Healthcare insurance - The view from Taiwan

Of all the many rally speeches I've heard over the course of the 2011 GE, one that stands out for me is that given by NUH Senior Consultant Paul Tambyah at the SDP's downtown lunchtime rally on May 5, where he points out the dire inadequacies of Singapore's healthcare system and how ordinary Singaporeans fall through the cracks in the events of major illness and disease, due to inexorably costs of medical care.

"You can afford to die, but you cannot afford to get sick", NUH Professor Paul Tambyah said to rousing cheers, obviously striking a common chord with the crowd.

“As a medical doctor, I come into contact with patients on a regular basis. I hear them tell me that in Singapore, you can afford to die but you cannot afford to get sick. I see people who have to sell their homes and move into rental flats to pay for their medical bills. Do you think this is right?”

“The problems with our healthcare system are known to you all – mostly they are about money.”

He further gave an example of the financial burden of one of his patients due to medical costs:

"A Patient of mine has an infection that has caused him a stroke. He needs medication that costs more than $250 a day. There is no subsidy for this medication . It is recommended in all the guidelines including local guidelines. If he does not take this medication, he will most likely have another stroke and could even die."

"I tried to help him by appealing to the medical social worker. We received the reply that he was unlikely to get help as he lives in a private condo with one of his sons. The other five siblings are not well off but this one son living in a condo disqualifies this citizen of Singapore from financial assistance. We even went to the extent of writing a prescription so he could buy his medications in Johor Baru but this did not work."

"How many people do you know living in condos with their own families can afford to pay $250 a day or $7500 a month for medications for three to six months on top of the needs of their own families???"

"There is something seriously wrong with our system."

I agree that there is something very wrong with our healthcare system, and the "can afford to die, but can't afford to get sick" refrain is an often heard one, even my mother said that one before. Quality, timely healthcare in Singapore is expensive, there's no denying. A week's stay at Mount Elizabeth (where wealthy Indonesian tycoons and Saudi sheiks rub shoulders) by my late grandmother racked up a bill in the region of $10,000, but that was no problem because my entrepreneur uncle could well afford it.

But that set me thinking, can my modest salaried income support my mother's hospital bills if she really needed the medical care in the future? Will it bring me and my family to financial ruin? This is a disturbing question to ponder, more so after listening to Dr. Thambyah's anecdote. And I'm sure, I'm not the only sandwiched Singaporean with such concerns.

But before I give my two cents, let me state for the record that having spent my entire working life in Taiwan, I have absolutely no idea how Medisave, Medishield and Medifund work, except that the first one is a paltry number that shows up in my yearly CPF statement. Hence, I will not attempt to make any comparisons.

I will instead give a picture of a healthcare system that I am familiar with and use on a daily basis - the Taiwan National Health Insurance (NHI), and let you, fellow Singaporean, to judge for yourself the difference between the two systems. I'm not a medical professional, just someone who uses the system, so I don't know what it's like from the healthcare provider's (i.e. the doctor's) point of view. If you're interested in the economics of health care in Taiwan, you can check out this paper.

Having lived and worked in Taiwan for the past decade, I've been enrolled in the NHI. In fact, all Taiwanese citizens and permanent residents are enrolled by default and must pay the monthly insurance premiums. So how much premium does one have to pay? It basically depends on two factors - your occupation and income.

Firstly, let's look at occupation. This determines the contribution ratio, or how much the individual, employer and government has to pay in terms of insurance premiums. So if you're an average employee in a public or private company, you pay 30%, the company 60% and the government tops up the remaining 10%.

People in the military, veterans and low-income households get full government assistance and don't have to pay any insurance premiums at all. Self-employed people pay 100% of their premiums.

Secondly, income. Basically, the more you earn, the more you pay. The average adult in Taiwan pays around NT$749 (~S$32) a month out-of-pocket in insurance premiums per person. If you're married have children, you can choose to peg the insurance premiums for your kids to the spouse with lower income to avoid paying higher premiums. An average family of four can expect to pay about NT$3000 (~$129) a month for healthcare insurance.

Okay, so you pay the compulsory NHI premiums every month. What do you get in return?

For starters, you'll be issued an IC card by the NHI, which entitles you to seek medical services at any NHI-registered clinic or hospital. The IC card above stores all your medical data and treatment history, so no doctor has a monopoly over your medical records, hence you're free to seek advice from any doctor, knowing that he or she has access to your medical history instantly and can make more accurate diagnoses based on it. Practically every man, woman and child in Taiwan has one. My daughter was issued an IC card on her birth.

In Taiwan, almost every single clinic or hospital, large and small is registered with the NHI. This means you can pick and choose which doctor to see, at your preference and convenience. No need to queue at some polyclinic for hours, because clinics are available everywhere. Only in the event of emergencies (or on Sundays when most clinics are closed) then you go straight to a hospital. If there are queues, people do so voluntarily because they prefer the doctor for some reason, not because they have no choice.

When you see the doctor at a clinic or hospital, you have to pay outpatient charges as a form of copayment, this is to avoid abuse of the system through overuse. For ordinary neighborhood clinics, one usually pays around NT$100 (~$4.30) for a visit (NT$50 for consultation and NT$50 for appointment fee). Disabled people pay a flat fee of NT$50 for medical care no matter at hospitals or clinics. Visits with referrals cost less than those without referrals.

After the consultation, comes the medication costs. For everyday illnesses like flu or cough, usually you don't have to pay anymore for the medicine. Only if the actual cost of the medicine exceeds a certain amount, only then you'll have to make up the difference. Medication co-payments are capped at NT$200 (S$8.60), so regardless if the medicine costs NT$2000 or $10000, you only pay NT$200.

If you have chronic illnesses such as hypertension or diabetes, you are exempted from the co-payments, and are eligible for "chronic illness refill prescriptions", i.e. you can get your medication straight from a pharmacy without having to visit the doctor.

Finally, let's look at coverage. What does national healthcare in Taiwan cover? Besides outpatient care at clinics and hospitals, it also covers:

• Chronic Disease Patients (includes cancer, diabetes, hypertension, etc.)
• Catastrophic Illness Patients (click here for full listing)
• Occupational Injuries or Disease
• Rare Diseases (click here for full listing)
• Emergency Care when Travelling Aboard

So what this means that all the major illnesses like cancer and diabetes is fully covered by health insurance. While this means escalating medical costs to the government, it makes a world of difference to the patient, especially those who are disadvantaged to start with.

And there you go. I know it's not a comprehensive report, but I hope it covers enough for you to get an idea of what it's like to be part of an affordable healthcare system. I don't have to worry about exorbitant medical costs breaking my piggy back, because I have an army of decent doctors (many with overseas degrees), dentists and ophthalmologists to take care of me and my family in case anything goes wrong.

Of course, it only covers the basics, so if you want extras like the latest medicine, high-tech medical tests and a single hospital suite all to yourself, you still have to pay extra. But forget the high-end, the rich can afford quality healthcare no matter the price. It's how we take care of the people at the lowest rungs of society that really counts, I feel.

Chinese New Year - Singapore vs Taiwan

Having been in Taiwan for the past eight years, I confess to have celebrated Chinese New Year here twice here in that period (this year included), the rest spent on extended overseas trips to take advantage of the long holiday. This year however, due to an extension to the family, I've decided to stay put in Taiwan for the celebrations.

Of course, being over 70% Chinese (in more ways than one), Singapore also celebrates Chinese New Year, albeit in a smaller scale (being the majority race, we must be sensitive to the feelings of our fellow Malay, Indian and Other Singaporeans, you know.)

Although similar, Chinese New Year in Taiwan and Singapore still differ in several ways that might put the average Singaporean off-guard when spending the festive season in Taiwan, so here's a rough comparison:

1. Length

Singapore - 2 days

Taiwan - usually 7 days, or more depending on weekends

2. Ang paos (red packets)

Singapore - Married people should distribute ang paos to children, and single relatives, etc.

Taiwan - Working people should distribute ang paos to children, parents, and schooling relatives. Once you start earning your own keep, sorry...no more ang paos for you.

3. Firecrackers

Singapore - Dream on.

Taiwan - Anytime, anywhere, anyhow! When you least expect it...

4. Entertainment

Singapore - Ban luck (blackjack), Mahjong (13 tiles)

Taiwan - Da Lao Er (Big 2 card game), Mahjong (16 tiles)

5. Shopping

Singapore - No luck. Orchard Road is dead for the Chinese New Year holidays.

Taiwan - Shopping centres are open all through Chinese New Year, so there's always somewhere to go when bored of Mahjong and vegging out in front of the TV.

How long more can the Starlight still shine brightly?

The crash of the Taiwanese F-5F Tiger fighter jet that killed 2 SAF "Starlight" personnel last Saturday, was an unfortunate metaphor for the strained relationship between Singapore and Taiwan in recent years, and also the issue of the Starlight presence in Taiwan.

Being a Singaporean working in Taiwan for the past 6 years, I'm naturally sensitive to such events, not because I'm worried of being spat by the locals with a mouthful of betel-nut juice, but believe it or not (coming from a so-called "quitter"), about the image of Singapore in the eyes of the Taiwanese.

An article by a China Times editor expresses her views on the crash, and summarizes quite succinctly the history of how Starlight came to being, and how relations soured to its present state. Here is my translation, any mistakes all my own.

The original article can be viewed here.

How long more can the Starlight still shine brightly?

by Sheena Chang (China Times)

The Taiwanese military fighter accident that killed two Singapore servicemen who were training in Taiwan, has forced Singapore to officially acknowledge for the first time the existence of the "Starlight program". This accident may not necessarily affect the continued existence of the "Starlight program", but Taiwan-Singapore relations, which has gone increasingly downhill these past few years, is really the question worth noting.

Due to Singapore's limited geographical size, there is no space large enough for military exercises, hence the need for co-operation with allied countries for training agreements. Thanks to the close friendship between former Singapore Prime Minister Lee Kuan Yew and the late Taiwan President Chiang Ching-kuo, both countries signed the agreement for the Starlight program in 1975, after which Singapore began to dispatch servicemen to Taiwan for training.

Military training agreements are different from normal bilateral cooperation, because national defense is the lifeline of a country's survival, and troop equipment, engagement plans and operational capability are of the utmost national security and obviously cannot be leaked. Allowing foreign troops to train with local forces exposes much of the internal workings to them, and this cannot be achieved without a certain degree of mutual trust. As a result, the Starlight program remains the best testimony of the relationship between Taiwan and Singapore.

Bilateral ties were really quite good in the past, as Lee Kuan Yew enjoyed the scenery of the Sun Moon Lake and A-Li Shan, and visited Taiwan on vacation every year, often in the company of Chiang Ching-kuo. After observing Lee Kuan Yew chatting with the locals in Hokkien, Chiang lamented his own inability to talk to converse with the locals, with Lee even exclaiming "I'm also a Taiwanese".

After Lee Teng-hui succeeded as president, he originally continued friendly relations with Lee Kuan Yew, making his first official foreign visit to Singapore. But due to Lee Teng-hui's criticism of Lee Kuan Yew's "Asian-style democracy" , leaving Lee Kuan Yew frothing at the mouth, the rift between the two Lees being to widen from that point on, with Lee Kuan Yew not returning to Taiwan on vacation for several years. But from a wider perspective, the two Lees represented two different models of Confucian cultural development. Lee Teng-hui professed to have founded democratic reform Taiwan, and Lee Kuan Yew's Singapore is the successful example of the patriarchal model. Lee Teng-hui felt that the significance of his democratic achievements surpassed that of Lee Kuan Yew, but of course Lee Kuan Yew begged to differ.

Once the seeds of discord were sown, ties were difficult to mend, especially when the "two Lees" were known for their temperament and pride. Afterwards to make matters worse, Lee Teng-hui's visit to the US ignited cross-strait tensions with China, which Lee Kuan Yew criticized repeatedly on Taiwan's actions. Of course, Lee Teng-hui was not known for accepting such face-on criticism, and this led to a further deterioration of ties.

The foreign media eloquently described Lee Kuan Yew as "a fish too big for its pond". Indeed, to a big fish like Lee Kuan Yew, a small pond like Singapore was not big enough to contain his political aspirations. Hence he hoped to play a bigger role in the international arena, including cross-strait relations and China's development.

He focused on the practical side, and felt that China's rise cannot be taken lightly, and cross-straits peace must be maintained. As a result, he disagreed with Taiwan taking a radical stance and standing for independence in defiance of the Chinese Communist Party, which obviously fell on deaf ears with the Taiwanese government.

The national interests of Taiwan and Singapore are certainly different, and it is difficult for the outsider to understand the long-term suppression of pride, the indignity and fear of security constantly being threatened. But Taiwan's reading and handling of the international situation is still at odds with international society, causing the country to distance itself with the rest of the world.

But Taiwan is still a very suitable military training location, and therefore although Singapore continues to sign training agreements with other countries, Taiwan-Singapore ties continue to turn cold, but the Starlight program still manages to hang on. The thing is, it may be quite impossible for the time being for Taiwan and Singapore to recover their former close relationship.