Sandwiched class Singaporeans in Singapore get it the worst when it comes to healthcare

TL;DR – The sandwiched class Singaporeans have to take care of themselves and also shoulder the burden of care for their children and parents.

The success of Singapore’s healthcare policy has been much studied and featured, with the Lee Kuan Yew School of Public Policy even calling it the “envy of the west”.

But do Singaporeans agree that our healthcare system is top-notch?

We deliberately spoke to people of different ages and demographic profiles:

(1) Younger Singaporean adults below the age of 30,
(2) Sandwiched class of Singaporeans
(3) Older Singaporeans.

Across the young, middle-aged and old, rising costs and quality of healthcare were common concerns. However the specific grouses varied depending on the life-stage they were in and whether they had safety nets to fall back on, such as adequate insurance and liquid cash assets.

Young Singaporeans: Lousy doctors, nurses, expensive treatments, but thank goodness we have insurance.

With almost three-quarters of direct care workers in Singapore and more than a quarter of doctors in the public healthcare sector here being foreigners, frictions such as miscommunications will happen, such as Mr V Samuel who had a bad experience with rude foreign nurses.

As Singapore races to train more doctors, there is a higher chance of patients encountering internship doctors on their rounds, which we heard negative feedback from Mr Melvin Ho when they treated his son.

Although some young Singaporeans feel the quality of healthcare is questionable and costs are rising, almost everyone we spoke to were grateful for MediSave and also their personal insurance coverage. Singaporeans can use up to $500 per year from our MediSave account with 15% co-payment.

Sandwiched class: Private hospitals are better than public ones, General Practitioners (GPs) are becoming more expensive, unexpected out of pocket costs, healthcare burden of looking after children and elderly parents.

The sandwiched class are generally critical of the quality of the public healthcare system and costs of outpatient treatment.

The out-of-pocket costs are a big concern for some people in the sandwiched class, especially when it comes to outpatient and hospital deposits.

Furthermore, if GP costs are seen as expensive, patients and families get a bigger financial shock when it comes to paying hospital deposits, such as Ms J Lim who had to fork out $10,000 for her younger girl’s NICU (neonatal intensive care unit).
Nevertheless, there are still instances where middle-aged Singaporeans had good experiences with the public healthcare system. Mr Siow WJ testified his father didn’t have to wait long to get a date for his operation, which was also heavily subsidised.

Having adequate insurance, access to subsidies and enough childcare leave are also important factors when sandwiched families cope with inpatient and outpatient costs and caregiving.

Elderly: Our public healthcare system offers subsidised treatments but there can be a strain on the system (shortage of manpower, shortage of resources), going private is an option. But not all elderly have insurance. The healthcare benefits under the Pioneer Generation (PG) and Merdeka Generation (MG) packages are helpful, but the burden of care-giving for elderly with chronic illnesses often falls on the sandwiched class.

A study carried out by Duke-NUS Medical School’s Centre for Ageing Research and Education and the Ministry of Health highlighted a worrying trend, that 37% of the above 60 year-olds who participated in the study had three or more chronic illnesses. With Singapore’s population moving towards an ageing population, healthcare expenses for the elderly certainly is a topic that needs to be discussed more thoroughly.

We spoke to several chronic illness sufferers – Mr Leong and Mr Chua who currently tap on the public healthcare system for managing their illnesses. Both have relatively positive experiences and also find the costs manageable.

When an elderly chooses to go private or does not have insurance, it seems the burden falls on their immediate family to pay for the costs. Mdm Soong’s operation at a private hospital saw the sum of $45,000 falling squarely on the family to pay in cash for.

That said, the toll on families may not be purely financial. In the case of Mr Neo, a Parkinson’s disease sufferer, his two children helped shoulder the financial costs but the sole caregiving falls on his wife. Mr Neo’s fussiness with food and tendencies to have mood swings have taken a toll on Mrs Neo, who has been falling sick herself. Mrs Goh, whose mother had an operation, had to juggle her full time work plus daily hospital visits. Even after her mother was discharged, she had to arrange to go back to her mother’s home everyday to help deal with daily post-operation injections. Not all companies provide family care leave or generous annual leave.

While the 3Ms – MediShield, MediSave and MediFund – generally help in terms of subsidising medical costs, there could still be some elderly that fall through the cracks. An ex-healthcare worker also offered us some insight from her years working in the A&E and pharmaceutical line where she witnessed some elderly not having enough cash to pay for their medication yet not being able to access their Medisave, for whatever reason, to pay for their bills.

Other pockets of elderly who are relatively healthy have it better. Mdm Tay had made an appointment at the polyclinic to get an eye check up as she was “seeing floating things”. As she has the Pioneer Generation card, the cost for her to see the doctor came up to only a few dollars at the Polyclinic.

In spite of the growing trend of elderly getting more chronic illnesses, there are some doing their part to keep fit and live by the mantra “health is wealth”. This was the case of Mdm Ong, who attends twice weekly exercise sessions and goes for regular subsidised health checkups at the nearby community centre.

Understanding Singapore’s Healthcare System

Singapore adopts the “S+3M” framework for our public healthcare system, which aims to keep healthcare affordable. The S refers to subsidies and according to the Ministry of Health, patients in public healthcare institutions enjoy subsidies of up to 80% of their bills. The 3M refers to Medishield Life, MediSave and MediFund.

Statistics have shown that in our public hospitals, 7 in 10 subsidised bills are fully paid without any cash outlay by the patient. In other words, 70% of all subsidised bills do not require any out of pocket cash payment by the patient at all. Of the remaining 30% of bills, one-third require payment of $100 or less in cash, and another one-third is paid for using a cash outlay of between $100 and $500.

So where are the gaps and challenges?

From the conversations we had with Singaporeans of different life-stages and from different walks of life, we have formed some initial impressions which may be worth a second or deeper look into.

For the younger Singaporeans, it appears that they are more informed about the entire healthcare ecosystem and they tend to plan early enough and are adequately covered in terms of healthcare insurance. One possible gap we can identify is the relatively high occurrence of mental health issues among the 18 to 34 year-old Singaporeans, depression being the top mental disorder and how the typical insurance and company health covers do not include this.

For the sandwiched class of middle-income, middle-aged Singaporeans, the rising costs of healthcare is a key issue. Many have spoken out about the high outpatient costs of seeing GPs, and we also note the financial burden on them for their dependents. It gets expensive when their children need to see the pediatricians, and it is double whammy if their parents and in-laws also require medical attention, aggravated by how many elderly folks are not adequately insured or the lower-income elderly may not have much in their MediSave accounts.

For the sandwiched class, the problem is not just about money. It is also the whole care-giving stress when they need to bring their dependents to the doctors, or when they need to stay home for caregiving duty. The situation becomes worse when the elderly dependents suffer from chronic illnesses.

For the elderly Singaporeans, outpatient costs are largely manageable, especially with the implementation of the Pioneer Generation and Merdeka Generation packages. But for complicated, chronic and/or even sudden medical emergencies, unless these elderly folks have a healthy nest egg for retirement and healthcare needs, the burden can be heavy on their children.

Food for thought

We think it is fair to say Singapore has a reasonably effective healthcare system, but there are gaps and also emerging trends that we need to tackle.

1. Can we do more for the sandwiched class, especially those who are not rich enough and yet not poor enough to qualify for most of the help schemes we have? And it is not just about the money.
2. How can we better help people who are suffering from mental health issues?
3. How can the manpower shortage in the healthcare sector be eased? Demand for manpower is going up, especially with the ageing population. Can technology and digital transformation projects help?
4. What else can we do to attract and retain healthcare talents? What about their mental well-being?
5. And of course, how can we promote healthier living for everyone? Keeping everyone as healthy as possible can obviously save a lot of money and pain.

So even if we concede and say that Singapore does have one of the top healthcare systems in the world, it is not the best and there is room for improvement.

In particular, our hearts go out to the sandwiched class.

(Featured image via)