字幕表 動画を再生する 英語字幕をプリント On September 6th, 2019, the 95-year-old former president of Zimbabwe Robert Mugabe died of cancer. He did not, however, die in Zimbabwe. Instead, Mugabe chose to receive his medical care, as he always did, in Singapore — a whole 5,000 miles or 8,000 kilometers away. Each of his many such trips required no fewer than 10 hours in the air each way, by which time he could've flown anywhere in continental Europe. The African revolutionary was not the only powerful person to seek treatment in this southeast Asian city-state of just five million. So too did the daughter of the Philippines president, the president of Bangladesh, several military leaders of Myanmar, and the former first lady of Indonesia, to name just a few examples. Heads of state no doubt appreciate Singapore's tight control of the press and lack of protestors, though their first priority is surely the same as its other 500,000 annual medical tourists — to receive what is perhaps the best healthcare on earth. Today the average Singaporean lives to be an astonishing 83 years old — a full decade longer than the world average, and only slightly behind Switzerland, Macau, Japan, Hong Kong, and San Marino. Another common metric for healthcare quality is the infant mortality rate, at which Singapore is among the best in the world — just 2.1 for every 1,000 live births. Finally, Bloomberg ranked the country second in overall efficiency. These are impressive outcomes on their own, but they become downright amazing when you consider how little they cost. The United States spends about 17% of its GDP on healthcare — making it an embarrassing outlier even among the most developed nations. The UK, a more representative example, stands at 10%, Australia, 9, and Israel, just 8. Singapore, on the other hand, spends just four percent of GDP. This is, in fact, lower than the minimum recommended by the World Health Organization. On this metric, Singapore is surrounded by poor countries like Sudan, Eritrea, and Madagascar. If you didn't know of its world-class outcomes, you'd assume, based on this number, that it must surely be a struggling backwater, not a thriving global finance hub. If the US spent the same proportion of its GDP on healthcare, it could afford, with those savings, to permanently finance 139 of the world's smallest countries. It could save three times the entire cost of the American military. Somehow Singapore provides the same or even better healthcare than the richest countries in the world at the cost of the poorest countries in the world. In designing healthcare systems, governments willfully chose at most two of the following: Price, quality, or equal access. They do so because they accept these “natural” trade-offs — believing that you can't have it all. Singapore, on the other hand, seems to have solved this M. C. Escher-level puzzle and delivered all three. Sponsored by CuriosityStream and Nebula — where you can watch the extended version of this video. When Singapore gained independence in 1965, healthcare was far from its highest priority. In the words of its health minister at the time, it ranked at most fifth — after national security, jobs, housing, and education. Facing an uncertain future and with the country's very existence at stake, the government had no choice but to ration its attention and resources. The U.S. performed its first successful kidney transplant in the early 1950s. But Singapore would have to wait twenty years to do the same. With just 50 specialists for a population of two million, it chose to focus first on more pressing issues, like the rampant spread of tuberculosis and pneumonia. This slow and methodical approach helped the country develop a set of guiding, foundational principles which informed its decision-making. While Singapore was still a British colony in 1948 when the English National Health Service was created, it chose a very different path. In fact, if there's one philosophy that defines its national approach to healthcare, it's a firm and unapologetic rejection of what was perceived as the over-generosity of the British. Believing that the general public was abusing, misusing, and under-appreciating government clinics, its first Prime Minister, Lee Kuan Yew was quick to impose a fee. It was decided that while every citizen would be guaranteed some form of care, nothing would be strictly free, motivating a sense of personal responsibility. But allergic as the government was to anything resembling “welfare”, it also had little confidence individuals could be trusted to manage their own healthcare savings. The compromise to this tension was called “MediSave”. The British had left Singapore with a compulsory savings account known as the Central Provident Fund. It required employees to deposit 5% of their income, which employers matched, to be withdrawn at retirement. Over the years, Lee raised these contribution rates and introduced several new components. Today, the average Singaporean is required to stash away about a third of their income into three accounts. The first — the “Ordinary Account” — can be used to pay for things like school and housing. A second “Special Account” is reserved for retirement, and merges with the Ordinary Account at age 55. Finally, the MediSave account can be used for medical care and insurance. In essence, every citizen is required to stash away some money for a rainy day. Most income at the beginning of one's career is directed to the Ordinary Account, which is one of the reasons so many Singaporeans can afford their own home. As you approach retirement, more and more of your money is sent to MediSave. And when the government runs a budget surplus, it often simply deposits the difference directly into these accounts, ensuring it's put to good use. In practice, the system functions neither like American social security, nor a fully self-owned bank account. It's somewhere in-between, which makes it somewhat controversial. On one hand, the government likes to boast that citizens own their own funds. In some sense, this is true. It's not attached to your employer, and thus doesn't end if you're fired or laid off. The money it contains is completely tax-free and can be willed away, like any property, at death. It's also guaranteed a minimum, competitive, interest rate between 2.5 and 5%. On the other hand, critics highlight how restrictive it is. Funds are subject to both a minimum and maximum balance, periodic limits, and deliberately designed not to fully cover any single medical expense, which the government argues would eliminate personal responsibility. In other words, it's entirely possible someone could go broke from exorbitant medical bills despite having plenty in their MediSave account — for no other reason than the government prohibits them from using it all. Every day of hospitalization, procedure, and treatment has a maximum proportion that can be paid for by MediSave — the rest is simply out of pocket. In 1990, the Singapore government addressed this inadequacy and introduced what they had been trying to avoid — insurance. MediShield Life, as it's now known, is intended as a defense against only the most catastrophic of conditions involving long-term treatment, like dialysis or cancer therapy. Even then, it activates only after patients have contributed a significant portion either out of pocket or via their MediSave account. But it's very affordable. A 20-year-old, for example, pays just $101 US Dollars a year, which can even be paid for with MediSave. Each age group pays however much is needed to make it independently sustainable. In other words, it's not simply a transfer of wealth from the young to the old, like the American pyramid scheme known as “Social Security”. Because of this, older people pay much higher premiums. $509 a year, for example, for those aged 90 or older. Still, MediShield is generally well-liked. Though compulsory today, more people participated when it was voluntary than in the U.S., three years after ObamaCare was made mandatory — 94% to 91. Those who want more comprehensive insurance have the option of buying upgraded plans from private companies, all of which are tightly regulated to ensure competition. Finally, in 1993, Singapore stepped in with a safety net of last resort for the lowest-income households. MediFund is a principal-protected, and thus indefinitely sustainable, endowment which pays for the medical care of those who can't. Any citizen who can prove their inability to pay can apply to a group of independent volunteers who make case-by-case judgments. Most applications are approved within 30 minutes, but the most complicated of cases can take up to three weeks. In 2019, MediFund paid $120 million involving over a million applications. These three “M's” — MediSave, MediShield, and MediFund, are often cherry-picked by those seeking to reform healthcare abroad. Some point to the mandatory savings accounts as evidence healthcare shouldn't be handed out for “free”. Others protest that MediFund is the real backbone of the system. In truth, neither is completely accurate. Each of the three M's is one layer of protection — without which the entire system wouldn't function. But don't get the wrong impression. The bulk of healthcare spending still takes the form of subsidies. In 2013, MediSave, MediShield, and Medifund accounted for 5.1, 2.1, and 0.8% of all healthcare expenditures, respectively. What's revolutionary about the 3Ms, however, is not how large they are, but how they control costs for everyone — including taxpayers. Singapore solves the American problem in which hospitals are incentivized to charge exorbitant prices which are merely passed on to insurance companies. Because patients pay more out of pocket, hospitals are forced to control costs. These lower costs are passed on to the government, too, when it distributes subsidies. In other words, while the sticker price may feel higher for Singaporeans, the total amount they pay, both out-of-pocket and in taxes, is far, far lower. All of this is enabled by transparency. The government makes all costs public and easily accessible online. Hospitals are required to provide patients with an estimate of their bill, as well as the average cost at competing hospitals. But how, you may ask, are these subsidies distributed? What system could possibly ensure that the poor get support while the rich don't abuse it? For the most part, people just sort themselves. Public hospital rooms are split into four classes: C, B2, B1, and A. The cheapest, Class C, have 8-10 beds in a fairly utilitarian room, while the most expensive, Class A, are private rooms with a TV and Air Conditioning. The important thing is these classes are treated as cosmetic, luxury upgrades. The same doctors operate all wards with the same standards of care. They have no monetary incentive to treat anyone differently. And much like airplane classes, more premium rooms cost significantly more with only modest improvements, which naturally separates patients based on their willingness to pay. Is it fair that the poor sit in a stuffy, crowded room during hot, humid summers? Answers will vary, but many would argue the alternative: high prices for everyone, is worse. In fact, so many patients were content choosing lower classes than they could afford, that hospitals eventually introduced means-testing. Anyone, with any income, can choose whatever room they prefer, but subsidies vary both based on ward class and income. Class A rooms, for example, offer no subsidy, while class C are subsidized up to 80%. For all these reasons, Singapore defies categorization. Is it a free-market, or is it centrally planned? Yes. In theory, hospitals are welcome to charge whatever, and yet the entire market is tightly controlled by the government, who, in regulating everything from MediSave minimum contributions, to what qualifies for MediShield, can influence whatever outcome it wishes. Is it public or private? Yes. 20% of primary care and 80% of secondary is public, but the two are expressly designed to work in concert. The system is not perfect. One challenge is that MediSave heavily relies on families who pool together costs for major operations. In 2010, for example, 44% of withdrawals were made for a family member. For example, someone's child, spouse, or parent. Today, however, the average Singaporean woman has just 1.15 children in her lifetime — the third lowest fertility rate in the world — meaning the population is rapidly shrinking. As the country gets older, it will experience significantly more chronic and complex illnesses, yet smaller families will mean fewer people can pool savings. Solving healthcare is an ongoing process. But Singapore can credibly say that it has paved a new, third path. Some countries offer medicine free-at-the-point-of-care, which results in long queues, others simply don't guarantee healthcare at all, and therefore have to leave behind the most vulnerable. Singapore, on the other hand, does neither. The million-dollar question is whether Singapore is a strange anomaly or a viable model for the rest of the world? Could this system work in the United States, for example? That's the question we explore in the extended version of this video on Nebula, which replaces what you're hearing right now with more of this video. Just about every other video, in fact, has bonus or extended content available on Nebula, which is the streaming site I, and other educational YouTubers created to host new and experimental content. I wanted to open my video about China's National Insecurity, for instance, with a dramatic contrast between the welcoming China of ten years ago with today's aggressive China, but realized it would most likely get demonetized on YouTube. So instead, you can watch it, in its full, intended form, along with a bonus video about next year's Beijing Olympics, on Nebula. You can also watch entirely exclusive videos, like my friend KentoBento's telling of the most insane hijacking in Japanese history, or Neo's beautiful “The Unknown City”. Plus, we've partnered with CuriosityStream — home to great documentaries on technology, history, and science — like this one on how Singapore's billion-dollar sports stadium was built — so that you can get it and Nebula for less than $15 a year. Sign up with the link in the description and watch the extended version of this video over on Nebula.