Response

Response:

Dr. Meng-Kin Lim pardons William Hsiao and me for getting "a few details wrong" in our contributions on the Singapore health care system because we are both "writing from thousands of miles away." Alas Dr. Lim has no excuse for his lapses, since he is a senior Singaporean academic on the spot.

First, he criticizes Hsiao for claiming that MediShield covers up to age seventy rather than eighty. In fact the extension of this coverage to age eighty began only in December 2001, and at the time of writing our contributions (and in fact at the time that Dr. Lim wrote his letter) Hsiao's statement was accurate and Lim's inaccurate. It is also worth noting that the announcement of the extension in MediShield was made only in September 2001, and Lim must realize that it could not have been taken into account in an academic journal with an August dateline.

Second, he criticizes both of us for not mentioning ElderShield. But ElderShield does not yet exist. It will not begin operation until the second quarter of 2002. This announcement was made in August 2001, so it would have been extraordinary if either of us could have mentioned it in our articles, which were proofed and finalized well in advance of August. Perhaps my colleague is too close to the decision-making process in these matters and is accidentally treating anticipated changes as if they have already happened because he has been living with their genesis for some time.

Moving on to Lim's more general criticisms, I agree that various statements Hsiao and I made in which we drew conclusions about the fundamental character of the Singapore health care system are "the authors' personal opinions." They are also our respective conclusions after conducting academic studies of our subjects. That is called qualitative analysis, and speaking for myself, drawing such conclusions is the whole point of my academic activity. If Lim disagrees with my conclusions he is free to present a counterargument. That is called academic discourse.

He also restates Mark Pauly's critique that I have been unreasonable in judging Medisave to have failed to curtail costs because we do not know what costs would have been if Medisave had not been introduced. Both writers argue that I have created an unreasonable baseline that judges the innovation (as it was when it was introduced in the early 1980s) to have failed simply because costs increased at all after its introduction. In truth I would have been content to judge Medisave a successful curb on health care expenditure if it had even reduced the rate of increase of health care expenditure. In fact the rate of increase in per capita expenditure grew from 11 percent per annum to 13 percent per annum with Medisave's introduction. The share of GDP absorbed by health care also increased. I am the first to admit that we cannot be at all certain that this increase was because of Medisave, but short of the government releasing detailed evidence that supports a contrary conclusion, I see no reason to revise my more modest conclusion that Medisave "failed to curtail costs." If Lim can show me evidence to the contrary I will be happy to amend my conclusions accordingly.

I find little to disagree with in the concluding paragraphs of Lim's letter. I take particular note of his statement that "Singapore has never shied away from incorporating 'what works' or jettisoning 'what's doctrinaire' in the face of compelling evidence." In fact the Singapore government has, since the publication of my article, begun winding down its innovative experiment with Medical Savings Accounts (MSA) and has begun placing more emphasis on conventional health insurance. ChannelNews Asia carried a report on 23 September 2001 in which Health Minister Lim Hng Kiang was reported as saying that "over time, insurance schemes like MediShield will play a bigger role in managing health care costs. Today, the...