Caning and caring: A model for LTC reform

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Staff Writer Tim Mullaney
Staff Writer Tim Mullaney

I say Singapore. You think … caning?

The Michael Fay incident — involving an expatriate American teenager whipped four times with a cane for vandalizing cars — put the Asian city-state of Singapore in international headlines for weeks back in 1993. Public opinion was split between those who found the punishment excessive and those who felt it was deserved, and that the United States might learn a thing or two about keeping its own delinquents in line.

However, the country famous for caning its youngsters ought to be better known for the way it cares for its elders. At least, that's the argument of a new book by William Haseltine, Ph.D., a former Harvard Medical School Professor and prominent biotech entrepreneur.

Haseltine provides a broad overview of Singapore's healthcare system, which outperforms the United States on outcomes while costing far less — only 4% of Singapore's gross domestic product goes toward healthcare, compared with 18% here.

It's debatable whether Singapore is a realistic model for what healthcare could look like in the United States. Singapore is a tiny nation — really, it's one big city — that has been ruled by a single political party for half a century. There are significant socio-cultural distinctions between Singapore and the United States (again, note the caning thing).

But it's just possible that we can learn a thing or two from how Singaporeans approach long-term care. As Financial Times reviewer Sarah Neville wrote: “It is here, in offering a humane and economically sensible approach to supporting people in the final section of their lives, that the lessons of this book have widest application — and offer a way forward for all countries as they confront the implications of demographic change.”

I won't be able to do justice to Haseltine's detailed account of Singapore's eldercare system, but I'll offer three highlights below. If you're interested in learning more, you can download his whole book for free here.

* Singapore recognizes that eldercare is about more than subsidizing nursing homes. In 2007, the government established a Ministerial Committee on Aging, which coordinates all the relevant government departments on four initiatives: giving seniors access to needed care at an affordable price; allowing seniors to remain in the workforce; enabling community-based living through improved transportation systems and other infrastructure; promoting physical and mental wellbeing through active aging programs.

* In 2009, the government created the Agency for Integrated Care, which provides consultations to seniors to help them get necessary care in the most optimal setting. The effort involves actually going door-to-door. The numbers speak for themselves. Haseltine wrote: “AIC refers about 6,000 patients to service providers each year of which more than 75 percent are older than 65 and require assistance in activities of daily living such as using the toilet, personal grooming, and feeding, or they may be bed-bound. Over 14,000 patients have been assisted, after hospital discharge to transition to their homes and their community.”

* Nearly all Singaporeans have money from their paycheck placed into the nation's Central Provident Fund, which includes the healthcare programs Medisave, MediShield and Medifund. As of 2002, it also includes ElderShield. Unless they opt out, Singaporeans and permanent residents are automatically enrolled in this program when they turn 40. The program is run by private insurers, and beneficiaries can pay premiums, up until they turn 65, using cash or their Medisave fund — a kind of personal health savings account. Once they have reached a certain threshold of premiums, plan members at any age are entitled to benefits that include $400 a month (in Singapore dollars) for up to 72 months of nursing home care. A higher amount is being debated, according to Haseltine. MediShield is an older program that also provides coverage for long-term care.

If this all sounds like too much government involvement in healthcare for your tastes, consider that Singapore also has sought for decades to create a system based on individual accountability. The money that people contribute to their Central Provident Fund account is theirs to spend as they see fit, incentivizing them to do comparison shopping and get the most healthcare bang for their buck. This has spurred competition and innovation among providers. By being transparent about the cost of common procedures at high-quality government-run hospitals and clinics, the government has made it easier for people to judge whether they're getting a good deal.

I have to say, reading Haseltine was kind of a depressing experience for me. When I picked up his book, I had just read the report from the Long-Term Care Commission — or, I should say, the reports from the Commission, since even the members on that panel couldn't agree on a single set of recommendations to give Congress. Partisan politics around healthcare now have ground the entire federal government to a halt. To read about Singapore's rapid implementation of long-term care reforms presents a dispiriting contrast to the current situation in this country.

However, Haseltine himself points out that the government of Singapore undertook changes around eldercare because the public demanded them and threatened to oust lawmakers if they did not deliver. Haseltine is hopeful that a similar pressure will lead at last to long-term care changes in this country, he said in a recent podcast. Granted, it seems now that the U.S. electorate's demands are more basic — like, keep the government open. But to end on an optimistic note, I'll leave you with Haseltine's words:    

“The Singaporean government is being extremely responsive to the eldercare issue because they want to stay elected. I see that as the hope for our country. That there will be an increasing pressure to solve these problems at an affordable cost. […] Our military and our businesses will apply political pressure, and eventually it will get down to the grassroots. We want good health for ourselves and our parents.”

Tim Mullaney is Staff Writer at McKnight's.Follow him @TimMullaneyLTC.


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McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.