What Can the U.S. Health System Learn From Singapore?

“Americans argue over insurance while Singaporeans keep perfecting the delivery of care.” says Dr. Aaron Carroll.

The following originally appeared on TheUpshot (copyright 2019, The New York Times Company).

Singapore’s health care system is sometimes held up as an example of excellence, and as a possible model for what could come next in the United States.

When we published the results of an Upshot tournament on which country had the world’s best health system, Singapore was eliminated in the first round, largely because most of the experts had a hard time believing much of what the nation seems to achieve.

It does achieve a lot. Americans have spent the last decade arguing loudly about whether and how to provide insurance to a relatively small percentage of people who don’t have it. Singapore is way past that. It’s perfecting how to deliver care to people, focusing on quality, efficiency and cost.

Americans may be able to learn a thing or two from Singaporeans, as I discovered in a recent visit to study the health system, although there are also reasons that comparisons between the nations aren’t apt.

Singapore is an island city-state of around 5.8 millionAt 279 square miles, it’s smaller than Indianapolis, the city where I live, and is without rural or remote areas. Everyone lives close to doctors and hospitals.

Another big difference between Singapore and the United States lies in social determinants of health. Citizens there have much less poverty than one might see in other developed countries.

The tax system is progressive. The bottom 20 percent of Singaporeans in income pay less than 10 percent of all taxes and receive more than a quarter of all benefits. The richest 20 percent pay more than half of all taxes and receive only 12 percent of the benefits.

Everyone lives in comparable school systems, and the government heavily subsidizes housing. Rates of smoking, alcoholism and drug abuse are relatively low. So are rates of obesity.

All of this predisposes the country to better health and accompanying lower health spending. Achieving comparable goals in the United States would probably require large investments in social programs, and there doesn’t appear to be much of an appetite for that.

There’s also a big caveat to Singapore’s success. It has a significant and officially recognized guest worker program of noncitizens. About 1.4 million foreigners work in Singapore, most in low-skilled, low-paying jobs. Such jobs come with some protections, and are often better than what might be available in workers’ home countries, but these workers are also vulnerable to abuse.

Guest workers are not eligible for the same benefits (including access to the public health system beyond emergency services) that citizens or permanent residents are, and they aren’t counted in any metrics of success or health. Clearly this saves money and also clouds the ability to use data to evaluate outcomes.

The government’s health care philosophy is laid out clearly in five objectives.

In the United States, conservatives may be pleased that one objective stresses personal responsibility and cautions against reliance on either welfare or medical insurance. Another notes the importance of the private market and competition to improve services and increase efficiency.

Liberal-leaning Americans might be impressed that one objective is universal basic care and that another goal is cost containment by the government, especially when the market fails to keep costs low enough.

Singapore appreciates the relative strengths and limits of the public and private sectors in health. Often in the United States, we think that one or the other can do it all. That’s not necessarily the case.

Dr. Jeremy Lim, a partner in Oliver Wyman’s Asia health care consulting practice based in Singapore and the author of one of the seminal books on its health care system, said, “Singaporeans recognize that resources are finite and that not every medicine or device can be funded out of the public purse.”

He added that a high trust in the government “enables acceptance that the government has worked the sums and determined that some medicines and devices are not cost-effective and hence not available to citizens at subsidized prices.”

In the end, the government holds the cards. It decides where and when the private sector can operate. In the United States, the opposite often seems true. The private sector is the default system, and the public sector comes into play only when the private sector doesn’t want to.

In Singapore, the government strictly regulates what technology is available in the country and where. It makes decisions as to what drugs and devices are covered in public facilities. It sets the prices and determines what subsidies are available.

“There is careful scrutiny of the ‘latest and greatest’ technologies and a healthy skepticism of manufacturer claims,” Dr. Lim said. “It may be at the forefront of medical science in many areas, but the diffusion of the advancements to the entire population may take a while.”

Government control also applies to public health initiatives. Officials began to worry about diabetes, so they acted. School lunches have been improved. Regulations have been passed to make meals on government properties and at government events healthier.

In the United States, the American Academy of Pediatrics and the American Heart Association recently called on policymakers to impose taxes and advertising limits on the soda industry. But that’s merely guidance; there’s no power behind it.

In Singapore, campaigns have encouraged drinking water, and healthier food choice labels have been mandated. The country, with control over its food importation, even got beverage manufacturers to agree to reduce sugar content in drinks to a maximum of 12 percent by 2020.

Singapore gets a lot of attention because of the way it pays for its health care system. What’s less noticed is its delivery system.

Primary care, which is mostly at low cost, is provided mostly by the private sector. About 80 percent of Singaporeans get such care from about 1,700 general practitioners. The rest use a system of 18 polyclinics run by the government.

As care becomes more complicated — and therefore more expensive — more people turn to the polyclinics. About 45 percent of those who have chronic conditions use polyclinics, for example.

The polyclinics are a marvel of efficiency. They have been designed to process as many patients as quickly as possible. The government encourages citizens to use their online app to schedule appointments, see wait times and pay their bills.

Even so, a major complaint is the wait time. Doctors carry a heavy workload, seeing upward of 60 patients a day. There’s also a lack of continuity. Patients at polyclinics don’t get to choose their physicians. They see whoever is working that day.

Care is cheap, however. A visit for a citizen costs 8 Singapore dollars for the clinic fees, a little under $6 U.S. Seeing a private physician can cost three times as much (still cheap in American terms).

For hospitalizations, the public vs. private share is flipped. Only about 20 percent of people choose a private hospital for care. The other 80 percent choose to use public hospitals, which are — again — heavily subsidized. People can choose levels of service there (from A to C, as described in an earlier Upshot article), and most choose a “B” level.

About half of all care provided in private hospitals is to noncitizens of Singapore. Even for citizens who choose private hospitals, as care gets more expensive, they move to the public system when they can.

So Singapore isn’t really a more “private” system. It’s just privately funded. In effect, it’s the opposite of what we have in the United States. We have a largely publicly financed private delivery system. Singapore has a largely privately financed public delivery system.

There’s also more granular control of the delivery system. In 1997, there were about 60,000 ambulance calls, but about half of those were not for actual emergencies. What did Singapore do? It declared that while ambulance services for emergencies would remain free, those who called for nonemergencies would be charged the equivalent of $185.

Of course, this might cause the public to be afraid to call for real emergencies. But the policy was introduced with intensive public education and messaging. And Singaporeans have identifier numbers that are consistent across health centers and types of care.

“The electronic health records are all connected, and data are shared between them,” said Dr. Marcus Ong, the emergency medical services director. “When patients are attended to for an emergency, records can be quickly accessed, and many nonemergencies can be then cleared with accurate information.

“By 2010, there were more than 120,000 calls for emergency services, and very few were for nonemergencies.

Singapore made big early health leaps, relatively inexpensively, in infant mortality and increased life expectancy. It did so in part through “better vaccinations, better sanitation, good public schools, public campaigns against tobacco” and good prenatal care, said Dr. Wong Tien Hua, the immediate past president of the Singapore Medical Association.

But in recent years, as in the United States, costs have started to rise much more quickly with greater use of modern technological medicine. The population is also aging rapidly. It’s unlikely that the country’s spending on health care will approach that of the United States (18 percent of G.D.P.), but the days of spending significantly less than the global average of 10 percent are probably numbered.

Medical officials are also worried that the problems of the rest of the world are catching up to them. They’re worried that diabetes is on the rise. They’re worried that fee-for-service payments are unsustainable. They’re worried hospitals are learning how to game the system to make more money.

But they’re also aware of the possible endgame. One told me, “Nobody wants to go down the United States route.”

Perhaps most important, the health care system in Singapore seems more geared toward raising up all its citizens than on achieving excellence in a few high-profile areas.

Without major commitments to spending, we in the United States aren’t likely to see major changes to social determinants of health or housing. We also aren’t going to shrink the size of our system or get everyone to move to big cities.

It turns out that Singapore’s system really is quite remarkable. It also turns out that it’s most likely not reproducible. That may be our loss.

Aaron E. Carroll, MD, MS  a healthcare speaker, professor of pediatrics at Indiana University School of Medicine who blogs on health research and policy at The Incidental Economist and makes videos at Healthcare Triage.