AFFORDABLE HEALTH CARE (Motion)

[Mr Speaker in the Chair]

Debate resumed.

Mr Koo Tsai Kee (Tanjong Pagar GRC): Mr Speaker, Sir, thank you for allowing me to join in this debate on the White Paper on Affordable Health Care.

Sir, I would like to say something as the President of the Consumers' Association of Singapore (CASE). The content of the White Paper is something CASE can endorse because it provides good affordable basic health care for Singaporeans who are consumers but, more importantly, CASE can endorse the findings of this White Paper because of the checks and balances it has drawn up to protect consumers. In particular, CASE endorses the concept of balance billing when private hospitals allow patients to pay part of the bill through Medisave.

Sir, the fear that balance billing might encourage private doctors in private hospitals to under-service patients is not likely because of the competition provided by Government and Government subvented hospitals. But experience in other countries, in the West especially, when balance billing is not there, there is a tendency somehow for bills to rise out of proportion. So CASE endorses the balance billing concept.

I share the concern of some of my colleagues in this House on balance billing and some doctors have also suggested that balance billing is not good for the patients because it encourages doctors and hospitals to take short cuts, to under-prescribe and to under-treat. If that is the case, then perhaps these people should actually lobby the Government to revert to the pre-1986 situation when Medisave could only be used in the Government subsidised hospitals. But so far, these people have not done so. Because the fact of the matter is that, right now, the choice lies entirely with the private hospitals. They can choose to exercise this balance billing when it is implemented or the hospitals can choose to take themselves out from this scheme by asking patients to pay the entire amount in cash. Therefore, to balance bill, or not to balance bill, is really not the issue. But I think balance billing provides some assurance on the size of the health care bill to consumers. And on this score, CASE supports it enthusiastically.

Sir, I was listening to my colleague, Dr Soin's point about this new scheme proposed by the Government about paying 1% of the salary into Medisave and thereby allowing the employee to use that 1% perhaps to buy insurance to cover any illnesses he or she might incur. And Dr Soin, if I heard her correctly, said that this scheme is regressive because, under the existing civil service scheme, all civil servants get universal coverage. In other words, they all get the same kind of coverage, which is not the case, because I serve in the NTUC and we sign collective agreements (CAs) with different employers. We also have the AUPE signing collective agreements with the Government and we know that different CAs provide for different kinds of coverage. Sometimes in one CA, we have different coverage for different categories of employees. So if you are a top executive, you might get Class A or B1. If you are lower down the scale, you might get Class B2 or C. So even under the existing scheme, there is no universal coverage and not everybody is covered equally.

Under the proposed new civil service scheme, young employees actually benefit from the scheme because they do not consume health care during the early years of their civil service employment and they can choose to either save the money in their Medisave which, when it reaches above a certain amount, will flow over to the Ordinary Account, or they can choose to buy insurance. So, I think on this score, perhaps Dr Soin is misunderstood.

Sir, the words "health care" are of recent minting. The original words were medical care. Because medical care was closely associated with hospital care which, in turn, evoked all kinds of unsavoury imageries, few people avail themselves of medical services. There was, therefore, no problem in medical care, until the words "health care" came along to replace it.

Now, people take health care as a right and demand instant services, where they want it, when they want it. This behavioural change is not inexplicable because Singaporeans believe that health care administered in large doses will extend their lease on life proportionately.

But this, of course, Sir, is a fallacy. Because the Americans who consume something like $1 trillion, or 14% of its GDP, do not live longer and healthier lives than the Japanese or Europeans who spend far less. In fact, the average Americans die one year earlier than the Germans, and 3.5 years earlier than the Japanese.

Clearly, the key to longer and happier lives is not to throw money at health care. The way to happiness is to reinforce traditional family values, empower people with jobs, and create a sense of purpose and self-worth in society.

Excessive spending on health care is a vicious form of poverty trap. If more money is spent on health care, less will be available in education and other social investments. Poorly trained people, and inadequate infrastructure will encourage joblessness which in turn demands higher consumption on health care. So each turn of the vicious cycle traps ever more people into joblessness and higher expenditure on health care. And the cycle will carry on and on until society is bankrupt.

Hence, Sir, the first important point I wish to make about the White Paper on Affordable Health Care is taken from the perspective of younger Singaporeans which, I think, not many of my colleagues have spoken out for, and I hope to represent them in my office as the Deputy Chairman of the National Youth Council (NYC).

Sir, the National Youth Council is an umbrella group representing most of the youth movements in Singapore. On 4th July 1993, the NYC debated on various issues affecting youth, including one on health care, and some of these issues are captured in this report "NYC Seminar - The Future in Your Hand". I suggest that everybody should read it. Since then, I have had various discussions with younger Singaporeans both in the NYC and outside. They all support the White Paper. All of them want good basic affordable health care for Singaporeans, especially for their aged parents and relatives. But they also recognise that in a hybrid system like the one proposed in the White Paper, the younger Singaporeans are the ones who will be paying for the subsidies on the B1, B2 and C wards.

Sir, in the United States, younger Americans are already fed up and disillusioned with the exorbitant health care cost because they have been asked to shoulder a disproportionate share of the nation's health care bill. Calling themselves Generation X, after Douglas Coupland's novel, this group of people see no future for themselves. When Generation X was born in the mid-60s, health care cost in the United States took up less than $100 billion because less was spent on health care. There was more money and everything else for people who were already in their 20s when Generation X was born in the 1960s.

So by the time Generation X started their careers a few years ago, their seniors, who are already in the late 30s and 40s, whom Generation X called the Boomers, were already entrenched in well-paying jobs, while the younger ones were left to pick up the crumbs. And Generation X is very angry and disenchanted with their seniors. Part of the reason is that they think that health care cost is to be blamed. Between 1961 and 1992, health care expenditure in the United States shot up from less than $100 billion to its present $800 billion, and by next year, it will be about $1 trillion. Generation X, the younger people, thinks that it is not fair to them because they are not consuming health care services but they are paying taxes on them.

Sir, younger Singaporeans in Singapore are not so antagonistic. They want to share in this health care programme for their parents and their seniors, but they like me to suggest to Members of this House to take their views into consideration when implementing any health care policy. Because while they are not consuming health care now, they will be consuming health care in 20 to 30 years' time. And they are afraid that by the time they get old, there will be not much left for them.

Sir, my second comment on the White Paper comes from my perspective as a Member of Parliament for Tanjong Pagar GRC and as labour MP for Singapore workers. Sir, most of my wards in Tiong Bahru and the unions are senior citizens, who are either economically inactive or working class people, with little cash savings.

Unlike younger Singaporeans who are paying into the health care system but are not using up their share, my residents and my workers are beginning to consume some of the health care services. Fortunately, these are not demanding people. In fact, their needs are quite simple, albeit well-defined. The things they look out for are:

(a) adequate and prompt medical treatment;

(b) humane attention from medical staff; and

(c) affordable health care. Sir, the White Paper promises to deliver on all three counts. Hence, for the vast majority of my residents, they are reassured that this Government will not let them down.

Sadly, Sir, a few of my residents are really so poor that even affordable is prohibitively expensive. But I am glad to note that our system takes care of even the destitute. Over the last two years, since I became MP in September 1991, I have made several representations on behalf of my poorer residents to get waivers on hospital bills. I am happy to tell everybody in this House that the Ministry of Health has always looked at all these destitute cases personally and sympathetically. In fact, the CEOs of the restructured hospitals have replied to me personally, explaining each case in detail. Sometimes, they have even called me up. I want to take this opportunity to thank the civil servants in the Ministry of Health for this human touch in health care.

Sir, because the hybrid system proposed in the White Paper is essentially a cross between the pricing system (which is a fee-for-service system) and the queuing system (which is a free medical system) I think it would be wise to do a means test for people who qualify for the lower wards, the B2 and C wards.

Why means testing? Basically because the ward charges in these two wards are heavily subsidised through general taxation. Yes, right now, there does not seem to be a rush for people into the Class C wards. But I believe that, over time, more and more people will rationalise their demand and want to bed themselves into the B2 and C wards primarily because of these reasons.

First, the Government is overhauling the image of class C wards. I heard the Minister's persuasive speech yesterday trying to convince us that class C is as good as class B2, B1 and A in most of the services with the exception of a very small category of medical benefits. Sir, the more successful the Minister and the Government sell the class C and B2, the more people will want to go to B2 and C wards. It must be. Because, after all, Singaporeans are rational consumers. And certainly there is a difference in the C class wards of yesteryear and the C class wards of today. Yes, there is still some social stigma attached to being warded in a class C ward today. But the reality will sink in that class C wards give very good value for money. And I think the more successful the re-imaging process, the higher the demand for C wards.

Second, as our population ages, more people will need more health care services. Even if the proportion of people going to B2 and C wards does not increase, the absolute number of people going in will increase over the years, meaning more demand for class C wards.

Finally, in the jobless growth era, consumers are evaluating the worth of every single purchase. This is happening in the West and I believe it will come to the East. In the West today, people drive for miles, 10, 20, 30, 40 miles, to get discount rates in WalMart, in discount stores. In Europe, airlines are redesignating first class seats into business class and redesignating more business class into economy class. Many 5-star hotels are retrofitting into 4-star hotels and some 4-star into 3-star.

Why this behavioural change? Because in their search for value, consumers in the West are looking for a product's intrinsic worth, not its cosmetic value. If what the Minister says is true, our class C is almost as good as our B1, then why would a person go to B1 instead of going into C? Sir, as the huge cost of health care begins to sink in, Singaporeans will also re-evaluate the worth of their purchase and I think the tendency to migrate from A to B1, from B1 to B2, B2 to C will start sooner rather than later.

Sir, since the Government is taking this opportunity to revamp the entire health care system in Singapore for the 21st century, I think it will be wise now to signal to the public that at some point later, if not sooner, means testing would be inevitable. After all, we do means testing in many things. For example, in HDB applications, we do a means test. Means testing is also a fair way of rationing scarce resources under any hybrid system, unless you free it altogether and go for the fee-for-service system.

I note that in the White Paper, the Committee chose the words "equitable access" instead of the words "universal access". Clinton's health care plan uses the words "universal access". "Universal" means everybody gets what he wants. Therefore, means testing is not necessary. "Equitable access" means that there will be some form of rationing and therefore I think some means testing is not out of place.

Sir, the equitable and efficient way to means testing is to set some simple and easy to administer barrier which prevents the rich from consuming the services for the poor. For a start, if I may suggest, we can set very high limits so that for all practical purposes, the vast majority of both the rich and the poor can have access to B2 and C wards. Then over time, as health care costs rise, the original means test will progressively filter off the rich into A and B1 and allow the less rich to use the heavily subsidised B2 and C wards. One way to do it might be to look at the CPF amount available or withdrawn to gauge the wealthiness of a patient.

Sir, I support recommendations of the White Paper.

Mr Yeo Cheow Tong: Sir, can I ask Mr Koo to clarify one point? He stated at the beginning that CASE strongly supports the concept of balance billing. But he also suggested that should there be any problems with the quality of health care, since some doctors have stated that with balance billing, doctors will cut corners, he proposed that we revert to the pre-1986 arrangement whereby Medisave could only be used in the subsidised hospitals. But he did not explain whether CASE will support this as an alternative.

Mr Koo Tsai Kee: Sir, CASE would prefer the balance billing concept. Because under the present concept put forward in the White Paper, there is already a provision for hospitals to withdraw themselves from using Medisave payments. So if a hospital thinks that balance billing is bad, the hospital can say, "Look, I encourage all my patients to use cash." If the hospitals take that position, it is equivalent to the pre-1986 position.

Dr Tan Cheng Bock (Ayer Rajah): Mr Speaker, Sir, I would like to declare my interest. I am a medical practitioner.

This White Paper has managed to crystallise the many ideas and issues brought up inside and outside this House. It has addressed many issues like health costs, the role of restructured hospitals, Medisave usage, medical training and education, and financing. I think it is a frank and fair appraisal of the state of health care. The solutions to the issues posed may not be acceptable to all but, on the whole, it is a commendable attempt.

I have always lamented the lack of emphasis on the health care delivery system in previous health reports. But this time I notice that it has been given more coverage and emphasis, which is correct. Because you need a good health care delivery system to carry out the policies and to better inform Singaporeans of the choices and accessibility to our many health care institutions. I think we have a more structured and defined health care delivery system with the Government identifying the three levels of health care, namely, primary, secondary and tertiary.

The next step will be to educate Singaporeans on the proper utilisation of the many health care provisions at all the three levels. I hope that we can evolve a good health care programme. Some degree of flexibility is needed in its implementation. And this flexibility of implementation was emphasised many a time in the White Paper. For example, on the topic of basic health care, realising that it will not be practical to enumerate all the items in the basic package, it was suggested that, and I quote from page 23, line 3:

"A great deal of judgment as to when exactly to carry out a procedure or to prescribe a drug must be left to hospitals and doctors. They are the ones who actually diagnose and treat the patients."

Now that we have clearly defined three levels of care, namely, primary, secondary and tertiary, we should not allow these institutions to work in isolation but to encourage cooperation and coordination among the many hospitals and primary health care institutions. Restructuring of our hospitals has encouraged competition and independence of operations. While competition is good, too much of it may lead to isolation and non-cooperation. I find most of our health institutions tend to develop in isolation, eg, day care centres, outpatient clinics, the Home Nursing Foundation. Are they working closely together or each doing their own task? How close are our hospitals to the primary health care institutions? There must be a conscious effort on the part of each one of us to get these institutions to work together as part of a single organisation.

Maybe for a start we can refine our present health care delivery system. We could divide Singapore into four or five zones, each zone to have primary, secondary and tertiary health care institutions including community hospitals, private and OPD clinics. For example, if we take the western zone, you can have NUH as a tertiary hospital, Alexandra Hospital as a secondary hospital, then you have community hospitals, private clinics, OPD, day care centres, the Home Nursing Foundation and hospice care, all linked to a common system. In other words, we have a system of delivering health care to the people in a systematic manner to the western zone. You could have a department in MOH to collect and process information and data, collate and coordinate the services available of such institutions. It is a proactive role of delivering health care including health education to the people in the western sector of the island. It is a system that once developed can be duplicated in the north, south and east zones and elsewhere. There is no need to build tertiary hospitals for all the zones. They can share SGH or NUH. A better informed people will help to appreciate the system better, saving cost and time.

I agree with the White Paper's emphasis on basic medical care. Basic medical care is open to many interpretations. Many are trying to define basic medical care. Some worry that it may not cover certain modalities of care. We can debate this at length, but finally we must come to some understanding. I think the White Paper's definition by excluding certain care is acceptable. There are two important points in the definition of basic medical care in the White Paper: (i) good up-to-date medical practice; and (ii) essential and cost-effective medical treatment of proven value. I think this is a good start and later, with more experience, we may have to refine the basic health care.

The section on basic medical care that has to be treaded carefully is the part on treatment options. This is a sensitive area because hard decisions will have to be made whether we want to institute active or passive management of such cases as incurable diseases with no chance of survival and whether life support should be given to severely damaged patients or intensive care for premature newborns who are unlikely to survive. Or even if they survive, their long-term prospects are uncertain. If the decision to institute active treatment is made, then one cannot expect the Government to back you at all costs because this is beyond the basics.

There are many cases of patients who remain in coma for months or years on life support machines. In my years of practice, I find that the people who demand and insist on a particular care or procedure for a relative or friend are those not paying the bills. Those who pay the bills are then made to feel guilty if they do not agree. People must exercise their own judgment carefully in consultation with doctors and care givers so as not to be swayed by emotional guilt feelings. As for myself, if I am brain dead and I depend on the respirator and other life support aids to keep me alive, then I better go. I have told my family members not to allow my medical colleagues to save me by making me undergo active management but just to institute passive treatment. I would not want to live if my quality of life is that of a vegetable. This is my living will.

On balance billing, I think I would not talk on this as too many Members have spoken on it.

Restructured hospitals have been criticised for the tendency to over provide services and duplication of services, not enough C class beds, more A class beds and more intensive care beds. The White Paper's call for control on the total number of hospital beds and intensive care unit beds is very necessary. Each subsidised hospital cannot have more than 13% class A beds and must have at least 65% class B2 and C beds. However, I disagree with the White Paper's recommendation that subsidised hospitals that want more A class bed wards for new unsubsidised services should develop the services on a commercial basis and as a distinct entity. The provision of such A class beds is a detraction from the role of our subvented hospitals. Do not invite problems. You are only tempting our doctors to do private practice in a public hospital setting. Leave this to the private hospitals. There is no doubt that this move will put a strain on the hospital's resources, including manpower. There are already complaints that doctors, especially specialists, are not paying enough attention to the subsidised patients. The introduction of such class A beds will again lead to such complaints.

This White Paper is trying to set right the poor image of subsidised beds, but this move will set it back. The subsidised B2+, B2 and C class beds are already having an image problem, as pointed out by Mr Koo Tsai Kee. Do not add more to this. If the idea behind this is an attempt to retain our specialists, I would suggest that you improve upon the Visiting Consultants Scheme where good specialist consultants are invited to join the hospital doctors in the management of patients. The reason why this scheme has not worked out well in the past is the prejudice of the doctors in the hospitals against the private specialists. But they must know that they will face a similar prejudice if they leave the Government and get invited to go back as Visiting Consultants. I think in the interest of the patients we should overcome this.

While we cap at 65% the total beds in our subvented hospitals for B2+, B2 and C class beds, I would request flexibility when applying to the community hospitals because community hospitals are in its early stage of evolvement. It may require more than the 65% for such hospitals because the patients are probably older and chronically ill. I ask for flexibility because this percentage could be related to funding of the hospitals. Do not apply the rules of funding for such community hospitals as you would have for a secondary or tertiary hospital.

Undergraduate training. The training of our future doctors must be relevant to our needs and our national health policies. The emphasis in the White Paper on family health care would mean that our undergraduate must be exposed to such teaching, as ultimately 60% of each cohort of doctors will practise as family practitioners. To do so effectively would mean a careful reappraisal of undergraduate training. For a long time our doctors have been trained to be institutional doctors. We follow the British Medical School system where training is confined primarily to the wards and hospital surroundings with a token posting with general practitioners or family practitioners for about two weeks.

We should perhaps look elsewhere for other models of medical training. One such institution we could look to for guidance is the School of Medicine of the Ben-Gurion University in Beersheba, Israel. I know it is not included in the 28 Medical Schools. But it does not mean that this is not a good school. When I was in Israel, I was pleasantly surprised to find the school training their undergraduates to be, first, community-based doctors before specialising. In this way, the doctor who finally becomes specialist understands a community well because he started out in the community. The school makes use of the many health institutions at all three levels of health care - primary, secondary and tertiary - as training centres. Let me read to you the goal of this University, and I quote:

"to turn out the highly competent doctor who will have been given a sound basis for specialised training in all branches of medicine and who would have been exposed to a particular emphasis on the importance of the integration into all specialities of a community medicine orientation. To provide the training and expertise which will enhance the graduate's motivation and ability to become a highly trained specialist in the provision of primary health care for patients and families."

Sir, NUH has only 14% of the total acute beds in subvented hospitals. This would not be adequate for the training of our undergraduates. Therefore, the other subvented hospitals and polyclinics, as rightly pointed out in the White Paper, must also be involved in the teaching of our students. Some coordination and regulation is definitely essential. I sense the restructuring of our hospitals has affected our medical student training. This White Paper's recommendation that the Ministry of Health provide all subvented hospitals, including NUH, the same rates of subvention to meet the clinical service role is timely, and the Ministry of Education will separately fund the additional resources which the subvented hospitals will need to support undergraduate teaching is most welcome.

The call to NUH to regularly review its medical undergraduate curriculum together with the Ministry of Health and the Singapore Medical Council and the setting up of an Advisory Committee on Medical Specialists to advise it on postgraduate training are also good moves. In the past, before restructuring, in every Government hospital the doctors were keen to teach medical students. But with restructuring the situation changed. Because the emphasis was for the doctors to pursue clinical work instead of teaching. I hope this would change with the special grants from the Ministry of Health and the Ministry of Education and, most important, the attitudes of the administrators of the restructured hospitals.

Mr Koo Tsai Kee: Sir, if I may make some clarifications. When I said CASE supports the concept of balance billing, I meant CASE supports the concept of limiting balance billing. In other words, capping the amount over which hospitals allow Medisave to be used.