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Healthcare Inequality

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Inflation. We often hear this word being thrown around in coffee shops by old “ah gongs” complaining about how everything is so expensive nowadays and that last time they could buy a full meal for just $1. I think everyone has a rough understanding of inflation and generally associate this to being an inevitable symptom of economic growth, but I think what's commonly misunderstood is the impact of inflation on our lives. More specifically, I'm interested in the healthcare aspect and how inflation may widen healthcare inequalities as well as some measures which try and bridge this income gap. 

With the current economic climate in Singapore and across the world, I think one sector which needs to be more carefully scrutinised is healthcare accessibility and affordability. Speaking from a purely ethical standpoint, I believe that everyone should be given equal access to healthcare services and should be able to afford the healthcare services they require to lead a healthy life without it crippling their finances. What I mean by this is that people should not have to refuse or discontinue treatment on the basis of financial insecurity. Without getting too political, I believe that the US gives a good negative example of this. From the news articles and reports, I have seen numerous reports of people running away from paramedics or running out of hospitals to prevent being slapped by a huge hospital bill. To put things in perspective, the cost of a single ambulance ride in the US, depending on the region, can cost several thousand dollars while in Singapore it's limited to 200-300 for non-emergency cases. Hence their profit motivated healthcare system makes healthcare more like a luxury than a necessity. So the question is now, are things different in Singapore? Well the bad news is no, not really. Though our issues may not be as prominent, there is still a palpable welfare gap and in turn healthcare inequality between groups of people.
 

Healthcare inequality from income

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It is well-established that low socioeconomic status (SES) influences one’s health status, morbidity and mortality. Housing type has been used as an indicator of SES and social determinant of health in some studies. In Singapore, home ownership is among the highest in the world. Citizens who have no other housing options are offered heavily subsidised rental housings. Residents staying in such rental housing are characterised by low socioeconomic status. A study published in 2018 titled “A systematic review of health status, health seeking behaviour and healthcare utilisation of low socioeconomic status populations in urban Singapore” by PubMed showed that staying in public rental housing was found to be associated with poorer health status and outcomes. They had lower participation in health screening, preferred alternative medicine practitioners to western-trained doctors for primary care, and had increased hospital utilisation. So why is there such a disparity in healthcare despite the multitude of government schemes and funds to support lower income groups? The short answer: people. Psychological egoism is the view that humans are always motivated by self-interest and selfishness, even in what seem to be acts of altruism.

Let's take insurance companies for example. Although practical on paper as it safeguards people from bearing the brunt of large medical bills or accidents, the system fails to take into account that many of such organisations are profit motivated. Hence this manifests in lopsided selection criteria which favours the rich, young and healthy as they are deemed to be “low risk” patronage which will earn them more revenue. As such, many of those who are old or have pre-existing medical conditions would be much less likely able to secure healthcare insurance as companies deem them as “high risk” and not a fiscally profitable customer. Though I will acknowledge the existence of non-profit organisations and voluntary organisations that work to provide services to its members and people, these are far and few between with the majority of companies, at least to my knowledge, being profit motivated. Hence this would often mean that though healthcare services are present, those that need it the most are ironically those that are least likely to get it or are the most vulnerable to paying exorbitant healthcare fees. 

 

And actually, because of the pandemic, this issue has spilled over into the workplace with some businesses incentivising their workers to not take MCs or sick leave by giving “attendance bonuses”.  Even machines need downtime and maintenance and employees are certainly not mechanical bodies. Though I have no objections to incentivise employees and workers through bonuses or promise of a promotion to encourage them to perform well and distinguish the better performers from others, I do believe it to be morally wrong to discourage low income workers from taking MCs or sick leave with the threat of not receiving a bonus pay which many of them rely on to make ends meet. Hence I think this accentuates the healthcare inequality in Singapore as those who are not financially restricted don’t have to worry about receiving the bonus pay and can take greater care of their health while those in a pinch may be deterred from reporting sick even if they are unwell.

Healthcare inequality from education

Furthermore, this disparity is deepened by the fact that those of a lower SES generally have a lower access to education. Despite the government advocating that “all schools are good schools” I do think it makes a difference which school one comes from. More than just the quality of teaching, the environmental influences of a student will also play a large factor in their academic performance and overall development. Though I do acknowledge that it is entirely capable of someone for a quote unquote “neighbourhood school” to excel, from a statistical standpoint, the vast majority of such high performers come from “branded” schools. Hence this creates a domino effect as those with a lower education level are less likely to land high paying jobs and as such have lower access to healthcare and educational facilities from financial restrictions. This perpetuity is dubbed the “poverty cycle” as the poor stay poor while the rich get richer.

Expanding on the point of education, I also believe that those from a lower educational background are more vulnerable to illness or diseases as they are less knowledgeable about good health care practises. However, in the context of Singapore, I believe this point bears less significance because of our relatively comprehensive health education through primary and secondary school which teaches many proper hygiene, diet and lifestyle practises.

Healthcare inequality from age

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However, to truly grasp the nature of healthcare inequality, we must address this issue from different viewpoints and not limit our approach to simply socio-economic factors. In my opinion, age also plays a large factor in the nature of healthcare services provided. 

Reiterating the point on insurance companies, the older generations generally would have a harder time securing healthcare insurance because of the preconceived notion that they are more susceptible to illness and are more liable to major illnesses like diabetes or kidney failure. 

 

Additionally, though this is a purely speculative conjecture, there may be unconscious bias amongst healthcare professionals who are more likely to either not start or discontinue medication or treatment for elderly patients because they don't believe it to be to their overall benefit. Instead they may advocate for the elderly patient to be referred to palliative or end of life care rather than attempting to treat the disease. Although I acknowledge this is a logical decision and may even be to the overall best interests of the patients to discontinue treatment, I would still categorise this as healthcare inequality simply because of the disparity in treatments offered which may shorten the lifespan for some elderly patients who could have lived longer if treatment continued or was started.

Healthcare inequality from gender

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Gender powerfully shapes all aspects of health and wellbeing. Socially and culturally constructed gender norms determine roles and opportunities for all people, affecting social and structural determinants of health, health risk behaviours, and access to and quality of health and social services. As a result, restrictive and harmful gender norms, values, and expectations result in inequalities in health and wellbeing that extend across the life course and across generations. 

For the sake of completeness, I would also put forward the notion that psychiatry and other forms of mental healthcare also fall under the purview of healthcare as a whole. Mental illness is the main area where I believe gender biases affect the diagnosis and treatment provided. According to a study published by the World Health Organisation (WHO), overall rates of psychiatric disorders are almost identical for men and women. However despite this equal incidence rate, there is a disparity for the treatment of such mental health issues with women more likely to receive treatment for things like depression. I think this boils down to certain gender norms and social stigmas which make men less likely to openly discuss mental or emotional troubles for fear that it's “emasculating”. Hence I think that more can be done to syphon out those in need and break down certain gender stereotypes and stigmas on how men and women are supposed to act or behave.

Conversely, for the area of pain management, women have reported being not taken as seriously as they should be by some healthcare professionals. For instance, a physician may shrug off complaints of chronic abdominal pain from an adolescent girl as simply menopause without taking the extra time to consider other possibilities such as possible appendicitis or gastro-intestinal ulcers. As a result, some women may not be able to receive the appropriate treatments or given proper attention during diagnosis because of these pre-existing gender biases. Similar to mental health for men, I think more provisions should be given towards women such that their concerns and worries are taken more seriously which also stems from eliminating gender biases and for physicians to treat each patient objectively.

Bridging the gap (Healthcare subsidy schemes)

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Despite these disparities in healthcare provisions between these groups, I believe that the current schemes and systems have actually proved to be effective in narrowing the gaps, particularly for the area of income and education inequality. So briefly allow me to provide a badly put-together overview of our healthcare subsidy schemes. 

(Having lived in Singapore for the better part of 20 years, you would’ve thought I knew our healthcare system by now, but nope! There are so many different schemes and plans which cover so many different and niche groups of people that it would be impossible to list them all in this article. However, I guess that serves as a testament to how comprehensive our healthcare system is like!)

 

  1. Medisave

    • National medical savings scheme that helps individuals set aside part of their income to pay for their personal or approved dependents' hospitalisation.

    • Can be used to pay for insurance premiums, inpatient care, outpatient care and long term care

  2. Medishield life

    • basic health insurance plan, administered by the Central Provident Fund (CPF) Board, which helps to pay for large hospital bills and selected costly outpatient treatments.

    • All Singapore Citizens and Permanent Residents, including the very old and those who have pre-existing conditions.

  3. Medifund

    • Social safety net for patients who face financial difficulties with their remaining bill after receiving government subsidies and drawing on medisave and medishield life. 

  4. CHAS

    • Provides subsidies for doctors visits to households of various income & to the Merdeka & Pioneer generations

    • Households with monthly income per capita of $1200-2000 are eligible for the CHAS orange card which subsidises up to $10 per doctor's visit

    • Households with monthly income per capita of less than $1200 will receive  the CHAS blue card which subsidises up to $18.50 per visit.

  5. Eldershield/ Careshield Life

    • Basic long term insurance scheme with monthly payouts

  6. Chronic disease management programme (CDMP)

    • Covers 20 chronic diseases including diabetes, asthma, parkinsons and heart disease.

    • patients with complex chronic conditions will be able to use up to $700 per patient yearly amongst other subsidies and benefits

  7. National screening programme (Screen for life)

    • Subsidised screening for all Citizens and PR from $0-5 for a full health check up.

 

Despite its merits, I believe that there are still some stubborn kinks that need to be ironed out in our current healthcare subsidy system. One short fall would be the social stigma that some people possess against receiving financial assistance. To elaborate, I think some people may not want to declare their financial struggles to institutions as they see it as “shameful” or  “embarrassing”. 

Then there is the issue of the “sandwiched class”. For example in the case of the CHAS scheme, a household earning $1201 monthly income per capita would be no better off then another household earning $1199 but would only have to be eligible for the orange CHAS card with the $10 doctors visit subsidy rather than $18.5 Having said this however, I must acknowledge that due to budget constraints and the complexity of the issues, there may be no easy fix for these solutions.

References:

  1. ADDminn. (2021, September 8). How to reduce income inequality in Singapore. Kickmymages. Retrieved February 10, 2022, from https://kickmymages.blogspot.com/2021/09/how-to-reduce-income-inequality-in.html 

  2. Chan, C. Q. H., Lee, K. H., & Low, L. L. (2018, April 2). A systematic review of health status, health seeking behaviour and healthcare utilisation of low socioeconomic status populations in urban Singapore. International journal for equity in health. Retrieved February 10, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5879561/ 

  3. Define_me. (n.d.). Retrieved February 10, 2022, from https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30354-5/fulltext 

  4. Non-emergency ambulance. Homage. (2021, August 10). Retrieved February 10, 2022, from https://www.homage.sg/services/non-emergency-ambulance/#:~:text=Cost%20of%20Non%2DEmergency%20Ambulance,%2Demergencies%2C%20Homage%20can%20help. 

  5. Today. (n.d.). Health equity in Singapore: A plan for action. TODAY. Retrieved February 10, 2022, from https://www.todayonline.com/singapore/health-equity-singapore-plan-action 

  6. Wikimedia Foundation. (2021, October 13). Psychological egoism. Wikipedia. Retrieved February 10, 2022, from https://en.wikipedia.org/wiki/Psychological_egoism

  7. Partner, Q. (2019, September 16). Exploring gender bias in healthcare. Fierce Healthcare. Retrieved February 10, 2022, from https://www.fiercehealthcare.com/sponsored/exploring-gender-bias-healthcare 

  8. Alcalde-Rubio, L., Hernández-Aguado, I., Parker, L. A., Bueno-Vergara, E., & Chilet-Rosell, E. (2020, September 22). Gender disparities in clinical practice: Are there any solutions? scoping review of interventions to overcome or reduce gender bias in clinical practice - International Journal for Equity in health. BioMed Central. Retrieved February 10, 2022, from https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-020-01283-4#Sec6 

  9. 2017, P. P. 04 O., Patnaik, P., & 2017, 04 O. (2017, October 4). The growing income inequality. NewsClick. Retrieved February 10, 2022, from https://www.newsclick.in/growing-income-inequality

  10. Breese, V. (2019, November 15). Age discrimination: 5 signs to know. Law Office of Christopher Q. Davis. Retrieved February 10, 2022, from https://www.workingsolutionsnyc.com/age-discrimination-5-signs-to-know/

  11. Segal, J. A. (2018, April 11). How gender bias hurts men. SHRM. Retrieved February 10, 2022, from https://www.shrm.org/hr-today/news/hr-magazine/pages/1015-discriminating-against-men.aspx

  12. Warshawsky, M. J., & Biggs, A. G. (2014, October 6). Income inequality and rising health-care costs. The Wall Street Journal. Retrieved February 10, 2022, from https://www.wsj.com/articles/mark-warshawsky-and-andrew-biggs-income-inequality-and-rising-health-care-costs-1412568847

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