MEDICAL ENDOWMENT SCHEME BILL

Debate resumed.

Mr Koo Tsai Kee (Tanjong Pagar GRC): Mr Speaker, Sir, I rise to support the Medical Endowment Scheme Bill.

Mr Speaker, Sir, the Prime Minister once said, "this Government does not believe in welfarism." But that is not to say that there is no welfare for our people. This Medifund scheme would allow the very poor among us, the destitute, to tap into our medical services and get at least basic health care. But the catchwords must be "the poor and the destitute". Because if this Medical Endowment Fund is to fund for everybody - you, me, the rich - then the very poor who needs this fund most will be deprived. If a person is very poor, he or she will not be asked to be sent to Mount Elizabeth or Gleneagles Hospitals. Because if you allow people to go to Mount Elizabeth or Gleneagles Hospitals and allow him or her to use this Medifund, the next step will be he may want to go to St Vincent in Sydney or he may want to go to Mt Sinai in America. I think we must tell the poor, "Look, you cannot help yourself. Yes, we look at your circumstances. We ask the community leaders to vet you. If you deserve help, then you should go to SGH, which I think is the best hospital in Singapore." There is no need to extend the fund to outside non-authorised hospitals. I am not sure if Mr Low Thia Khiang really is in favour of allowing everybody to get--

Mr Low Thia Khiang: May I clarify a point raised by Mr Koo?

Mr Speaker: Do you allow Mr Low to clarify?

Mr Koo Tsai Kee: I will repeat myself, I was interrupted. I am sorry. I am not sure if Mr Low Thia Khiang will allow people to go into Mount Elizabeth Hospital and turn to the fund, because he is for the poor. I think we must learn from the experience of other countries like Australia or the UK. They also have the equivalent of Medifund, but it is funded out of general taxation. It is for everybody. This means that the people who really need medical services have to queue up for years. By the time they reach the hospital bed, many of them do not need the cure any more.

I just came back from China. I talked to some of the Chinese officials. The Chinese officials are now telling the Chinese that free medical health care is bad because if everybody goes for free medical health services, then the queue will be lengthened unnecessarily long and people will go for all kinds of services when they do not need one. So they are also thinking of a scheme where they will only allow the people who really need it, the people who cannot afford to pay, to tap into the services.

I share the concern of Dr Soin and Mr Walter Woon. But let us get first thing first. This scheme is meant to help Singapore citizens. I think what they are referring to is mainly immigration problems. We must help our citizens, many of whom live in my area, the Tanjong Pagar GRC. Many of these san shui po [ ] came from China. They have worked hard, but they were caught in a time warp, they have no savings. Now they are destitute in the sense that they do not want help but they need help. These are our citizens. I think we help these people, the people who really need our help, instead of trying to dilute the fund, which is limited in the first place, to helping potential beneficiaries. 3.45 pm

Mr Choo Wee Khiang (Jalan Besar GRC): ( In Mandarin): Mr Speaker, Sir, I fully support the Medical Endowment Scheme Bill introduced by the Minister for Health.

However, having heard the speeches by so many Members of Parliament, I am rather puzzled by what Mr Low Thia Khiang has said. He suggested that Medifund should also be extended to cover patients who stay in private hospitals and also those in wards A and B1. He seems to suggest that this fund should be made available to everybody. Everyone should be entitled to apply for the use of this Fund. This is not consistent with what the Minister has proposed and it is contrary to the primary objective of this Scheme, that is, to help those Singaporeans who are poor and destitute. If what he said is true, then I think it will not be necessary for us to have this Medifund. We might just as well have a Singapore Fund! Since it is inevitable that everybody will one day become old and fall sick, then would it not be better if we just give everyone a sum of money, so long as he or she is a Singaporean? Why should we go through all the trouble of setting up Medifund?

Therefore, the use of Medifund should be selective. Only those Singaporeans who are poor, who do not have a Medisave Account and who truly deserve our help should be allowed to make use of this Fund. If everybody is entitled to apply, then as the Chinese saying goes: the gruel is meagre and the monks are many - there will not be enough to go round. The Fund will not be sufficient to cater for the needs of all those Singaporeans who really deserve our help. So I believe that Mr Low Thia Khiang should clarify his point.

Another point raised by Mr Low is that any patient who satisfies the condition for the use of this Fund should be automatically granted this assistance. I think for everything we do, there should be a proper procedure. We should let the Ministry of Community Development, the grassroots leaders and the relevant officers from the Ministry of Health to come in and investigate, examine and check whether the patient who is making the application is truly a deserving case. If we do that, we would be able to check any misuse of this Fund and, at the same time, we would be able to understand the needs of these people: what is their medical condition and how much help they need.

Finally, Mr Low asked what would happen to the outstanding medical bill left behind by these patients who have passed away. If the family of the deceased has the means, I think they should pay up all the outstanding medical bills. However, for those families which do not have the means, I hope the Ministry of Health will adopt a sympathetic attitude and waive all the medical expenses left behind by the patient concerned.

I support this Bill.

Mr Chia Shi Teck: Sir, I rise in support of the Bill but would like to raise some concerns.

It is most assuring when we hear both the Prime Minister and the Minister for Health assuring us that no Singaporean who cannot afford to pay his bills will not be treated. But on the administrative side, we often hear and get the feedback that it is not that easy and that the administrative procedure is difficult and unless they can produce their Medisave account, they may not even be admitted to the hospital.

As Dr Tan Cheng Bock has said, we hope that the whole procedure could be simplified. As we are an Asian society, I think the sensitive part about having to fill in long forms and all the details sometimes deter people from filing their applications.

My biggest concern is that when Medisave was first introduced, there seemed to be an upward momentum in the medical costs. Now with this wonderful fund, will the doctors be just jacking up the fees since there is a fund to pay for all patients? There is this danger of an upward momentum.

There is also this feeling that many of the patients do not wish to get into ward C. One perception, and I tend to believe it is real, is that there are certain surgical operations which are not given in ward C simply because they are too expensive. That perception, if it is not real, should be taken away, because the latest we hear is that the number of C ward beds will be reduced because of less usage. But less usage could be because they fear that they are not given equal treatment.

Dr Vasoo: Mr Speaker, Sir, I must say that this Medical Endowment Scheme is a very innovative scheme so far. With the growing number of the single unsupported aged in our community, particularly those living in estates that are greying, there is an urgency to see how this scheme could be implemented as quickly as possible.

I agree that the principle is to assist those who really need the fund, but the question is whether those who really need it will get their needs addressed as quickly as possible. I think we should be concerned about the time lag from the time that a person applies to get the fund to the time the decision is made. And if the scheme is indeed to help those who really need the support, then I feel that they should be given the Medifund support as quickly as possible. Otherwise, one would find that various types of means tests are applied by the bureaucracy. If applicants are made to wait unnecessarily longer, then I think the scheme would lose its credibility.

Sir, the other question that we should address is the question of how flexible the scheme is. I would like to ask the Minister whether, besides the essential criteria that are established in the Bill, the scheme would be compassionately applied to people who really require it but they may not necessarily be citizens, ie, those who are permanent residents. Will they be eligible to apply? For those who really are rooted in Singapore and who have spent a large part of their years contributing to Singapore, we should see how the criteria should be compassionately applied and the necessary support given to them.

I would like to find out from the Minister whether other more specific eligibility criteria will be spelt out to provide access to Medifund.

The other concern that I have is the people who are sitting in the committee verifying and assessing the applications. Would there be a wider representation of community leaders or would the committee comprise mainly people who are within the hospital system? I want to argue that a broader representation of people from the community itself, particularly community leaders assessing the cases, would provide probably the best input in terms of the cases that are being reviewed.

Mr Umar Abdul Hamid (Ang Mo Kio GRC): ( In Malay): Mr Speaker, I support the Medifund Bill.

I would like to say that the proposed Medifund scheme is very timely. As Singapore moves on to further development and progress, we cannot ignore the inter2ests and the health of its population. A healthy population will bring about a more stable development and economy for Singapore.

Mr Speaker, I welcome the Medifund scheme because it would reduce the burden of needy, poor families in meeting rising medical costs. Furthermore, the Medifund scheme would act as a safety net for every citizen, rich or poor. Every citizen, rich or poor, should not be denied access to quality medical care.

Mr Speaker, the Government has been a responsible one. It has spent a lot of money introducing various schemes, medical and otherwise. I would like to propose a further improvement to this scheme.

May I suggest that the criteria for approving disbursements out of the Medifund should not be too strict, so that more needy families could enjoy them. On the other hand, we should also ensure that the scheme would not be abused in the manner suggested by Mr Low Thia Khiang, because if we are not cautious, the scheme could well result in unfairness.

Mr Low Thia Khiang: Mr Speaker, Sir, will you allow me to clarify in regard to the speech made by Mr Choo?

Mr Speaker: All right.

Mr Low Thia Khiang: I was just asking the Minister for Health whether or not he will approve private hospitals, like Mount Elizabeth, to use Medifund. I am not in favour of private hospitals using the fund. So there is no suggestion whatsoever. This is my position. I think many Members have misunderstood me.

Mr Choo Wee Khiang: Sir, I just want to clarify. If that is the case, Mr Low Thia Khiang should not have raised this point. It is understood that private hospitals will not allow their patients to apply for such fund.

Mr Low Thia Khiang: Mr Speaker, Sir, under the Bill, it says that "hospital ... approved by the Minister". So it can be any hospital approved by the Minister. I would like the Minister to clarify the type of hospital. It could be a private hospital and there are some Members who suggested community hospitals for that matter. I am raising this as an example, and not that I am in favour of private hospitals using Medifund.

Mr Yeo Cheow Tong: Sir, first, I would like to thank all my colleagues in this House for their very active participation in the debate on this Medical Endowment Scheme Bill. I am glad that many of the colleagues have spoken out strongly in support of the Bill although they have some questions on some specific clauses in the Bill.

Sir, I would like to go through the concerns of the Members, one by one. Mr Loh Meng See has asked about waivers in 1992. I quoted the 1991 waivers and that we waived about $1.7 million in 1991. He has asked whether that figure is in the same ballpark for 1992 as well. In 1992, for the first nine months, we waived about $700,000. If you pro rate it for the full 12 months, you will expect the 1992 waivers to be close to about a million dollars. So the $5 million that we have allocated for 1993, I think, should be more than adequate in the light of our previous years' experience.

He has also expressed some concern about the need to tie Medifund to our ability to generate a budget surplus. Sir, I think that is very important because the Government has a limited pool of money. There are a lot of competing demands - education, defence, on-going programmes. We must make sure that our budgetary process allows us to generate a surplus so that we can contribute to Medifund. But whether or not we have the surplus, the endowment is safeguarded. We are already starting off by putting $200 million in the endowment and for the next few years, we hope to be able to contribute another additional hundred million dollars a year into Medifund. The $200 million that we are talking about for this year will be invested in Government bonds which are guaranteed, because it is the job of Medifund to safeguard the capital of the fund and not to invest in speculative investments. It will be invested in very safe, very guaranteed type of investments so that there will always be a continuing income to Medifund. And investing in Government bonds, I think, should get us, even with just the $200 million, about $5 million or $6 million quite easily every year.

As Medifund capital increases in the coming years, the amount of income available to Medifund should increase and I think it should be more than adequate. Even though the income should be more than adequate, there must be the proviso that the Hospital Medifund committees act responsibly. Because in a hospital like Singapore General Hospital, the expenditure each year comes to the region of between $200 million and $300 million. So if the Hospital Medifund committees are not responsible, the few million dollars that we give to them would be quickly dispensed with. We must therefore make sure that they live within the budget given to them and they prioritise, identify and give out the available funds only to those people who genuinely need the assistance. This process is very important.

To identify who are the people who genuinely need the assistance, we must get them to fill in a form and give some basic data about the family - family income, how many are there in the family, how many dependants, etc. These are very basic details which most patients have no problems filling them. Patients who are deterred because they need to fill the form and who can find other ways of paying for their treatment are clearly not amongst that group who really need help to pay for their hospital bills. We must have some basic criteria. We must ensure that people apply and provide the necessary financial data. And we must make sure that we vet carefully so that the sum that is available, which must always be limited, is used carefully and wisely.

Mr Loh Meng See asked which would be the approved hospitals. He asked whether community hospitals would be included. Mr Low now says that he is asking for clarification as to whether Mount Elizabeth and the private hospitals would be included. Sir, we must get back again to the objective of Medifund. Medifund is to help poor, indigent Singaporeans who need medical care in the hospitals. So we must only make sure that those hospitals that are catering for this group of patients will be approved. Obviously, Mount Elizabeth and the other private hospitals would not be catering for these people, unless they have a welfare or charity section of their own. Mount Elizabeth and the other private hospitals will therefore not qualify. Yes, we will also be considering the community hospitals and we will be in favour of approving them because they too perform a very vital role in our health care system.

How would the grants be allocated? We will be waiting for the advice of the Advisory Council when it is formed. But I would expect them to take into consideration the historical waivers being given by the hospitals as well as the composition of the wards - what percentage of the beds are in class B2 and class C, because the poorer patients would be using this sort of beds, and the absolute number of beds in each of these hospitals.

Mr Loh has asked that the audit and administrative costs be kept low. The main secretariat support will be provided by my Ministry and there will be no charge to Medifund. For the hospitals, we expect them to continue processing claims for waivers as part of their service to patients and, therefore, not levy a charge to Medifund.

Mr Low Thia Khiang again opened up with a quote from other people, which he did also in the last Budget debate, that one can afford to die but cannot afford to get sick. Sir, I hope that when he does come across such people, and being more aware of the health care system, he would act responsibly by explaining to them that that is not true in Singapore. It may be true in other countries, including the US, where 37 million people are without medical insurance and, therefore, cannot get access to medical care. But in Singapore, no one is ever deprived of medical care. A person who is very poor, who does not have any Medisave, is provided treatment the moment he arrives at the hospital, and billed later. The medical treatment and the billing are two entirely different things. Priority is given to treatment. If they cannot pay, they will be sent to class B2 or class C ward where there is vacancy. But treatment is given first and then the hospital worries about billing. I am glad that in the eight years that I have been in Parliament, I have not come across any case of a Singaporean being driven away from any Government hospital because he could not pay the bill. There has never been any case of that nature, and we are very proud of that.

Sir, our aim is to make sure that the poor and the indigent get treatment. And Mr Low has asked whether we can give an assurance. Sir, that is an assurance. Every Singaporean, no matter how poor he is, will be given medical treatment and, later when his bills are sent to him, if he applies, we will waive them. I assure him that we will provide free treatment to those very poor Singaporeans who cannot afford to pay their bills.

There has been some concern about clause 13(1) on applications for Medifund by citizens of Singapore only. Sir, that is the basic objective of Medifund. Medifund is meant as a privilege to be extended to Singaporeans, and Singaporeans only. And that is why clause 13(1)(a) is very specific. Some Members have expressed concern about children and parents who are non-Singaporeans. Dependants of Singaporeans, either the children or parents, who are permanent residents, already get subsidised services because they are free to go into class C wards and be subsidised 80%, even though they are non-Singaporeans. We have to look at this, not just in the context of Medifund, but in the overall perspective of how do we discriminate positively in favour of Singaporeans. At the moment, non-Singaporean children of Singaporean parents do not pay the same fees as Singaporean children when they go to school .It cannot be. We must discriminate in favour of Singaporean children. Similarly, with Edusave and Medifund. That is the privilege of being a Singaporean and we should be proud of that.

Dr Soin has suggested that we should consider allowing Medisave account holders to opt in and donate their Medisave funds to Medifund when they die. It is a good suggestion. Unfortunately, this is not currently provided for. We will take a look. But there is nothing to prevent any Singaporean from willing his assets, whether it is Medisave or otherwise, to Medifund, and we would be very glad to accept that.

Dr Toh Keng Kiat expressed some fears. He has expressed the view that, although the 80% subsidy for class C is very generous, some people still cannot afford the 20% co-payment and, therefore, they fear that health care is not accessible. Sir, the fear, if any, is without basis because we have always been treating Singaporeans regardless of income level and regardless of their ability to pay upon arrival at the hospital. The waiver system has been in existence all the while, and it is not a new thing. It has been in existence for decades and that system has ensured that no one is ever deprived of health care.

Mr Tong and others fear that in lean years, there will be no Medifund income and that medical illnesses are recession-proof. Sir, the investment of Medifund will be in long-term bonds and the interest income will continue to be available regardless of whether there is a recession.

Mr Walter Woon has asked how do we help children who are not Singapore citizens. I have answered that. But I also want to put it in perspective. Medifund is not the only safety net available. The fact that they are non-Singaporeans does not preclude hospitals from reviewing and considering the appeals of their Singaporean parents. The hospitals are at liberty to waive fees using their own financial resources, but of course not from Medifund. So that does not preclude other forms of assistance. The hospitals will review. They will consider carefully and if there are good reasons, good justifications, I am sure the hospitals will proceed to give them assistance.

The last speaker, Mr Chia Shi Teck, also mentioned that class C ward, based on feedback received by him, is not popular because some operations are not available and therefore the patients are not being given equal treatment. Sir, in the class C wards, most operations are available. Yes, there are some tertiary operations that may not be available in class C but they are available in class B2. Patients who go there and who cannot afford to pay the B2 bills will still get waivers. There is no reason for them not to use the subsidised wards in the hospitals.

Sir, Dr Vasoo is worried that the Medifund procedures will be so complicated and so time consuming that patients may not get treatment in time. As I have explained earlier on, the treatment and the billing procedures are two different things. They will first get treated regardless of whether they are Medifund applicants and then they will be billed later.

Dr Vasoo asked who are the Medifund committee members. They should not be hospital administrators. Sir, I explained in my Second Reading speech that they will comprise mainly members who are community and social workers. In fact, the intention is not to put any hospital administrator on the Medifund committees.

Sir, I believe I have answered all the questions.

Mr Low Thia Khiang: May I seek clarifications, Sir?

Mr Speaker: Yes.

Mr Low Thia Khiang: First, is the Minister saying that Medifund will only be available to C class wards? Will it be available to B2 as well?

Second, would the Minister or the Hospital Medifund committee spell out under what specific circumstances Medifund will be granted to applicants?

Thirdly, would the Minister confirm what Dr John Chen said, ie, the Government is committed to providing a safety net for people who cannot pay their medical bills and he suggested that if the hospital is lacking in funds in future, he believes they can apply to the Minister and the Government will be obliged to provide the funds.

Mr Tong Kok Yeo: Sir, I think the Minister forgot to clarify one point which I raised and that is whether the treatment will include ordinary or specialist outpatient treatment.

Mr Yeo Cheow Tong: Yes, patients in B2 and class C wards will be eligible to apply for Medifund. As for B1 and A class, if they are poor they should not be going to A and B1.

As regards the criteria, I would expect the Hospital Medifund committees as well as the Advisory Council to publicise the criteria when these are finalised.

As regards hospitals lacking funds, Sir, as I explained earlier on, some funds will always be available. But as in everything, the funds are finite. The hospitals must ensure that they utilise the funds in the right way. And if they do that, I think the funds would be adequate. This means that they must stick to the criteria and not deviate from them. But if there are some exceptional reasons, I am sure the Advisory Council will be prepared to consider.

Mr Tong has asked about outpatient treatment. For patients who are receiving outpatient treatment in the hospitals and they cannot afford to pay their bills, yes, they are also eligible to apply for Medifund.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. - [Mr Yeo Cheow Tong].

Bill considered in Committee.

[Mr Speaker in the Chair]

Clause 1 -

The Chairman: The citation year will be changed to "1993". This will be done.

Clause 1 ordered to stand part of the Bill.

Clauses 2 to 27 inclusive ordered to stand part of the Bill.

The Schedule ordered to stand part of the Bill.

Bill reported without amendment; read a Third time and passed.