Khaw Boon Wan
Singapore
“Motor vehicle dealerships and showrooms have been closed since the start of the circuit breaker. As COE bidding is done mostly by the motor vehicle dealers on behalf of prospective owners, the Land Transport Authority (LTA) suspended COE bidding for the months of April and May.”
“Though stressed by the financial pain, they press on with the immediate priority of fighting the virus and supporting essential services. Post-pandemic, we will see how public transport evolves. Will demand for public transport services simply return to the pre-pandemic level?”
“Under our rail financing framework, the Government fully pays for the cost of building new rail lines. In other words, we do not recover the cost of building the Cross Island Line (CRL) from commuters through fares. The CRL project is being implemented and the final costs will depend on tender bids.”
“There are around 5,000 private bus operators with a combined fleet of 13,500 private buses. As we do not track the number of private bus trips and passengers, we do not have data on their carbon emissions.”
“There are nursing rooms at 50% of our bus interchanges. We will provide nursing rooms at all new bus interchanges and integrated transport hubs. For the MRT network, we will provide nursing rooms at all new interchange stations. We will also explore providing such facilities when MRT stations undergo upgrading.”
“Over the last three years, Singapore carriers have reported a total of 20 incidents of food allergies on board their flights. None required the use of epinephrine or emergency flight diversions.”
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“Sir, I can certainly assure the Member that affordability must be one of the key elements in the design of the 3M system because, if it is not affordable, what is the point. It may be a good plan on paper but if most people are excluded, then it does not serve any purpose. That is the reason why in the last MediShield reform, I sought advice from Members and I remember Mdm Halimah and Dr Neo gave me very good advice that the premium increase should not exceed single digit which limits it to about $10 a month. That is why we designed the last MediShield reform that way. But once you are limited by $10 per month, the payout is also limited and that is why I was not able to bring the co-payment down from 60% to 20% which was the target I set out to do. But, never mind, we achieved quite a good outcome in reducing it to 40% and this year I hope that the public, at least based on the people whom we have spoken to during the focus group discussions, will find it reasonable to have another round of increase of a few dollars a month and, hopefully to bring co-payment down to 20%, if possible. The various computations are actively being done now. I hope this is something that we can achieve and we can discuss this next month. On the inadequacy of Medisave for the elderly, whenever the budget allows it, we have some top-ups for the elderly. I am looking forward to the Budget Statement next month. Hopefully, there is some good news for us too.”
“There is an immediate target to double it to $2 billion and I am sure the Minister for Finance will be sympathetic.”
“Sir, I am certainly as concerned as Dr Lily Neo and, rightly so, because if you stay out of insurance thinking that you will never fall very sick, then when you are hit with a major illness, life will be rough on you. As for the 30% uninsured - I thought it was 25% but I cannot remember the figure but it is a significant minority - not necessarily all of them belong to the lower income group. I have looked at some of the data and there are those in the middle-class and many of them are housewives of middle-income families. My message remains the same: please buy insurance for your spouse. Most of them are female who are not working and they look after the family, so as husbands, please look after them and buy them insurance. But a large number are children who are not yet in the workforce. Because they are young, their insurance is actually very low. I remember it is only about $30 a year. Please buy insurance for your children as well. They may be young and fit, but you never know, when something happens and you want to buy insurance, they may be excluded because of pre-existing illness. It is far better to sign them on when they are young and healthy. I think we have discussed this in this House several months ago. A large number of them are young and below 20 years old. We will eventually catch up with them because once they start working and contribute to CPF, we have a way of reminding them. But it is the spouses whom some husbands may have forgotten, but please sign them on. As for the adequacy of Medifund, certainly with ageing, the demand will grow and that is why every year, around this time, I will be reminding the Minister for Finance to top up Medifund, if possible.”
“I hope to achieve clarity by next month so that we can discuss more of this in this House.”
“Sir, both reviews of MediShield and ElderShield are on-going. I hope to complete the reviews within the next few months so that we can have them implemented this year. There will be many rounds of public consultations during the review so that we can forge the best solutions for Singaporeans. The basic MediShield reform is more straight-forward. We did one last year which has brought about many benefits. The industry structure is now sustainable. Cherry-picking has been eliminated. MediShield has regained its financial viability. Patients with large bills have benefited from larger payouts, with co-payment reduced from 60% to 40% of hospital bills. They have saved thousands of dollars. But 40% is still high for many patients. Preliminary soundings suggest that Singaporeans are prepared to pay higher premiums for greater MediShield payout, provided the premium increase is not too big. Our actuary consultant is helping us in the review. In addition, we are reviewing the deductible imposed on the private MediShield enhancement policies. The current level of $3,000 may be too high and there is scope to reduce it by $500 or so. We will settle the details within a month or two. This will particularly benefit the middle income group who use the private unsubsidised wards. As for ElderShield, this is a four-year-old scheme launched in 2002 to provide some basic financial protection for Singaporeans with severe disabilities. It is contractually bound for a review and renewal by September this year. So we will conclude the review within the next few months and be clear on what to do come September. Our actuary consultant has been on this assignment for a few months now but it is a complicated review.”
“On this subject, the best help I can offer is to assess what the industry needs, project future requirements and really step up the training, because the need for those manpower and different grades will grow. Part of the problem that VWOs face today is because there is no active training programme for this group of allied health services. So, when you are short of workers, and everybody is pinching from the same limited source, it is trouble all round. This is certainly one area of priority.”
“I will just give a short reply. On mental health, yes, it is a topic which I feel important enough that I inserted that sentence in this particular Addendum, because I do intend to take a look at it. The numbers are growing. It depends on how you define mental illness. I was in Auckland, New Zealand, a few months ago and they happened to have just published a survey on mental illness. The newspaper's front page headline screamed out: "Half of New Zealanders are Mad!" I read similar reports that say that mental illness applies to everybody, 100%. We have to be practical, but let us also acknowledge that the mental illness management programme this year compared to, say, 10 years ago is vastly improved but there is still scope for making progress, and I will do so. On the other two points about reforms to MediShield and Eldershield, these are my priorities too, and we will get it done within 12 months.”
“Sir, I should clarify that on GST, it is not to waive or to exempt, but it is to offset. There are good reasons why we have minimal exemptions for GST implementation. But for subsidised medical care, it is possible to arrange for an offset package, so that it makes no difference to the patient. As for administrative charge for Medisave withdrawal, the administrative charge is just like the credit card charge. When one uses his credit card, the credit card company will charge a certain percentage for handling the particular transaction. So it is part and parcel of operating a business, because a person either pays cash or pays through his credit card. Every transaction costs money. So there is a need to impose a fee, and it has been imposed ever since Medisave was introduced 22 years ago. I do not think it is wrong to have such a pricing policy.”
“Sir, yes, I have heard her maiden speech a few days ago when she mentioned this. I was a bit surprised because we do allow Medisave to be used for cancer care - radiotherapy, chemotherapy. However, we do set limits, and probably it burst the limits and therefore her resident got into trouble. Probably that was the reason. In any case, if the Member could let me have the specifics, I would be happy to look into it.”
“Sir, Dr Lam is correct. Certainly, there is a shortage of doctors who are interested in geriatric care, and we will try and build them up. But I think more important than having more doctors are also large numbers of allied health professionals. When I visited the day care centres, they are not manned by doctors or nurses, because most of the time, the care is out of the heart, a lot of counselling work, attitudes, social workers. In these areas, the allied health professionals have been neglected for too long, and part of my job is to assess, if ageing continues at this pace, what sort of manpower do we need. And I suspect we need a huge pyramid with doctors sitting on top, but we need a large number of nurses and non-doctors and non-nurses in the supportive group providing this sort of care all round. I have been looking at the labour statistics from the US for many years, and we know that the top four or five jobs are all in this category of how to look after the elderly frail or semi-frail. Because we are still a very young society, we have somehow not paid sufficient attention, but it is never too late.”
“Sir, I wish to thank Dr Neo for bringing me back to reality. For a moment, I was out there. Yes, certainly, I can understand why people worry. I worry too about the future, what will happen to me? Will I be hit by a serious illness? And whatever savings I have may just disappear. All of us have that kind of worry. But do not stop worrying. I think we should convert worry into action. I will continue to nag - healthy lifestyle, do not eat too much salt and too much fat, do exercise, do not over eat - but still prepare for eventuality. Therefore, please sign up for MediShield. Just now I answered a parliamentary Question by Mr Yeo Guat Kwang. For the housewives who are uninsured, the husbands should insure their wives and children. The 56% of the uninsured are children - insure for them. I have read Ms Denise Phua's report on parents with special needs children. They worry that MediShield does not cover pre-existing illnesses. For a congenital problem, it is a bit difficult because a person is born with it, although we are looking at it. But for pre-existing illnesses, one can protect himself by buying insurance very early. As soon as the baby is born, please buy insurance for your baby, so that if anything happens, you are secured. After all, it is only $30 per year. I think this is what we need to do. We will continue to reassure and I will do my part.”
“But all can do their best to be kind and helpful to all fellow human beings and make this world a better place. I will do my part. [Applause. ]”
“He rattled it off without hesitation: " kono michi ya; yuku hito nashi ni; aki no kure". Let me translate for Members: "All along this road Not a single soul - only Autumn evening" It appears, in spirit, to be similar to the Chinese poem "the beauty of sunset, unfortunately it is fleeting" (xi yang wu xian hao, zhi shi jin huanghun ). But it is not. Basho was a serious Zen practitioner and had realised the road of poetry, the road of Zen and the road of life itself. He was not lamenting his impending death. He was sharing his insight when he was confronted with the solitude of an autumn evening. We came to this world alone and we will leave the world alone, whether we are rich or poor, strong or weak. But how we live this life makes the crucial difference to our final eventual exit. When he undertook his journey over the mountains, the journey itself was the destination, as he wrote in his own words, and I quote, "in old age leading a tired horse into the years, every day is a journey, and the journey itself is home". Basho was not rich, in fact, far from it. He was a wandering poet, with merely [his own words] "a traveller’s hat on my head; straw sandals on my feet"; Seng Han Thong's "soft shoes". But he left behind a rich legacy of wonderful haiku which immortalised him. He lived a full life doing what he loved, and taught us how to live, how to age gracefully and how to make a wonderful exit when the end is near. Few of us have the talent and the spiritual strength to live and achieve as Basho did. But all of us can strive to be a good person, a responsible spouse, a caring parent, a good child, a helpful neighbour. Different people play different roles in society; some achieve more than others; some have greater responsibilities than others.”
“But I will recommend to the Ministry of Finance to fully offset any GST increase on medical costs incurred by subsidised patients. Happy ageing Last week, inspired by what I saw in Japan, I decided to visit two elderly day care centres here in Singapore even though they do not come under my Ministry’s portfolio: one in Tampines run by Tampines PCF, another one in Marsiling run by NTUC Eldercare. They are doing very good work, caring for the elderly whose option is otherwise home alone in front of the television, counting the hours and minutes. I know of a group of bank managers who do voluntary work, visiting the old folks at nursing homes and checking out what they need. It turned out that the single biggest issue with old age is loneliness at home and loss of dignity when they feel that they are no longer useful and sometimes unable to even control their bodily functions. There is a lot that the Japanese are doing that we can learn from. Basho certainly had much to teach us about ageing and living. As his own health deteriorated, he continued to work, composing poems. In Osaka, he penned this famous haiku: "This autumn Why am I ageing so? Flying towards the clouds - a bird" Although he was ageing, his spirits remained free. He knew he was dying but he remained calm to his last days. And before he drew his last breath, he wrote his final haiku: " On a journey, ailing My dreams roam about Over a withered moor" This is a more difficult piece, but if you reflect on it, you know that his message to mankind remains optimistic, free, high spirited. He died, what I call, a happy death, at peace with himself and the environment. I asked my Japanese friend - there are so many Basho haiku - which is his favourite haiku.”
“Third, information on this sector is incomplete and hazy. Patients do not know the full range of step-down care choices that are available to them. Some feel that they are stuck with no option other than their current provider. Last month, we published the key data on nursing homes and community hospitals. It is a first step, a small step but I will refine the publication as we go along. Fourth, we do not know if our range of step-down care services is comprehensive enough. Probably not. Are there gaps? I am sure there are. Are there niche services which are absent today but can usefully meet a real need? Some of these services go beyond my Ministry’s portfolio, and we will work with other Ministries to ensure that genuine needs are adequately met. Sir, our population will continue to age. We will try to slow it down by raising births and stepping up immigration, but we cannot avoid it. The better prepared we are for this inevitable demographic change, the better we can ensure that elderly Singaporeans face old age with confidence, calm and peace of mind. My Ministry will do its part to anticipate rising demand for healthcare services, both at the acute and step-down care sectors, and marshal resources to ensure that there will be sufficient beds, manpower and expertise. Today, we spend about 4% of our GDP on healthcare services. Considering the high standard of our care and Singaporeans' health status, this is quite an achievement. But to meet the future needs of our population, it is not possible to keep healthcare expenditure in this region of 4% indefinitely. It is bound to increase. This increase will have to come from all stakeholders: Government, employers, insurers, patients and their families. This is part of the reason why GST has to go up.”
“The enhancements will ensure that Singaporeans continue to have access to high-quality care, without causing severe financial strain to themselves or to society. But with the continuing ageing of the population, I will now begin to spend more time focusing on primary healthcare and step-down care. Unlike tertiary care, this is the unglamorous cousin. But for the elderly, this is a more important sector. The better a sick elderly patient is cared for by his family physician or in the step-down care sector, the better off the patient will be. We will study how best to strengthen and grow this sector. This sector ranges from care at home to care at day centres, to GPs, to nursing homes, hospices and community hospitals. We do not yet have all the solutions, but some of the problems are known. First, the care is not well-integrated. When patients move from one care provider to another, they often encounter obstacles. Patient flow across facilities and institutions is certainly not seamless or hassle-free. To make proper chronic disease management happen, our doctors, nurses and other professionals need to work together, in a different, improved manner across inpatient, outpatient and step-down care. We need to have public sector specialists collaborate with private sector GPs. We need VWOs running community hospitals and nursing homes to work with acute care institutions and family physicians, to deliver better patient care. Ideally, all care providers should regularly share information and consult each other, but the reality is not quite there yet. Second, the care quality varies over the range of providers. While some providers do provide good care and service within their facilities, there are places which do not do as well.”
“The public hospitals do so systematically because I require them to do so, but the private hospitals less consistently. I am thinking of making it a requirement for all hospitals to disclose the hospital bill sizes if they want to claim from Medisave. I think that is a reasonable request. This way, patients to private hospitals will also benefit from greater transparency. Fifth, I plan to publish service standards of our hospitals and how well they are being met, to help our hospital CEOs focus on the key concerns of our patients. How long do patients have to wait for their new clinic appointments? On the day of an appointment, how long do they have to wait before they get to see the doctor? Standards vary between specialties and between hospitals. We do not have comprehensive data yet, but I will publish what we have compiled so far and improve on the data collection as we progress. Sixth, we have implemented in polyclinics this year the policy of differential subsidies among citizens, PRs and foreigners. This way, we keep heavy health subsidy as a citizen's privilege while requiring foreigners to pay for their own cost. PRs continue to be subsidised although slightly less than citizens. We will look into extending this policy to hospitals. The Government will work with employers of foreign workers and require them to buy medical insurance for their foreign workers. As the workers are generally young and healthy, the premiums will be affordable. We will announce the details when available, probably next month. Focusing on the unglamorous These enhancements are largely for the acute care sector, where patients receive treatment in hospitals and specialist clinics.”
“I am glad that you appreciate the efforts. I am not through yet. There are still some more enhancements that I want to do. First, Medisave will cover three more chronic illnesses (stroke, high blood pressure and high cholesterol) from next January, ie, in a few weeks' time. The pilot for diabetes has gone well. Last month, over 7,000 diabetic patients have benefited from this Medisave enhancement. But my interest in this scheme goes beyond just funding. I hope the scheme will raise the level of care for these common chronic illnesses so that patients can avoid severe complications in the future. Today's medical science offers no cure for diabetes, so we cannot eliminate diabetes. But my ambition is to make Singapore the best in the world for diabetic patients, where there is early detection of the disease and effective long-term care of the disease in the community. The science for this is well-known but turning it to reality requires full cooperation and compliance from the patients. Second, I am planning a sequel to last year's MediShield Reform. If there is public support, I hope to further increase the MediShield payout for patients with large hospital bills. Preliminary sounding suggests that patients are prepared for such an enhancement if the premiums do not go up by too much. Third, at each budget cycle, I will apply to the Ministry of Finance for top-ups to Medifund and Eldercare Fund. So far, I have been successful because they have been very understanding. I will continue to try, but I know that this assumes healthy budget surpluses. Fourth, I will press on with greater information sharing so that patients can make informed choices and hospitals can learn best practices from one another. We have published hospital bill sizes for the common illnesses.”
“Stronger 3Ms Sir, I went to Japan not to study how they cope with ageing. I went there to enjoy the autumn leaves with my wife and to be inspired by Basho's poems. But I return reminded that we too should prepare early for a future when ageing will be even more pronounced. As PM put up yesterday, today, Singaporeans above 65 are less than 8% of our population. But by 2015, it will be 11%, but still not yet quite like Japan’s 21% today. But one day, we will be. By 2030, one in five (18%) will be above 65. And there will be a significant number of the "old-old", people living beyond 90. What does ageing mean in our context? How can we make ageing a smooth and graceful process in our society? We cannot wait until it hits us. We need to intensify our planning efforts and begin the process today. In the Health Ministry, we are acutely aware of this demographic trend as most of our clientele are elderly. Our 3Ms framework was put in years ago, precisely to address ageing. Medisave is growing at about $1 billion a year. MediShield, after last year's reform, is building up its reserves again. And we are steadily topping up Medifund and Eldercare Fund as and when we have budget surpluses. All these efforts are in anticipation of the day when we will be drawing down Medisave, MediShield, Medifund and Eldercare Fund faster than we put in. Hence, I worry each time I hear requests to me to use Medisave for this illness or for that condition. I have to be the unpopular gate-keeper that says "no". But I do not say "no" all the time. Where appropriate, I have said "yes". In that way, I am not that unpopular. Several Members have commented on the 3Ms' enhancements which we have made over the last three years. Mdm Cynthia Phua just did that. I thank her for her kind words.”
“You see them in their late 60s, the women, many hunched up because of osteoporosis, manning counters, sweeping floors, cleaning spas, directing traffic, ushering tourists. They work, keep busy, stay active both physically and economically. Second, their elderly are well-represented among the self-employed, running small businesses, like mom-and-pop shops, ramen stalls. They keep the cost of living low for the consumers, while allowing the elderly themselves to make a living. Third, shops and businesses are responsive to the needs of the elderly clientele. The mini-marts' items reflect elderly needs, while the stores have wide corridors for wheel-chairs and the price tags are large in font size, really huge ones. I asked them, "Why so?" They said that sometimes for "8", they thought it is "3" and they got into trouble at the counter. Fourth, there is an active programme to develop devices and systems to allow the elderly to be home alone, while giving peace of mind to the children who have to work outside. They have bracelets or wrist watches which monitor heart beats, blood pressures, body temperatures and transmit the readings wirelessly via the Internet to a central monitoring centre. This way, if an elderly suddenly appears to be motionless, like there were no readings or abnormal readings, an alarm will sound and the operation centre can alert the neighbours to quickly pop in to take a look. Fifth, the community builds on the traditional Japanese sense of neighbourliness to help support each other as a system. They help to check on one another, cook and buy groceries for the frail, clean the house. I help you while I am okay; you reciprocate when I am frail. The community self-help spirit is strong.”
“Very high standard, top-of-the- range, very good facilities, with happy residents. As a typical hospital administrator, I asked how long do the residents stay. He said, "Well, until death do us part." It was buzzing with activities, both indoors and outdoors, day and night. Of course, it comes with a high price tag. The residents co-pay about 10% of cost, with the rest paid for by long-term insurance. I asked the home for the admission criteria because, as far as we could see, the residents did not look sickly or frail at all. They said that all applicants were interviewed. The main criterion is that their children were unable to care for them at home. But I said that would surely qualify practically everyone. In a typical Japanese way, they answered "no", but I think they meant "yes". There is, therefore, a very long waiting list. But all this while, demand was still manageable because most Japanese consider it shameful to put their parents in nursing homes. But my Japanese friends told me that, unfortunately, that attitude is eroding. I commented that the long-term funding prospects for such a model must be poor. They confirmed that this is in fact their biggest challenge going forward. Meanwhile, Japan's shrinking birth rate does not help and the Japanese attitude against immigration further compounds their problem. But the Japanese are actively thinking out solutions to their demographic trend, and they are trying out various experiments, pilots and different approaches. They have not got all the answers but some of their approaches offer useful reference for us. First, the elderly in Japan work longer years.”
“Mr Speaker, Sir, last month, my wife and I explored the northern Honshu region of Japan. We went from Sendai to Matsushima facing the Pacific coast. In between, we crossed the mountain range to the western side of Honshu, spending some time in the mountains, hiking and visiting ancient temples. Mr Speaker, Sir, that was how I geared up for the 11th Parliament. We re-traced a section of a long journey made by Matsuo Basho over 300 years ago. Basho was a Zen practitioner and one of the most popular poets in Japan. He left behind many poems or haiku, and is well-loved by the Japanese. He is the equivalent of Li Bai in Japan. At Yamadera, which is a village in Yamagata Prefecture, among the temples and mountains, we paused at where Basho wrote his famous haiku, in English translation: "Silence Penetrates the rocks – The cry of the cicada" I was grateful for the opportunity to savour that wonderful moment when Basho, the rocks and the cicada all melted into one. Mr Speaker, Sir, after 50 speeches, I am sure you wish for such a moment of tranquility in this Chamber, too! But please hear me out first. The Japanese villages and towns that we explored are no longer like what Basho experienced. The population has grown and, in particular, it has aged considerably. In the villages, the old visibly outnumber the young. Conversation topics are distinctly elderly: "How is your knee? Does it still hurt?"; "Are you sure that mochi is good for you? Is it not too sticky for your dentures?" Active ageing During those few days, I had a glimpse of what Singapore may be like in the future when our population would be as elderly as Japan is today. Though on holiday, I asked my Japanese friends to arrange for us to visit a nursing home and we did.”
“If they have worked before, they should have enough Medisave funds to pay MediShield premiums for many years. For those with insufficient Medisave funds, they can tap their husbands’ or children’s Medisave funds to pay for continued MediShield coverage. For those who have never worked, they would have been automatically signed on to MediShield at the point of marriage registration, using the husbands’ Medisave funds to pay for their MediShield coverage. The Ministry will continue to remind all Singaporeans, through regular publicity, to join MediShield early and to stay insured. 3.00 pm”
“Mr Speaker, Sir, about 830,000 Singaporean residents - citizens as well as permanent residents - do not enjoy the insurance coverage of MediShield or its enhancement products. They make up 24% of the resident population. My Ministry will continue to encourage them to come on board, as otherwise they may be financially vulnerable should a major illness strike. Among the uninsured, there are three groups. First, the vast majority are the young below the age of 21. They make up 56% of the uninsured. They are largely students who have not yet started working. When they do and start contributing to the CPF, they will automatically come under the MediShield opt-out enrolment scheme. Meanwhile, we encourage their parents to subscribe to MediShield for their children early. Premiums are low, at $30 per year. Early subscription will prevent future regrets as MediShield has to exclude pre-existing illnesses. Second, a small group of the uninsured comprises elderly Singaporeans above the age of 75. They make up 9%. Their exclusion may not be by choice, as MediShield has a maximum coverage age but we are taking steps to improve this. This year, we raised it from 80 to 85 years old. We will continue to review the maximum coverage age, although we have to recognise that the benefits of risk pooling diminish for very old age groups. Third, the rest of the uninsured fall between the age of 21 and 75. They make up 35% of the uninsured. This is a heterogeneous group who opt out for various different reasons. Some are well-covered by their employers; others may not feel vulnerable. But like Mr Yeo Guat Kwang, I have a special concern about the housewives who are not insured. They and their husbands should sign them on. There are many opportunities for that.”
“As for the doctors who were alleged to have freely dispensed Subutex, the Ministry has investigated them and is in the process of referring them to the Singapore Medical Council for further investigations and disciplinary actions, if necessary. SINGAPOREANS NOT COVERED BY MEDISHIELD 15. Mr Yeo Guat Kwang asked the Minister for Health (a) how many Singaporeans are not covered by MediShield or any other Shield plan; and (b) whether the Ministry has any plans to bring those currently not insured on board, particularly housewives.”
“Mr Speaker, Sir, the Institute of Mental Health (IMH) conducted the Subutex Voluntary Rehabilitation Programme (SVRP) from 21st August to 13th October 2006. More than 3,000 Subutex users signed up for the programme, 2,452 turned up for their first consultation and about half, 1,590 completed the medical detoxification phase. It is still early to evaluate the effectiveness of the programme. We will work closely with IMH and the enforcement agencies, such as the Central Narcotics Bureau (CNB) and Singapore Police Force (SPF), to monitor the situation. Success ultimately depends on the individual's commitment and determination to remain drug-free and the support he receives from family, friends and the community. SVRP was a massive logistical exercise. The scale of the medical detoxification phase is unprecedented, both in Singapore as well as in any other country. The Ministry of Health had to mobilise locums and additional medical and paramedical staff from several hospitals to help run the programme that ran into the evenings and over the weekends. Additional security personnel and support staff were also deployed to enable the SVRP Clinics to run smoothly. I thank them all for their valuable contributions to this project. The smooth implementation of SVRP is testimony to the collaborative spirit that prevails amongst the many agencies involved in this issue. Drug addiction remains a potential problem and there will always be some who succumb to it, whether it is heroin, Subutex or some other chemicals. We must never be complacent and the Ministry of Health will continue to support the CNB in its zero-tolerance approach to this problem.”
“Dr Tan Boon Wan asked the Minister for Education (a) how many schools have benefitted from the Adjunct Teachers Programme so far; (b) how many retired teachers have benefitted from it; (c) what is its application and selection criteria; and (d) does the Ministry have any plans to encourage more schools to adopt it.”
“Fungal infection of the cornea is a serious condition. The treatment is not straight-forward, as patients react to anti-fungal treatment agents differently. It is usually prolonged and may take weeks or months. The extent of damage will depend on the severity of the fungal ulcer. Some may end up with residual corneal scar from the infection and may need an elective corneal transplant. In extreme cases, it can even lead to blindness unless a successful cornea transplant is done. Fortunately, for this particular episode, most of the affected patients have improved their vision with treatment. It is, however, premature to say what the final outcome would be as some patients are still on follow-up by their doctors. As for the cause of the increased incidence of fungal corneal infections, investigations are still ongoing. They are complex and will take several months. And sometimes, despite extensive investigations and testing, the cause cannot be determined with certainty. But I am glad that my Ministry has taken the precautionary step of sounding the alert early to help prevent further unnecessary infections and tragedies. TEACHERS (Shortfall and Adjunct Teachers Programme) 17. Mdm Ho Geok Choo asked the Minister for Education (a) what is the current shortfall of teachers; (b) how many teachers have either resigned or retired in 2005; (c) what are the reasons for teachers resigning; (d) how has the 5-day week impacted on the turnover in the teaching profession; and (e) how many relief teachers are there in service. 18.”
“I am awaiting their report in a few months' time and then we will study their proposals. Part of the trigger for the review was because of gambling addiction discussed during the IR debate. That is why we get them to start thinking about addiction to gambling, chemicals and all sorts of other things. But the end result would be the same, which is, if you upgrade the capacity and the expertise within the mental health institutions, the other mentally ill patients will also benefit from it.”
“Sir, the liberalisation of Medisave to look after costly outpatients, particularly the chronically ill, as I explained, is not a simple subject. What is my worry? My worry is abuse, because the barrier to access for outpatients is very low. At the hospitals, I can at least control, through the number of beds, and it is very costly to build hospitals. So, therefore, there will always be a limited supply of beds, and access is harder. Whereas, for outpatients, you can just hang up a signboard and you are in business and patients can just walk into clinics. The worry about abuse, overuse and over-servicing at the outpatient level is that Medisave may then run out. Do not forget that 21 years ago when we started Medisave, the reason was because we worried about expensive hospitalisation. So I do not want, in solving one problem, to create a bigger problem of people suddenly finding themselves, when they are really old and need to be hospitalised, do not have enough money in their Medisave. So I am taking my time, carefully thinking it through, but it is something that I am giving priority. I hope I can make major announcements during this year. Now, on the second topic of the mentally ill. It is tough being a Health Minister because there is a whole range of illnesses, diseases. So, at any one point in time, we can only focus on a handful of things and, as I explained earlier in the House, this year I want to pay particular attention to the chronically ill. But I have not neglected the mentally ill. Globally, good mental health programmes are also very limited. I am not aware of any country that has really done it well. Last year, we formed a national Committee on Mental Health and the experts have been studying it.”
“Please read the Hansard when this was debated with Mr Steve Chia. The concerns were fully addressed. Let us not get the impression as if NCSS was aware that there was hanky-panky going on in all those things that are now discovered by KPMG. There was none of that kind. The concerns raised were totally different and, frankly speaking, minor in nature, and they were addressed. MOH studied it, analysed it and since there were no reasons to reject the IPC, of course, they approved the IPC. It is easy on hindsight to say, "Hey, why didn't you do this? Why didn't you do that?" But, as I explained at that sitting to Mr Steve Chia, when a CEO, helped by a group of people, in this case, the Board of Directors or at least some of them, went all out to mislead the public, they will be discovered but it does take some time. I also made a critical point which was that while KPMG came up with this thick report but only about a year ago, when KPMG was actually commissioned by the Ministry of Health to look into NKF, they discovered some minor things which were all fixed, but they did not uncover the problem that we now read in the report. So let us put this thing in perspective. On hindsight, it is easy to say, "Why didn't we do this? Why didn't we do that?" In many ways, as I told Mr Steve Chia at that time, the former CEO misled all of us, including Mr Steve Chia, myself and Mr Low Thia Khiang, because he was also in this Chamber for several years and, if he had known about all this, he could have raised it too. But I am quite sure he was not aware, we were not aware, all of us were misled. But never mind, now the problem has been uncovered, let us progressively fix them, and we are fixing them.”
“Perhaps, Mr Low was not in the Chamber, and it fully addressed what are the NCSS' concerns. I clarified them and these concerns were properly addressed. Time does not permit me to go into it. Perhaps, I think Mr Low may want to just read up the Hansard so that we do not waste everybody's time here. He did ask a point about who is the final authority on charities. There is a Commissioner of Charities who currently is also the Commissioner of Income Tax. But if you read the consultation paper, which is now in circulation, and MCYS will make a formal response to it in a few days' time, their intent now is to separate the two roles so that there will be a new Commissioner of Charities and he will be supported by the various deputies, because there are so many charities in Singapore, a few thousands of them - some in sports, arts and healthcare. I suppose, in the case of healthcare IPC, there will be a person identified and he will be the Deputy to the Commissioner of Charities.”
“It will also be a place for health screening and health promotion. If we can tear down barriers between public and private, GPs and specialists, hospitals and step-down care homes, and leverage on technology, I see an opportunity for a transformation of the way we traditionally manage chronic diseases. If we do it right, year by year, we will see improvements, not only in service standard, but also in the health status of the patients. Let us start with a couple of the most common chronic diseases, say, diabetes, perhaps hypertension, where there are established clinical guidelines on how such diseases should be managed over time, and let us get more GPs, specialists and patients to join the programme and embrace the new approach. Earlier, I said that we are studying how Medisave can be liberalised to pay for costly outpatient care. I therefore see an opportunity to leverage on this initiative to help nudge the profession and patients towards this direction. Dr Tan Sze Wee asked for data on Government spending on primary healthcare. More than 60% of the Government's subsidies goes towards hospital care, 7% is spent on primary healthcare. This is much lower compared to the various countries he mentioned - Canada, UK and New Zealand - where they spend up to 30% of their health budget on primary care. But I must caution here that the figures are not comparable because, in their case, the primary healthcare is 100% public, whereas in our case, 80% of primary healthcare is in the private sector by GPs. So the spending is not captured. Our 6% is only on public healthcare. Finally, let me respond to Mr Low Thia Khiang's point about NKF and IPC. I remember I had a full discussion with Mr Steve Chia - unfortunately he has left - not too long ago, maybe last month.”
“In other words, you should be treated at the right place, not in the wrong place, higher cost, more hassle and unnecessary "one Singaporean, one family physician": every Singaporean, if you do not have a good family physician, start looking for one and make sure find one that is good, and build up that long-term relationship. One Singaporean, one electronic medical record - this can be done if we fully exploit IT. And we need IT so that electronic medical records can be shared with all the partners in healthcare so that we can then collectively, as a partner, look after these patients as the centrepiece. It also requires effective partnership between GPs and specialists, opportunistic health screening, cooperation and compliance by patients, and many more such concepts. This is a tall order, and that is why no country has so far done it well. I am counting on our being small and compact and better organised. I think it can be done. I have been in healthcare for many years now and for the rest of my term as Health Minister, I want to focus on this subject. If we can make a significant difference to the way we handle the management of chronically ill, I think we can then make a major contribution to the health of Singaporeans. It is unglamorous, it will not attract headlines, media attention, but it will make the most crucial difference to our health status. We are building a Health Centre at Jurong West to be one focal point to deliver this transformed service for the residents there. If it succeeds, I will replicate it elsewhere. It will be a one-stop health hub, providing a range of services from, say, outpatient specialist, diagnostic and day surgery services to chronic disease management for common chronic illnesses.”
“Many are even able to adjust their insulin dosage with help from nurses. The outcome has been very satisfying. Patients' blood sugar level is better controlled. Complications are detected earlier and treatment to prevent deterioration initiated earlier. Their experience suggests that one of the most feared complications of diabetes, namely, progressive kidney failure, can be stabilised with good management. We should expand such success stories widely, to benefit many more patients and also others with other chronic diseases, such as high blood pressure and asthma. Both hospital clusters are spearheading a few structured disease management programmes for their chronic patients and they already have good results to show. For example, patients under the NHG cluster's asthma programme are less likely to end up with emergency asthma attacks. The programme must have saved many lives and avoided unnecessary deaths due to asthma. Another disease management programme is for heart failure patients - patients who have survived a heart attack. Results are also very encouraging. 3.30 pm I am very cheered by these innovations and their success stories. Quietly and unglamorously, our polyclinic family physicians, working jointly with the hospital specialists, are helping our chronically-ill live longer and healthier lives. Let us help push these programmes nationwide. To succeed at the national level, many things will have to happen. Time does not permit me to elaborate, but they include successful implementation of concepts like right-siting of care - a topic that Dr Tan Cheng Bock mentioned just now.”
“The simple trick is to help the patients control their blood sugar, look out for early signs of complications and treat the complications before they become a big problem. Many of the complications of diabetes can be avoided totally or, at least, delayed for many years. Today, many diabetic patients are middle-aged and are better educated than their parents. They have the ability and motivation to help themselves. We should really re-orientate our healthcare to work with the patients and enable them to lead a long and healthy life. We actually have many success stories right here in Singapore, at helping diabetic patients live a long and healthy life. For example, SGH and Alexandra Hospital, and likewise other hospitals as well as Kandang Kerbau and NUH, have diabetes centres to run structured disease management programmes for the patients. Their staff work with the community and employers to screen the population. Those with mild diabetes are referred to their family physicians for follow-up. For those with more severe diabetes, the specialists assess the patients thoroughly at the beginning of the programme, draw up individualised treatment plans. Non-specialists and other team members then take over and work with the patients to control their blood sugar and to screen for complications, at appropriate intervals, under the supervision of specialists. Once the conditions have stabilised, they are referred back to their family physicians for routine follow-up. The key is to make patients and their family members the main carers of their diabetic condition. Patients are taught individually and in groups, to enable them to help themselves. They adopt healthier eating habits with the help of dieticians. They exercise more and they reduce their weight.”
“I asked our hospitals and polyclinics to help facilitate this transformation. The hospitals have an interest to see this succeed. Many of their patients in the specialist clinics can be competently treated by family physicians, at lower cost. They are keen to partner with willing family physicians through shared-care programmes at the community level. Let us take diabetes as an example of how this can be done. We already know quite a lot about diabetes. It is a common chronic disease, and affects one in 11 Singaporeans. So it is a large number. Diabetes occurs when the body loses its ability to control the blood sugar level. When poorly controlled, doctors can almost predict what will happen to the patient at different stages over the next 20-30 years. Compared to others, diabetic patients have a higher chance of getting heart attacks, stroke, blindness, loss of limbs and kidney failure. In early stages, there are no symptoms, and many patients are unaware. Left untreated, the condition will just deteriorate over the years. Many suffer greatly from multiple organ failures towards the end. Many diabetic patients start treatment late, ending up going to multiple specialists for treatment of their many problems as and when each problem surfaces. It is not unusual for a diabetic patient to consult a cardiologist for his heart problem, an orthopaedic surgeon for his leg problem, an eye specialist for his eye problem, and a neurologist for his loss of sensation. The suffering, the time spent at each hospital clinic and the cost of treatment can be unbearable. Yet, that need not be and should not be the case, if their diabetic condition is detected early and managed well.”
“Recently, I visited one in Toa Payoh and I am impressed with her practice. She has a base of regular clientele - many elderly with chronic diseases. She knows them well, including their family members, and that is really what a good family physician ought to be. When one of her patients suffered a fracture and could not walk, she arranged for a physiotherapist to provide home therapy twice a week, instead of simply referring the patient to the hospital. The patient had so much pain that walking was not possible. After a month of home therapy, the patient was able to walk. In this way, unnecessary hospitalisation and operations were avoided, and the money saved from inpatient charges was used to engage the therapist. When another patient was diagnosed with terminal cancer, she personally arranged a shared-care programme with the hospital oncologist - cancer specialist. This way, she was able to continue the patient's intravenous antibiotics at home. That was also the patient's strong preference, to spend his last few months in the company of his loved ones, rather than wasting precious time waiting in the queue in hospital clinics. The patient eventually passed away peacefully at home, avoiding unnecessary hospitalisation which would not have made any difference. His family got to spend quality time with him at home. When death came, this family physician was there to sign the death certificate. This is what good family physicians can do to bring about better care at lower cost and less hassle for their patients, instead of simply referring them to hospital specialists. There are many such good family physicians in Singapore. But we should grow their numbers and profile them to the public, so that such care would become standard best practices here.”
“Mr Andy Gan also asked about the adequacy of nurses to serve our patients. For nurses, we will continue to both train locals and recruit foreigners from abroad, and there has been a progressive increase in the nursing population in Singapore. Just last week, NUS announced the launch of Singapore's first local nursing degree course in NUS, for year of admission 2006. This is a milestone event for our nurses. The programme is designed to meet international standards, and the first batch of nurses will graduate in 2009. Dr Tan Sze Wee is worried that our cluster polyclinics may game on their block budget, and refer subsidised patients from polyclinics to hospital A&E Departments of the other cluster, so as to save on cost. Let us look at the data. First of all, very few percentage of polyclinic patients get referred to hospital A&E Departments - less than 2% each year. The vast majority of such referrals were within each cluster. So this so-called cross-cluster referral is tiny. As far as I can see, there is no evidence for such gaming going on. I am pleased to say that our doctors are largely ethical, and we should be proud of them. Let me now spend some time on chronic diseases, which Dr Lily Neo raised earlier and was also mentioned by Mdm Halimah and the other Members as well. This is a very big topic, because it affects a large number of patients, and most of them tend to be elderly, and it consumes a large amount of resources. No country has managed it well. There is much scope for transformation and improvement. It is my personal goal to see how we can cause the transformation of the care of chronic diseases, so that patients with chronic diseases can enjoy better care at lower cost and with less hassle. To achieve this goal, family physicians play a critical role.”
“Actually, the project was approved and funds were allocated. But after the Asian financial crisis, there was a review of all the capital expenditure projects in the public sector, and this was one of the projects that was decided to be delayed. In any case, those years are over, and we will get the project going again. We are going to rebuild it on a new site within the SGH campus. Planning has begun and we hope to open the new facility around 2010. In fact, if Members check the Budget book, they will see an entry on this particular project. Besides buildings, we will continue to invest in new equipment. Mr Andy Gan has noted a rise in high-tech diagnostic machines. It has been so for many years and, in fact, it is a factor which contributes to rising healthcare cost. But we will pace it appropriately, balancing between inevitable cost increases and enhanced healthcare standards. As a principle, I prefer the public hospitals to be slightly behind the curve, but not too much behind. For example, the current interest in high-tech scanning equipment - the 64-slice CT scanner, which costs a few million dollars. The first unit was brought into Singapore in 2004 by the private sector. But soon after that, others also bought such scanners, including public hospitals. By being slightly behind the curve, we allow ourselves some time to evaluate each new machine and establish its cost-effectiveness. Ultimately, it is not investment in technology for its own sake, but, really, investment in patient outcomes that matters. Given the high cost of such equipment investment, I agree that wherever it is possible to share it with the private sector, public hospitals should do so. But sharing has to be done at the right price, and certainly not at the expense of public patients.”
“Sir, Mr Andy Gan asked whether the supply of our healthcare services is adequate. Frankly speaking, supply of healthcare services will never be fully adequate. This is because in healthcare, supply does create its own demand, particularly if that demand is heavily subsidised. Among health economists, there is a well-known observation called "Roemer's Law", which states that "a built (hospital) bed is a filled bed". It is, therefore, wise to keep public hospitals slightly under-supplied and run it at high occupancy rates. That is why, last year, I resisted tackling the overcrowding in Tan Tock Seng Hospital by simply allowing them to expand. By forcing the hospital to understand its sources of overcrowding, we then discovered outdated policies, like free treatment for foreign workers infected with chickenpox and cumbersome discharge procedures which kept patients unnecessarily in hospital. But we cannot sit on the cap forever. Periodically, we need to expand our facilities to meet real rising demand. That is why we are building a general hospital in Yishun. Mr Steve Chia asked for some details. The site has been finalised. It is a good site, near to Yishun MRT and bus interchange. Planning of the hospital has started. In fact, a design competition is ongoing, and I understand that Prof. Ho Peng Kee will soon organise an exhibition of the design proposals that we have received for this hospital, so that we can get some public consultations and opinions on them. We expect to ground-break before the next Chinese New Year and, eventually, open the hospital in phases from the year 2009. Dr Tan Sze Wee asked me about the building of the Pathology Department at SGH. The project was a little bit a victim of the Asian financial crisis in 1997.”
“In that way, patients who have minor ailments and, therefore, drugs are simpler, they may be actually paying above cost to the polyclinic, but it is still $1.40. Let us say, if one is unlucky and very sick, the drug may cost $20 per week of prescription, but you still pay $1.40. So, in that way, patients who have cheaper drugs subsidise those who have more expensive drugs. Until today, I will defend that policy. I think that is the correct policy. But, a few years ago, I do not know when, somehow the hospitals decided to go more precise. So they removed this policy and they just said, "Well, let's look at the drug, if it is 20 cents charge 20 cents, 50 cents charge 50 cents and $2 charge $2, and whatever". So you can argue which is the more correct system. I believe in the Robin Hood's principle. I feel that the $1.40 per week, regardless of medication, is a better way for the patients. Maybe I should persuade the hospitals to move back to the polyclinic system. Primary Healthcare”
“My advice to Dr Tan, so that he can in turn help his patients, is to look at the total bill. Do not just look at one single item and say that you want the cheapest of everything possible, like drugs, X-rays, and so on. But you have to look at it on a total basis, ie, is your total bill in a polyclinic cheaper than your total bill in a hospital? At the end of the day, that is what counts to the patient, how much he has to pay. If he goes to SGH, how much will he have to pay, and if he goes to Toa Payoh polyclinic, how much will it cost? At the principle level, I agree with Dr Tan that we should not distort the pricing so that it becomes silly for patients, who want to downgrade, to have difficulties. 2.45 pm Since I am on the floor, let me just take one minute to explain this. Actually, I know the reason for the discrepancy. Years ago, I helped to formulate the pricing policy for polyclinics. Those of you, like Dr Chong, who had read the Lianhe Zaobao's interview of me, would know that I believe in the Robin Hood's principle in healthcare, because healthcare is so expensive that the only way to ensure healthcare is affordable is you must play Robin Hood. How? One, the rich subsidises the poor through taxation. Two, the healthy subsidises the unhealthy, who is more sickly, through insurance. There is no other way. And, therefore, when I looked at the pricing of drugs at that time in the polyclinics, I suggested to them - which is still the policy today - "Charge patients $1.40 for drugs". The last time it was lesser, maybe $1; now it is $1.40 per week of medication. In other words, regardless of the medication, cheap or expensive, you pay $1.40.”
“Yes, there are several such efforts in various countries, because drugs are now so expensive, and for every new drug, before it comes into the market, they will evaluate the cost benefit of it. Should we start such similar units? I do not believe in doing so because our scale is small. Let us leverage. I have always advised our people to leverage, because why reinvent the wheel. The UK and US publish all their analysis and we just go and take a look. We may want to do some local analysis because Singapore's situation might be different. But that is always a good starting point, instead of trying to replicate what others are doing and unwittingly push up healthcare cost. Finally, Dr Lily Neo has made a number of comments on step-down care, homecare and heart diseases affecting women. We will respond to those points later today.”
“But, on an overall basis, we should ensure that the total treatment cost in a polyclinic is less than that in an acute hospital for the same treatment. Otherwise, I agree with Dr Tan that there will be no incentive for patients to move out of expensive acute hospitals. Mr Low talked about our bulk purchase of drugs and whether we would do so not just for generic drugs but also for non-generic drugs, ie, patented drugs. Bulk purchase covers both, in other words, so long as there are economies of scale to be exploited, we will go for a major tender and coordinate them. It is not done by the Ministry of Health because there are two clusters and they coordinate. There is a central procurement unit which calls tenders on behalf of both clusters. And, as I have said, it applies to both generic as well as non-generic drugs. In fact, the savings are a lot more in the case of non-generic drugs because generic drugs, by nature, are low cost. So whether you call bulk tenders or you call smaller tenders, the price will be low anyway. But even then, the benefits ought to be exploited. Mr Low also asked who decides on what is subsidised and not subsidised. Really, the question is who decides on what are standard drugs and what are non-standard drugs. I think we have explained this previously in this House. There is a panel of experts because these are clinical issues. They will review, when new drugs come in, and decide whether to substitute this normal drug with another drug. So it is a purely clinical decision. Of course, they take into account efficacy as well as cost to the patients. But it does not mean anything that is expensive is non-standard; and everything that is cheap is standard. That is not the criterion. Mr Low mentioned a unit in UK.”
“30 pm Dr Chong Weng Chiew asked about means testing. He has always been a strong supporter of means testing and I appreciate his support. I believe in it and I have always felt that our 3M model would be stronger if we make it 4M and the fourth "M" is actually means testing. But two years ago, when I started exploring this subject, I remember at that time the GPC Chairman was Dr Lily Neo, and she gave me very good advice and a word of caution, because there are a lot of complications, as outlined by Dr Chong. She felt that I should only start working on it after we have fixed a few other things, especially MediShield reform which, at that time, I was exploring with her, and now, Medisave. So that is why when Lianhe Zaobao interviewed me, I said that it is something that we would do next year or the year after. We cannot rush this sort of thing even though it is a good policy. Dr Tan Cheng Bock and also Mr Low spoke about the cost of drugs. Dr Tan quoted an example of a patient being referred to a polyclinic from NUH, thinking that it would save him money, only to find that his drug bill there cost him more. I have looked at the example which he handed to the Ministry of Health. Of the nine medications in the bill, indeed, as Dr Tan noted, some were cheaper at the polyclinic but some were more expensive. The costlier drugs tend to be cheaper in polyclinics, in other words, the more expensive patented drugs are cheaper. The reason is this. First of all, the polyclinics and hospitals are different entities, so identical items may not attract identical prices. It is just like X-rays. There is a whole range of X-rays, but they do not coordinate - maybe they should - until every item is the same.”
“In this exercise, I will give priority to chronic diseases, a subject which I will discuss later, in the second segment of the debate. Let me now respond to Mr Chiam's comment on the use of Medisave for IVF and various assisted reproductive technologies. It does. Medisave covers them and, in fact, as part of the Baby Bonus scheme last year, we raised the quantum. Relying on memory here, I think you can claim up to $6,000 for IVF, which will therefore cover items like drugs, etc. But we made a distinct decision to limit it to three treatment cycles, and the reason is properly and rationally grounded. You can check the data on the success rate. Each time the couples repeat, it is greater and greater disappointment and, after the third cycle, the chance of a success is very, very low, and you are really throwing away a lot of money. Yes, maybe we are a little bit paternalistic here by saying that Medisave ought to be for other uses and therefore we limit it to three cycles. But it is for a very good reason. If we just open it up - imagine $6,000 per treatment - and we have, say, run it to five cycles, that is a lot of thousands of dollars. Medisave, even though it is significant for some middle-income group, there is an upper bound to it. So it is not as if it is a lot of money and you can just waste it to pursue IVF and the various techniques. So I hope Mr Chiam can accept that explanation. On ElderShield, I thank Mdm Halimah for her various suggestions. I will take note of them. We are bound by the contract governing ElderShield which does not allow changes for five years. The five-year period will run out in September next year. But I will begin the review process this year. I will certainly bear in mind the various suggestions made by Mdm Halimah. 2.”
“So, if they are PRs, they are included if they want to. But MediShield is not compulsory. So, you will have to make an effort if you want to join in, although it is opting out. But, as far as I know, many foreign workers may have been covered by their employers, so they may not see the need. But it is really up to them. The point about the foreign workers is that if they are non-Singaporeans, basic MediShield is based on Class B2, which is heavily subsidised and, therefore, we keep the subsidy for Singaporeans and, in fact, at the moment, also PRs. But non-citizens are not included. In fact, just last month, there was a specific case. One of my residents, the maid fell down while cleaning windows. So major surgery in Tan Tock Seng. The bill came to $15,000. They forgot to buy insurance for the maid. So they came to my MPS and say, "Please help." But I cannot help because she is a foreigner. How can I use taxpayers' money to subsidise foreigners? I hope there is a lesson there, ie, employers, please make sure you buy insurance both for yourself and your loved ones, including any foreign domestic workers with you. I am enhancing Medisave. From lst April 2006, the daily withdrawal limit will be raised from $300 to $400. This will particularly benefit the middle-income group and save them hundreds of dollars per admission. This is the first step. My next step is to allow Medisave to help cover costly outpatient treatments. But this is not straightforward. That is why I am taking some time to think it through carefully. If we are not careful, Medisave accounts will be prematurely depleted, becoming insufficient for hospitalisation. That would be tragic. However, meanwhile, I have noted Mdm Halimah's various suggestions on this subject and will take them into account.”
“Luckily, they did not succeed. As a result, we now have collectively $35 billion in our Medisave accounts, for many, many rainy days ahead. I am glad that the Workers' Party has since achieved some enlightenment. Their latest manifesto no longer wants to phase out Medisave. But they have replaced the medicine with another. They are now proposing that Medisave be used for "a comprehensive Public Health Insurance scheme". We do allow Medisave for medical insurance. I believe in Medisave insurance, because pooling of risks is a very important part of healthcare financing. But Medisave must not unwittingly support comprehensive medical insurance which will only lead to disappointment and very high healthcare costs. This is not a theoretical argument. The argument has already been settled empirically. We only need to see the experiences of those countries with such comprehensive medical insurance schemes. Let us not repeat the mistakes of others. They are now trying to get out of that hole. Let us not walk into that hole. When I read the manifesto, I was reminded of a very interesting cartoon published by Zaobao a few days ago. President Chen Sui-bian suspended the Reunification Council, so there was this cartoon that shows President Chen leading the way and there was this big manhole, with Taiwan about to walk into the manhole. If we go the Workers' Party's way, I see this cartoon, maybe of Mr Low Thia Khiang waving Singaporeans into this hole. And you will find this hole is crowded. There are many people there trying to get out. So, I think, let us beware. Mr Low Thia Kiang suggested that we allow MediShield to include foreign workers. I do not think we exclude foreign workers, because MediShield is open to all Singaporeans and PRs.”
“The private hospitals are at various stages of this quality journey. Making the market work better is the best way to help manage healthcare cost. When customers vote with their feet, healthcare providers will sit up and work to fight the competition. That was how Lasik surgery fees dropped from $2,300, on average, in 2003 to below $1,400 now, saving patients almost a thousand dollars per surgery. At the same time, we must continue to remind Singaporeans to: (a) save up for their healthcare needs; and (b) insure themselves against catastrophic illnesses. Mdm Halimah asked if our healthcare model can cope with the ageing of our population. In particular, what about the healthcare needs of our future elderly? Will 3Ms be enough? This is really a very dynamic situation with many unknowns. What are the new technologies that are coming in? At what cost? What are the changing population attitudes towards sickness, health, etc? And, of course, how much can we afford, which is economic growth? That is why I agree with Mdm Halimah that we need to periodically review and update our 3M system. And we do. Last year, we updated MediShield. This year, my focus is on Medisave. Our healthcare system is unique in the world because of Medisave. Medisave has now entered its 21st year. Every year, the average Medisave balance of Singaporeans just gets bigger. Among working Singaporeans, four out of 10, ie, 40% or nearly half a million Singaporeans, have Medisave balances exceeding $25,000. This happy outcome applies to low-wage workers too. Those nearing retirement have an average of $12,545, enough for many, many hospitalisations. In their earlier manifestos (1994/1998), the Workers' Party wanted to abolish Medisave. "Phase out the Medisave Scheme as soon as possible", they said.”