaval but at ~1/3 the cost and longer life expectancy it could be worth trying. Assuming the locals were up for it.
It's doable because Singapore is a small city-state, easily regulated, strongly controlled and managed. The largest hospitals are public, and the smaller ones private, i.e., the government has positioned itself to be the main healthcare provider, ergo, their strong ability to manage and control healthcare costs is all but guaranteed.
In doing so, they have blocked profiteering, collusion and exploitation by vested interests, but this can be challenging to impossible to achieve in other countries due to the obvious reasons.
144 comments
[ 3.1 ms ] story [ 228 ms ] thread>What Makes Singapore’s Health Care So Cheap?
I think they missed the most obvious reason: China
Singapore's public health system does not shy away from purchasing a lion share of pharmaceuticals, disposables, and medical equipment from China.
And about C class, the 'conveyorised' healthcare is one of biggest cost cavers when Singapore's medical specialist salary is approaching Western levels. Doctors focus on throughput. The goal is to fix the person and kick him out of hospital as fast as possible, and not to make everything possible to extend his stay as '5 star hotel hospitals' do in USA
From my experience they are happy to kick you out right after surgery while still charging a ton of money. My girlfriend just had a surgery. Took 5 hours from entering the building to leaving the building. Cost was 40k. This is just for the surgery center. The doctors were extra.
I'm sorry but how does spending two years there as an exchange student a decade ago add any weight to your opinion? As an exchange student weren't you still part of your parents insurance? Also do you think nothing has changed in 10 years?
And once they've exhausted your insurance or personal finances then they kick you out.
Google Image Search for "Swedish Seattle birthing" and the childbirth suites resemble 5-star hotel rooms, complete with in-room hot spa.
It's becoming a huge issue in US hospitals
We'd see the same thing in other industries if market interference led to the customer not being price sensitive. Like higher ed.
I've heard many stories where waiting for insurance authorizations would have literally cost people their lives, but the insurance has grounds to refuse payment without it, so the hospital ends up eating the entire cost of the person's care.
The system is so incredibly fucked up. Far beyond what most people think.
That being said, maternity wards are apparently the college campus of the hospital world, which is why you see so many of them being built in rich areas. They are insanely profitable.
One of the best things about the US removing itself from the TPPA is the fact that one of their conditions of entry was the fact that Pharmac would have had to buy branded pharmaceuticals from US companies rather than the Generics that we usually get which would have increased the cost that the country pays for pharmaceuticals massively.
No
Well, a city, in that it's significantly larger than any city in the US other than NYC.
https://en.wikipedia.org/wiki/List_of_the_largest_urban_aggl...
Yes, if you said “Singapore is of similar size to a large metropolitan area in the U.S.”, rather than “...a city...”, then, yes, the comparison would be to a category where Singapore's population would be reasonably typical, rather than just shy of the biggest.
But when you say “city”, it doesn't communicate something bigger than a city just because the thing you are comparing to a city is, itself, not just a city.
Saying it does't make it true. How about justifying why you think it matters? Because we can talk about any population in terms of percentage which factors out size. I suspect when you try and explain why size matters, you'll run into a better argument to make.
But economically it's obviously nonsense.
Singapore is not only more diversified than the US, it is the most extreme case of religious diversity in the world [1]
[1] http://www.pewforum.org/2014/04/04/global-religious-diversit...
I'd love to see a US state try to do some drastic health care reforms. CA has toyed with single-payer options, though it's hampered funding-wise by the federal government, and the fact that, despite popular appearances, CA has a large segment of conservative voters.
Singapore and, say, South Carolina, have similar populations, so you'd expect to be able to implement Singapore-style healthcare on a state level if your only objection is population.
In reality, though, consensus-building and lobbying dollars tend to be the biggest obstacles to US-wide reform.
> Singapore is also very small, and the population may be healthier in general than in some other countries. It’s a little easier to run a health care system like that.
but what I don't get is why so many people will simply say this without any further evidence that this is true.
if size is a benefit, will a country with a population of 1 have an extremely efficient healthcare system? how about a country with a population of 10? obviously no. But does it get better at 1m people? 10m? 100m? I think the size of the US is a red herring, and there are so many other reasons why the US doesn't work, like the way the healthcare economy is structured, social contribution, population sprawl, etc that size offers no economies of scale advantage and in fact works against it. Under the right conditions, being larger really should help a healthcare system, not hurt it.
It actually isn't in any simple fashion.
What happens if state A implements health care much better than the state next door, so everyone flocks to state A and deluges the hospitals?
Do you make so that only state residents get the 'state rate' for health care?
What about the people who are stuck in the poor, badly managed states that get left behind?
People would be far less likely to overuse health services if they felt they were paying personally.
That's a powerful idea.
No data to back it up, might be wrong.
I can tell you I absolutely loathe pouring money into health insurers to prop up an overused and wasteful system. I'd much rather something like this personal account idea.
From the end of the article:
> [American] Conservatives will point to the Medisave accounts and the emphasis on individual contributions, but ignore the heavy government involvement and regulation. Liberals will point to the public’s ability to hold down costs and achieve quality, but ignore the class system or the system’s reliance on individual decision-making.
Here's the quote.
In a 1995 paper in Health Affairs, William Hsiao looked at how health spending fared in Singapore before and after the introduction of Medisave. He found that health care spending increased after the introduction of increased cost-sharing, which is not what most proponents of such changes would expect.
[0] https://www.bloomberg.com/view/articles/2017-09-19/want-a-be...
As I understand it Bernie’s plan is a bit more than this and would expand Medicare to be a full single player plan.
At this point though it seems we have more than enough comparisons and data telling us to do something. They’re all going to be nearly night and day in terms of comparison to what we have currently.
Japan seems to have a mixed private/public insurance system, but has government control of the fee schedule.
https://en.wikipedia.org/wiki/Health_care_system_in_Japan
"The government has well controlled cost over decades by using the nationally uniform fee schedule for reimbursement."
"Fees for all health care services are set every two years by negotiations between the health ministry and physicians. The negotiations determine the fee for every medical procedure and medication, and fees are identical across the country. If physicians attempt to game the system by ordering more procedures to generate income, the government may lower the fees for those procedures at the next round of fee setting"
"Public health insurance covers most citizens/residents and the system pays 70% or more of medical and prescription drug costs with the remainder being covered by the patient (upper limits apply)."
For Singapore: https://en.wikipedia.org/wiki/Healthcare_in_Singapore
"Singapore has a non-modified universal healthcare system where the government ensures affordability of healthcare within the public health system, largely through a system of compulsory savings, subsidies, and price controls."
Notice the "price controls"... It really doesn't seem to matter strongly exactly what mix of private/public does the actual administration. To capture first order cost savings better than what the US pays you need to control the fees.
The good:
* It's cheap
Prices for services are set by the government IIRC. Needed an MRI, was covered by insurance. Asked for copy of data. $25 for a CD with all my MRI data and free open source software included to view it.
* It's easy to use
Go to any doctor you want any time. Just show up at a doctor's office and hand over your insurance card
The bad:
* The doctors are not qualified
I've had many experiences with quack doctors in Japan. First doctor I went to 20 years ago gave me an ultrasound and then declared I had hepatitis.
Another doctor I went to for hives on my forehead just said "I don't know what that is". No referral, nothing.
Another doctor was telling every patient to breath through a respirator for 5 minutes. Every patient was using the same respirator, same mouth piece, no changing of anything.
Many doctor's offices are filthy. Machines are covered in goop (caked on bodily fluids?). Now that I have a smart phone I've started documenting this.
Lots of foreigners complain no matter what the symptoms they're given the same 3 to 6 medicines. Break an arm, get the flu, catch a cold, always the same 3 to 6 medicines.
* Nurses require zero training
To be a nurse just show up. Becoming a nurse in Japan requires no more training than working at fast food.
* If you want to good doctor for surgery you must bribe them
If you need some serious surgery you research who the best doctor is then hand them an envelope with $$$$-$$$$$ and beg them to take your case. This is a common topic on Japanese TV dramas and no, the dramas are not making it up. I have several friends who've needed one kind of surgery or another who paid the bribe.
* Long waits
Went to a major hospital in Kanagawa. Hospitals in Japan are not like Hospitals in the USA. In Japan you can go to the hospital for every day medical issues (colds, flu, etc...). Had to wait 2.5 hours in a room with about 300 other sick people.
I will say I don't know how common that is. Waits that long have only happened to me twice as I've only gone to a hospital for service twice. They're just something I haven't experienced in the USA partly because I don't know a single place in the USA that has a waiting room that big. I did experience similar in the UK, the long waits part not the 300 people. Doctors offices have normal waits (5-10 mins)
I'm not trying to defend the USA's system. It's got lots of problems. I like the good parts of the Japanese system. It's just not all roses. The Japanese have pretty good health but I tend to guess it's genetics+lifestyle+diet and not so much because of health care.
https://www.pri.org/stories/2009-11-10/fat-japan-youre-break...
More to the point, the climate hasn't changed but the percentage of obese people there, like in most countries, is increasing. You therefore can't attribute that recent increase to heat and humidity.
Rising obesity rates can be related to the weather even if it hasn't changed if there is pressure on lifestyle from other areas (e.g. Work/life balance). E.g. People in the south USA are not increasingly obese even though the weather stays the same, life style pressure plus hot and humid climate combine to create the problem; climate makes the problem more difficult to fix once it appears.
The Singaporeans and Malaysians I know mostly tend to be heavier than Asian friends and acquaintances from other countries. Dunno if the stats bear that out or if I'm just an outlier. Likewise, I don't think that the climate is so different than other nearby countries, but the food is. Tons of fried, oily, greasy carbs. It's absolutely delicious, but you can feel your arteries slamming shut just looking at half of the things you'd get in a hawker centre.
Once the sun's down, I didn't mind the weather one bit. I just avoided going out during the day.
It's a great place for barefoot running, and midnight shopping.
With that said, tell your doctor and more importantly tell the MRI tech about all possible metal in your body.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4475571/
No surgeon should be casually dismissing these risks to a patient without getting any extra information at all.
On top of that, uninsured costs of healthcare are still significantly cheaper.
The previous health minister (who's currently the transport minister) is a joke among Singaporeans, since he took credit for managing the SARS incident that happened before his stint as health minister [1], and couldn't manage to fix rising house prices or the failing public transport system in his subsequent portfolios.
[1] https://en.wikipedia.org/wiki/Khaw_Boon_Wan#Minister_for_Hea...
"But when hospitals competed, they did so by... paying more for doctors..."
"Singapore heavily regulates the number of physicians, and it has some control over salaries as well."
What makes price controls for doctors wages different than failures with price controls in other industries?
It's not different conceptually, there are numerous negative consequences for the market and the doctors. It's different in terms of what's morally tolerated on the basis that healthcare is now viewed, very widely, as a right. Even in the US that's increasingly becoming the public view, which is why the Republicans (with the Presidency + both houses of Congress) couldn't get close to fully removing the ACA (eg the protections around existing conditions is overwhelmingly popular even for the majority of Republican voters).
If healthcare is a right, then the people working in healthcare are what exactly? You have a right to N healthcare, that must be provided by the labor of someone else. There are two common answers to that, based on what one believes ideologically: those workers are either economic slaves, or they're knowingly accepting a social contract of sorts by choosing to be in the field.
My Singaporean Uncle got stage IV nose-cancer two years ago. He has two kids, a stay-at-home wife and a job that pays only middle income. After a year of constant, weekly treatment by an assortment of doctors, he went into remission and paid in total less than one thousand dollars.
My Singaporean ex-girlfriend had systemic organ issues over her life, that have alternately caused her seizures and blackouts. She was hospitalized for years at a time. Again, middle income family, with three kids and a stay-at-home-wife. Her family paid virtually nothing for 15+ years of treatment, and then the government paid for her university. Full-ride. Oh and they also paid her directly to attend classes. About S$1500 per semester, last time I checked.
I have so many other great stories about my mother's country.
For now, my sentiment is that Singapore's society, government and people, on balance, cares about each other. Not a power-hungry "all glory to the nation" care, or a brainless "let's give everyone everything for free" care, but a "these people are people like you and I. If I put on their shoes, how would I like to be treated?" care.
In the United States, that basic, human empathy is in question.
Not only is two of these completely wrong, what does that have to do with anything anyways? The United States is 50 small countries in one big country, there is no reason why a Singapore system could not be done here.
The age of and diversity of a country have nothing to do with its healthcare system.
I'm not saying it's impossible for the US to have a better healthcare system, I'm saying that looking at what Singapour has and then concluding that people in the states lack empathy is not only unfair, but also lacking in perspective.
> The United States is 50 small countries in one big country
Not only are each of the states bigger than Singapour, but they're different to each other and at the same time they're not completely independent of each other.
> The age of and diversity of a country have nothing to do with its healthcare system.
A system that has been in place for a longer period of time, tends to become larger, more complex and harder to change. Moreover, a society that is more heterogeneous will have a harder time agreeing on an issue. Also in a democratic country, the larger the population, the more people you'll have to convince in order to change the status quo.
When can we stop to being so euphemistic and just call it corruption? I do not have to wear my PhD hat in economics to say that the relatively high cost care in the US pays for both the lobbyists' salaries and the now-even-higher dividends of the companies that choose to contract those lobbyists. Workers pay through the nose, rich folk get richer. Democracy subverted once again.
I see this sentiment touted a lot, but is there really that much difference between a Connecticuter and Rhode Islander, or a Mississipian and an Alabamian? A North Dakotan and a South Dakotan?
Singaporean here. How does one enjoy such education benefits? I haven't heard of them.
> My Singaporean Uncle got stage IV nose-cancer two years ago. […] After a year of constant, weekly treatment by an assortment of doctors, he went into remission and paid in total less than one thousand dollars.
An MRI here will cost between 700 to 1,000 dollars, even at subsidised hospitals [1]. I fail to see how a year's worth of cancer treatment would be that cheap.
We have mandatory hospitalisation and surgical insurance (MediShield Life [2]), but with the various co-payments and deductibles, a procedure would still cost anywhere between $2,000 to $4,000.
[1] https://www.moh.gov.sg/content/moh_web/home/pressRoom/pressR...
[2] https://www.medishieldlife.sg
Mind you, it isn't all sunshine and roses, since in return for the government paying for basically everything, she has to work more than a few years in the MOE public school system. Although they do get paid, you make much more money as a private tutor with credentials so people fresh from the degree program are always eager to get on out.
Regarding my Uncle, this is what he told me when I asked at the last CNY, but I can accept if he was off by a few thousand.
It should be noted that such "full-ride" scholarships are generally reserved for the top students in a cohort (scoring at least, I believe, AAB at A Level), and are not available to all citizens (as compared to EU citizens who enjoy heavily-subsidised tuition and student loans).
On the other hand, Singapore has a tuition grant available for all international students who are admitted into a public university [1], with the stipulation that they work for a Singapore company for at least three years after they graduate. (This is aimed at trying to get "smart" people to settle down in Singapore.)
Singapore's system heavily favours strong academic potential (the government's idea of "meritocracy" — which is starting to show its cracks [2]) over egalitarianism.
There are sadly no "student loan" schemes to allow for independent living.
[1] https://tgonline.moe.gov.sg/tgis/normal/studentViewTuitionGr...
[2] https://www.theonlinecitizen.com/2017/09/28/dr-chee-soon-jua...
Makes sense. She was going to go A-Levels after Higher Chinese but her illness threw her off, so she later went to Poly, and then did Primary School prepatory teaching, before going to NIE.
> This is aimed at trying to get "smart" people to settle down in Singapore.
I don't know if the bond is working. My Indian Classmates at NTU wanted to go straight to Silicon Valley, but got stuck at (what they called) the IBM and Amazon sweatshops. They're not happy about it.
> There are sadly no "student loan" schemes to allow for independent living.
The lottery selection on campus definitely makes it worse. My roommate at the time paid one of the lucky ones under the table for a slot but he was somehow exposed and had to move out halfway through the semester. Sad, but I got a two-bed room in the hostel all to myself!
If they were planning to go straight to SV, perhaps they should have given more thought before accepting the tuition grant offered by Singapore?
When different people want different things, who do we decide who is in charge? Should it be based on family and birth, like monarchy and aristocracy? Should it be based on who can seize power by force? What about ethnic and national identity? Or should we have a competitive testing system and metrics that select out an elite? Or maybe we should all vote on a person?
Or why even have a person at all who's in a charge? Maybe we should all collectively vote for every decision without any intermediaries? Or maybe we just give an equal portion of resources to every person, and let them individually decide what to do with it.
None of these systems are perfect. They all have deficiencies and can be gamed one way or another. Question is which one is the best for the particular situation.
[1] https://en.wikipedia.org/wiki/The_Rise_of_the_Meritocracy
It's not necessary to do MRI for cancer patients. BTW, you just assumed the person who posted this is lying. You should question his uncle not him. He is just telling you what he heard.
The price quoted is before subsidies, and after GST. For subsidised patients, the price is usually 50% off and no tax is charged.
I never really paid attention to singapore but I'll surely do now.
David Sedaris talked nearly two decades ago of having a treatment at a French hospital, and finding it hard to get someone to even accept payment. Mind you, he also liked that he could smoke in the hospital.
Singaporeans happily balance rights with responsibilities. It's a more collective outlook.
> In the United States, that basic, human empathy is in question.
I find it is the opposite. There is far too much "empathy" in the US.
This means that it's impossible to take the middle ground that the average joe can actually support. Each path becomes all or nothing.
For example it's politically impossible in the US to have free healthcare only for non-smoking healthy weight individuals.
But I don't want to pay for an obese persons knee surgery.
And I know people don't want to pay for the brain damage I might get from doing boxing.
Are Swedish people?
Etc etc.
I don't think selfishness or lack of empathy are responsible for the state of US healthcare.
I've personally found Americans are very welcoming. Especially in the south.
Many Southerners are friendly toward 1) visitors, and 2) people in their immediate social circle. When the scope broadens to people of different races, nationalities, or political/sexual orientations, the friendliness quickly fades.
Growing up in a small Mississippi city in the 1980s & 90s, I saw a small but steady influx of transplants from other parts of the country who came to work our booming aluminum siding factory. They were all received warmly at first, and seemed bowled over by the attention. But as soon as they demonstrated their alien-ness by attending the wrong church (or being nonreligious), or heaven forbid, commenting on racial or political issues, the welcome mat was pulled back. They'd last a year or two at most, and then transfer somewhere else. And people would gossip about the funny Yankees after they left. "Andy's wife was a real loony-tunes," they'd say. "Told her Sunday school group she didn't believe abortion was wrong. And you know what they said about her husband. [whispering] That he was a pervert!"
Sad, really.
I think the selfishness is just expressed differently.
Where do you think the massive taxes on cigarettes and alcohol in most first world countries comes from? The calls for taxes on fatty foods? Requirements for extra insurance to do certain extreme sports?
It's the way they say we don't want to pay for your life choices.
Yeah, this is lack of empathy (and understanding of the reasons behind obesity).
Why is it any more of a mental health problem than smoking?
You have the responsibility in Singapore to conform to societies expectations.
It's a very different mentality than we have in the US.
> But I don't want to pay for an obese persons knee surgery.
This is Poe's Law writ large.
I was saying that "far too much empathy" is not something that goes well with "screw you, you brought it on yourself".
How can you find a common middle ground with people who are overflowing with empathy?
Going off topic but gun control is a great example. There is a small group of Americans who want to take away the right to private ownership of firearms. It's a small group and not a real concern.
The problem is there is a decent chunk of Americans who are very empathy driven and you show them the picture of a little girl who was shot dead and reason goes out the window.
So what does the other side do? Push their own emotionally charged propaganda to combat it. And refuse to compromise even when they agree.
With these, any healthcare system will work well.
>>In other words, Singapore discovered that, as we’ve seen many times before, the market sometimes fails in health care.
Why is increased spending on buying new technology deemed a failure? Maybe the optimal healthcare spending level is far higher than what's spent now.
London needs to become a city state, then. Why subsidise those hillbillies?
In doing so, they have blocked profiteering, collusion and exploitation by vested interests, but this can be challenging to impossible to achieve in other countries due to the obvious reasons.