Risk burden too heavy on the public

Non-Constituency MP Gerald Giam is the Workers' Party's point man on health-care issues. He speaks to Andrea Ong about what he thinks needs to change in health-care financing and public transport policies, and the difference between being moderate and sitting on the fence.

The Straits Times, 18 Jan 2014

What outcomes do you hope to see from the review of national health insurance scheme MediShield?

Three days after the MediShield Life review committee was set up, I made an adjournment motion speech in Parliament where I gave a few proposals about how we can improve MediShield.

It's a good thing that they are looking at expanding the coverage to ensure everybody is covered, even those with pre-existing illnesses. But my concern is the new premiums. I accept that increased coverage will come at a cost, but the question is, who should bear the cost increases?



This is why I proposed a MediShield premium subsidy for vulnerable groups of people like the elderly with low income, people who have exhausted their Medisave accounts, people with disabilities and low-income people who already qualify for other government help schemes.

I also suggested pre-qualifying them so they don't need to apply separately for subsidies. Experience shows that when you require people to apply for subsidies, many end up falling through the cracks because they may not be aware of the schemes or how to apply.

Will pre-funding, that is, getting people to pay higher premiums when they are young, work?

Pre-funding is something to be considered, but it also comes with its risks. Not everybody who is young is earning a lot. If you increase the premiums for the young, you might end up hurting certain groups of people who are already struggling. Pegging premiums more in line with income would be more appropriate than looking at age alone.


You've spoken about the need to rethink health-care philosophy. Could you elaborate?

I believe that philosophy drives policy and if you want to change a policy, you have to change the underlying philosophy behind it. The Government's philosophy towards health-care financing was set out over 20 years ago in the Affordable Healthcare White Paper in 1993. One thing they put forward was that Singaporeans must take personal responsibility for their health. What this means is that there is no free health care provided and co-payments are necessary for all treatments, because the Government believes that if there isn't some element of co-payment, there will be wastage and over-consumption.

Another is that you cannot rely too much on government subsidies and medical insurance. If you take this to the extreme, a lot of the payment for health care is borne out-of-pocket by individuals. That's what we have seen in the last 20 years, where a lot of the health-care burden has shifted from the Government to individual patients. When people say they find health care unaffordable, it's because a lot of the payments they have to make is out-of-pocket at the point of treatment. According to World Health Organisation statistics, about 60 per cent of national health expenditure in Singapore is paid out-of-pocket. The global average among developed countries is 14 per cent.

Are you in favour of scrapping the co-payment principle?

I don't think it's necessarily wrong to have co-payments. But the principle of co-payments cannot be applied blindly across the board. Research has shown that high co-payments can discourage low-income patients from seeking the care that they need. If they are deterred from seeking care, they will end up getting sicker, they won't take their medication, they skip doctor visits, and they get worse. Then they will have to be admitted to hospital and that costs both them and the health- care system a lot more than if they were treated earlier on.

Some of your suggestions will require greater government spending. What is an appropriate level of government spending?

I don't have a target. What's more important is what the money is being used for. I would pay more attention to the proportion of out-of-pocket payments. That is a more important figure to target, rather than just looking at overall spending. But there definitely is a lot of room to increase the Government's health-care spending.

Do you see the recent moves as a change in approach to health-care financing from the 1993 White Paper?

They are attempting to increase spending and I think this is inevitable, in response to an ageing population. Now, it's not just a nice-to-have, it's a must-have. I think there is some attempt and MediShield Life is one example. But there needs to be a lot more boldness in moving forward and slaying some of those sacred cows when it comes to the philosophy of health-care financing.

There will be trade-offs to raising government spending on health care.

Yes, of course there are trade- offs, but health-care costs are increasing and if the Government does not increase its spending, someone has to pay for it. What is the trade-off for the Government not increasing spending? It is individual Singaporeans having to pay a lot more.

The Land Transport Authority (LTA) recently announced a pilot scheme where bus operators are either rewarded or penalised depending on whether they reduce or exceed excess waiting time. Will this improve service quality?

I think it remains to be seen. My first reaction when I heard about this new framework was, why do we need to give the public transport operators (PTOs) even more incentives for just meeting the minimum standards? Recently, we pumped in $1.1 billion in the form of the Bus Services Enhancement Programme to help improve service quality. Now we're talking about giving the PTOs even more money. I've filed a question in Parliament asking the Transport Minister what evidence the LTA relied upon to determine whether giving the PTOs additional monetary incentives for meeting the minimum standards can spur improvements in quality. I also asked where the money for these incentives is going to come from.

What incentives would improve the PTOs' service quality?

The penalty framework definitely needs to be there. What I've talked about before is that as long as the PTOs are profit-oriented entities, no matter how you structure the reliability framework, their incentive is still going to be to maximise profit because that is their responsibility to their shareholders. I think we need to look into changing the way the PTOs are structured, from their ownership structure to providing incentives to improve service rather than maximise profit.

We hope to see PTOs that are not-for-profit. They don't need to be listed companies that are under pressure to show profits to their shareholders. At least then they can focus more on meeting quality service standards rather than maximising profits.

Do the announcements in last year's Budget and National Day Rally mark an overall shift in the Government's policy approach?

There's been some movement for sure. I wouldn't characterise it as a shift but as service recovery from the excesses of the past 10, 15 years where too much risk was shifted from the Government to the people.

I'm glad to see the catch-up in infrastructure development. It is something that Singaporeans have been calling for for a long time.

You've said the 2011 General Election played a big part in the PAP seeing the need to respond to people's calls. If the PAP manages to fix the policy problems before the next GE, where does that leave the Workers' Party (WP)?

Honestly, that's not a primary concern of ours. We are glad when we see that policies are changed for the better and they benefit Singaporeans. Politics is complex and there are lots of other factors at play. One major factor is a growing desire in our electorate for more political competition and political diversity. That's not necessarily going to go away just because people feel they have more money in their pocketbooks.

On our part, we will continue to speak up where we need to and represent Singaporeans to the best of our abilities. We don't hope that the Government stumbles. We hope the Government performs well, because if the Government performs well, the people benefit.

The WP was recently criticised by some PAP MPs for sitting on the fence on issues like the hijab debate and the Ashley Madison website. What is your response to that?

There's a difference between sitting on the fence and being a moderate party. We're not a party of extremists and the positions we arrive at are based on what we feel is best for Singapore.

We have stated our stand on both issues. On the hijab, we called for a public dialogue to achieve consensus on the issue of donning it in the uniformed services. I don't think that should be interpreted as fence-sitting, because this is a very complex issue. All the communities in Singapore as well as the leaders of the uniformed services should be consulted. This conversation needs to take place and it cannot be decided hurriedly by government fiat.

On Ashley Madison, I had the opportunity to state my party's stand on TV last month. I stated clearly that I find the website an affront to the values that many Singaporeans hold dear and that my party supports the Government's decision to block that website. Nevertheless, I don't think we should be naive in thinking that just by blocking the website, it's going to solve the problem of adultery in Singapore. This is another thing that the Government cannot control on its own. It is up to society - parents, teachers, religious leaders - to take up that responsibility to imbue the right values in their children, students and congregations, such that society becomes better inoculated against these negative influences. If we leave everything to the Government to do, we will be poorer as a society for it.

As a parent of two children aged three and five, what are your worries and hopes for their future?

I see an education system that is ultra-competitive, and focused a lot on academic grades. I hope that when my children go to school, they will have the opportunity to experience a more diverse life and won't be constrained by academics alone.

I would like to see more mixing as well between children of different abilities. If you're going to put all the best students into one class, they lose out on the opportunity to help and show empathy to their fellow students.

What do you do to unwind?

I like to take long walks in the park with my wife, whenever we can afford the time. We just celebrated our 10th wedding anniversary. I also enjoy having conversations with my kids. Kids say the darnedest things - you'd be amazed at how deeply kids can think. I have great conversations with my kids about life, faith and science. Even about politics sometimes, although they still can't quite tell the difference between the Workers' Party and a birthday party!

What's for supper

Fengshan Food Centre, Block 85 Bedok North Street 4

- Chicken satay (15 sticks) and two ketupat: $10.20

- Sugar cane drink (two cups): $1.50 each

- Total: $13.20

THE SUPPER CLUB GERALD GIAM
Part 1: 'Rethink health-care financing philosophy'
Part 2: 'We’re a moderate party, not fence-sitters'