Best Obamacare alternative? Look to Singapore’s system

Ross Douthat

I have been devoting this space to deliberately implausible ideas lately, and the time has come to turn to an issue that our politicians are actually debating: health care reform. Though “debating” might be a strong word, since the politicians are all Republicans, and it’s hard to have a serious argument when most all involved (including our unhappy president) really, really wishes that they could talk about tax cuts instead.

Republican politicians may offer pandering promises of lower deductibles and copays, but the coherent conservative position is that cheaper plans with higher deductibles are a very good thing, because they’re much closer to what insurance ought to be — and the more they proliferate, the cheaper health care will ultimately be for everyone.

Is there an existing system that vindicates this boast? Yes, in a sense: There is Singapore, whose health care system is the marvel of the wealthy world.

However, there has never been a major Republican policy proposal that just imitates what Singapore actually does. That’s because the Singaporean vision is built around personal responsibility and private spending, but also a degree of statism and paternalism that American conservatism instinctively rejects.

First, Singaporeans do not spend money voluntarily saved in health-savings accounts. Under their Medisave program, they spend money saved in mandatory health-savings accounts, to which employers contribute, as well. Second, their catastrophic insurance comes from a government-run single-payer system, MediShield. And then the government maintains a further safety net, Medifund, for patients who can’t cover their bills, while topping off Medisave accounts for poorer, older Singaporeans, and maintaining other supplemental programs, as well.

The results are extremely impressive: By forcing its citizens to save and manage their own spending, the Singaporean system seems to free up an awful lot of money to spend on goods besides health care over the longer haul of life.

If you simply wish away the hurdles, there is a stronger case by far for trying to get to Singapore than for the jerry-built, incoherent thing that Paul Ryan is struggling to maneuver through the House.

What’s more, the compromise floated recently by Sens. Bill Cassidy and Susan Collins is a little closer to Singapore than many Republican plans to date. They propose that states be allowed to experiment with an Obamacare alternative that would 1) auto-enroll the uninsured in catastrophic coverage and 2) directly fund health savings accounts for the working class and poor. Together, they’re more Singaporean than what RyanCare does and doesn’t do, and better for it.

Of course, they’re also a bigger compromise with paternalism than the Republican Party’s True Conservatives are currently willing to accept. They have their principles, and making America Singapore is simply a nonstarter.

I just hope those principles are a comfort to them when the next wave of liberalism delivers us to a much more plausible health insurance destination than Singapore: Straightforward single-payer, in the form of Medicaid for almost all.