On Rising Healthcare Costs - And Why I'm Not Buying Opposition (or PAP) Promises

As a medical doctor, I read with concern claims by the opposition that rising health costs are the fault of "government mismanagement". Even more worrying were promises by the opposition to provide cheaper medical care (with one politician reminiscing of low healthcare costs in the 70s and 80s), with plans such a welfare scheme put forward by some parties, as if this were an end-all solution.

The reality is that healthcare is getting exponentially more expensive, by processes beyond the control of any government. The “cheap and easy” gains in health outcomes, such as vaccinations and sanitation, have been already been achieved. With demographic shifts reflecting those of first world countries, Singapore would soon be facing increasingly complex healthcare issues that require new, and often expensive, solutions. These would include an ageing population, with people living longer and developing more illnesses associated with old age (such as dementia, cancer and arthritis). Recent economic analyses from the US have demonstrated that any cost-saving from addressing preventable illnesses will be offset by these unavoidable “diseases of old age”.

Rapid advances in technology also mean that medical care today is a far cry from medical care from yesteryear (especially from the "good old 70s"). We have a larger number of more powerful drugs to treat conditions, many of which are being detected with more sophisticated tests. Technology has revolutionized medical practice, such as fibre-optic imaging in keyhole surgery. However, all of these advancements involve significant R&D costs, into the millions of dollars, which are then transferred to the end-users. By positioning ourselves as a medical hub, Singaporeans effectively now have access to these latest developments. However, if we want to continue to enjoy the latest pharmaceuticals or the most advanced imaging and surgical techniques, we will need to face the burgeoning costs associated with them.

What this means, is that healthcare is becoming more expensive at a rate never seen before, bringing the issue of healthcare costs to the forefront in many political debates around the world (the most recent, and perhaps significant, are the healthcare reforms in the USA). The best minds from around the world have sought a solution, but no easy answer has yet been found. Ultimately, the costs have to be borne by someone – in Australia and the UK, the governments have borne the costs through a welfare system. However, this is translated to significantly higher taxes for the people (close to 50% for some categories!) Even then, these governments are frantically searching for a way to curb the ballooning healthcare expenditure that is pushing the countries deeper into debt (as a friend of mine says – health care expenditure is basically a black hole). On the other hand, the USA has attempted to use a free market approach in an attempt to drive healthcare costs down via competition. Unfortunately, this has backfired for a number of reasons, leading to even basic healthcare being out of reach of a significant proportion of the population.

We should thus take any blanket promise of lower healthcare costs with a grain of salt, being aware that there is no simple answer to this complex issue. As the election draws close and more promises are being made, we should be wary of such utopian offers, realizing that there is no magic bullet to ease the pain of rising medical costs.

My 2 Cents, on probably the only topic I'm familiar with.

Sing Chee

On Swine Flus, SARS and perspective

This article from The Age pretty much sums some of the things going through my mind as people squeal in fear from the possibility of a pandemic from the H1N1 flu outbreak that will kill us all:

http://www.theage.com.au/opinion/fears-distorting-reality-20090429-ancz.html

Some extracts:

...why do the deaths of only some people from obscure diseases cause us to panic? And how can we be so unfeeling when we have the power to save the lives of millions by relatively simple, inexpensive precautions and treatments?....

...it seems that only when we perceive that infectious diseases threaten "people like us" do we respond with real urgency. The millions killed by TB, AIDS, malaria and other mass killers are doomed to fit the stereotype of people who live and die like that. We can accept it as the way of the world. Aboriginal Australians are just as much victims of the indifference that flows from such stereotyping.

In all reality, we only have 7 confirmed deaths from the Swine Flu (based on WHO analyses - Mexican databases aren't exactly stellar), in a country that is known for its gross inequities and dodgy standards of health and living. In contrast, the normal flu kills 250-500,000 people a year, of which 2000 are in Australia. Yet, all of the sudden, we have the leaders of the known world speaking up and declaring that they will spare no expense to contain this outbreak.

I admit the need for an effective public health response, and even acknowledge that there is more to gain from stoking people's fears and insecurities, hence keeping them on the alert, as compared to calming them. It's good to take appropriate measures at disease containment, for epidimiological reasons, but probably more so for political ones (this is already turning into opportunities to score political points if you read the news).

However, despite all the fearmongering about it being the "next big pandemic" and how we are "overdue for a massive outbreak"that "threatens the existence of humanity", in all likelihood this H1N1 virus thing is going to become something of the past, just as SARS did. Does anyone remember the HK flu from the 1960s that killed over a million people worldwide-no? In addition, the world of international communications and public health is incredibly different from what it was in the century of the last pandemic. Just google something like "Developments/achievements in the last 50-100 years" and you'll see what I mean (this includes the internet btw).

And so I come back to my original point - lots of fearmongering and scares at "possibilities" that are in reality mere shadows, revealing a distinct lack of perspective on disease and illness. This is in stark contrast to our ignorance at the daily epidemics and massive numbers of deaths in poorer nations around us. I believe these events do something more than threaten the health of us all - they reveal the hypocrisy and lack of perspective in our lives, how we spend with reckless abandon at anything that immediately threatens our welfare, but live in gleeful ignorance what happens beyond our own world (I'm just as much guilty of this). I cannot help but think about God's anger - not expressed through disease as a punishment, but against us, for our indignancy, and our love for evil, not good.

PS: For those who are freaked out by the WHO near declaration of a pandemic - look up the definition first, see see how vague it is. The only thing that separates a "pandemic" from something like the normal flu, is the fact that it's new to populations.

Confessions

I confess - I'm not itching and raving to drop everything and go work in a developing world.

I know how much of a need there is - I've spent 3 months living with the people (mud huts and all) in the poorest regions of India (it isn't much, but it's something). I've read article after article quoting international statistic after statistic, with plenty of case commentaries to demonstrate the difficulty of the situation. Mentors and friends have shared stories about the challenges and trials of working in these areas. I have been moved to tears by sights of poverty and hopelessness.

Unyet, I don't feel like dropping everything I have and heading over there ASAP.

Don't get me wrong, I have immense respect for people who sacrifice much to work overseas, and believe there is a genuine need for all Christians (including myself) to be involved in global missions, in whatever capacity. However, at the same time I can't help but feel that we have "glamorised" the overseas experience, and fixated our eyes on it, while Rome burns.

You don't need to be a genius to realise that our society is cracking at the seams - our health systems are breaking, families are being destroyed, street violence is on the rise, and so on. In many ways, the developed world is a ticking time bomb; we have archaic systems and mentalities in place that are woefully inadequate to meet the changing needs and demands of society, yet this is a society that is integral to the global village (the recent economic crash is a typical example of the central role developed nations play in the world).

An example has grown out of my experience in community pediatrics over the last one month. It has been decades since the concept of the "new morbidity" has been put forth, when pediatricians began to notice the replacement of "developing world" diseases such as meningitis, with developmental problems - learning disabilities, behavioral problems and so on.

"Bah" you may say, "having difficulty learning is nothing when compared to starving to death". In some ways that is true, but consider this - in todays highly educated, competitive and academically oriented culture, a learning disability is going to have massive social repercussions, much more than in a more traditional culture. The label of "dumb" rapidly progresses to bullying, school dropouts, and eventually substance and drug abuse, unemployment and involvement in street violence. Child Safety Commissioner Bernie Geary is quite certain where many of these kids end up: prison. It doesn't take long to see what a social disaster this could become, with up to 20% of Australian kids now having a functionally significant learning impairment. Can we seriously make a value distinction between the impact of starvation and the impact of violence/substance abuse/imprisonment?

In many ways, I can't help but feel that this is going the way of Christian evangelism: for years it was "the West to the Rest", but now, for a variety of reasons, it's very much "the Rest to the West". Unless we keep vigilant on what's happening at home, we could easily end up on a downhill slope in society. Already Keating and Hertzman (1999) have noticed this "paradox of modernity" - that Marmot's social ladder of health is beginning to falter in our modern world.

And so the next time you are tempted to think that the third world is only place needing prayer and transformation effected through the work of the body of Christ, remember events such as this merely scratch the surface of a deeper disease beginning to eat away at the roots of our society.