Means testing a minefield

Means testing a minefield
ST: April 19, 2007 Thu

MEANS testing to allocate subsidy for using the public hospital system appears imminent. Health Minister Khaw Boon Wan has gone so far as to suggest that, for a start, a limited form of sorting to steer more aid towards low-income patients could be the five-day threshold.
Patients who have stayed longer than five days in B and C class wards will have their finances checked to determine how much or how little support they should receive, based on their means. It is important that the basis of evaluation is understood.
There is no quarrel with the thinking that rationing of state-funded health-care resources is necessary since these are limited by the Government's fiscal priorities. An unequal shareout among patients can be defended if done with fairness. It is unlike subsidised education, which is not means-tested as it is an inalienable right of citizens. There is a political dimension to the issue as well, in that the Government has to demonstrate its seriousness in minimising the bad effects of the wealth gap.
Implementation is the tricky part. Devising the yardsticks to make the means test least objectionable is going to challenge the most imaginative of ministry bureaucrats.
Should it be the income or assets test or something else? On income, the ministry can expect to run into a thicket of exceptions and objections. Patients of the middle-income bracket and upwards will reasonably expect undiscounted subsidised care, if they choose to, as they pay tax. Two-thirds of the workforce do not pay tax but receive the most state benefits.
The middle-income group will not begrudge non-taxpayers receiving the full subsidy, but will resent the means test as discriminatory of them. There are other inherent weaknesses. People of 'means' could be supporting aged or ailing parents. Assets test then? Assets can be hidden in trusts or are simply undeclared. Statutory declarations are intrusive, which will invite more resentment.
Retirees living in private housing but on limited savings would be most fearful of the cost of falling ill. They are a large group of health-care consumers. The assets test will probably penalise them.
In the end, the Government will come under pressure to increase its Budget allocation for health. Careful thought must go into the means exercise so that the system does not end up alienating one segment of the citizenry while helping another. The best neutral advice: Those who can afford it should consider taking out private medical insurance. It is the soundest bet against an inexorable trend of ever costlier treatment and husbanded resources.
http://www.straitstimes.com/portal/...e:1177019940000 http://forums.hardwarezone.com/showthread.php?t=1590174&page=2&pp=15
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Have disease-specific time limits for means testing
I REFER to the editorial, 'Means testing a minefield' (ST, April 19). Most people would agree with the principle that the less well-off should receive more subsidies. However, follow-up questioning would likely reveal that none of them would consider themselves as 'well-off', and therefore they, too, should be deserving of subsidies.
Therein lies the difficulty of means testing - everyone agrees with the principle, but the devil is in the details of the implementation. I would like to make the following suggestions for the public and Health Ministry to consider.
Firstly, on the qualifying criteria for subsidy, no matter how the cut-off line is drawn, there will be unhappiness among those above the line. The use of a sliding scale, so that everyone enjoys at least some subsidy, is to be commended.
Furthermore, the criteria should keep pace with healthcare inflation. For example, the current maximum of $500 per capita family income for downgrading to C class was implemented in 2001. Data from Statistics Singapore shows that health-care costs have risen by almost 10 per cent since then, and only 238,000 households met this limit in 2005.
Secondly, the proposed limit of five days' stay in a public hospital is too simplistic. Certain conditions, by their very nature, necessitate a stay of more than five days, e.g., colon-cancer operation. It is also for these very conditions that we worry about chalking up large bills, rather than one-off admissions like childbirth, hernia surgery or knee replacement. With disease-specific data readily available from Casemix, the ministry should instead set disease-specific time limits.
Lastly, the public is apt to view this exercise as a cost-cutting measure. To assure us otherwise, the Government should channel the projected savings back to us, especially to those who will be affected adversely by means testing. This could be in the form of an upgrade of our MediShield packages, to assure us that although we may no longer qualify for C-class subsidies, we would still be able to afford the necessary health care when the need arises.
Gerald Tan Jit Shen
http://angrydr.blogspot.com/2007/04/subsidy-and-other-preoccupations-11.html