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  • 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 worldjust 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 healthcaremaking 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 thesenaturaltrade-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 Nebulawhere 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 fifthafter 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 resemblingwelfare”, it also had little

  • confidence individuals could be trusted to manage their own healthcare savings.

  • The compromise to this tension was calledMediSave”.

  • 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 firsttheOrdinary Account” — can be used to pay for things like school and

  • housing.

  • A secondSpecial Accountis 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 accountfor 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 MediSavethe rest is simply out of pocket.

  • In 1990, the Singapore government addressed this inadequacy and introduced what they had

  • been trying to avoidinsurance.

  • 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 asSocial 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 forfree”. 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 everyoneincluding 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 lifetimethe

  • third lowest fertility rate in the worldmeaning 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 beautifulThe Unknown City”.

  • Plus, we've partnered with CuriosityStreamhome to great documentaries on technology,

  • history, and sciencelike this one on how Singapore's billion-dollar sports stadium

  • was builtso 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.

On September 6th, 2019, the 95-year-old former president of Zimbabwe Robert Mugabe died of

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シンガポールが医療を解決した方法(How Singapore Solved Healthcare)

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