PROBLEM OF SUCCESS: Much-improved Class C wards have become so popular that 9 per cent of the patients there are in the top 20 per cent in terms of per capita household income. -- ST PHOTO: TERENCE TAN

One such joke is about three friends going to the neighbourhood char kway teow stall for their fried noodles.

Chia Hong Chu gets his plate within two minutes, and with five extra cockles. Goh Pang Sek gets his half an hour later, with three extra cockles. Sah Pang Sek waits a full hour, and gets no extra cockles.

When the bill comes - you guessed it. It's $10, $5 and $3 respectively for the man living in private property (Chia Hong Chu), the five-room flat (Goh Pang Sek) and the three-room flat (Sah Pang Sek).

Says the char kway teow man, after pacifying each customer in turn: 'You see, we have limited resources.�Can only fry so many plates one night.�Only so much manpower. So must ration lah.'

Health care, of course, is a lot more complicated than char kway teow. And while you can forgo that oily lunch if you have the will, you can't really forgo that hospital stay unless you wish to cut short your stay on Planet Earth.

No wonder, then, that the prospect of means testing for hospital stays has added to the concerns of a population already worried by rising costs in most other areas of life.

When the Government planned for means testing to be formally announced this year, after having first mooted it back in 2002, it could not have bargained for inflation being at its highest in a quarter of a century. It could not have anticipated that 2008 would see record oil and food prices, record taxi fares, and probably - my guess, for the data is not out yet - the worst income inequality index in Singapore's history.

But if the Government has the courage of its convictions, it has to go ahead with the move. To continue to allow unfettered access to heavily subsidised health care at a time when the population is ageing fast and health-care resources severely strained is fiscal suicide, and worse.

For an idea of the 'worse', read the provocative article 'Real cost of not having means testing' in today's Straits Times (Review, page S12). Its original was published two years ago in the SMA News, the journal of the Singapore Medical Association.

I think the writer overstates his case somewhat, but the essence of it is fair.

'The biggest cost to the country as a whole is the wrong 'site-ting' of care,' says the writer. 'Patients who can easily be treated at the GP or polyclinic, community hospitals and private nursing homes refuse to be treated at these places because hefty subsidies are freely available to all at the public hospitals.'

This leads to over-crowded public hospitals, long waiting times, and stressed-out doctors, which in turn leads to lower care and even medical research standards.

How times have changed. In the late 1990s, according to my colleague, Health Correspondent Salma Khalik, the trend was towards more patients opting for higher class wards.

Former health minister Lim Hng Kiang had to step in to encourage greater usage of the lower class wards. At the same time, the ministry improved conditions in the lower class wards, to such an extent that demand for them today exceeds supply. A problem of success, indeed.

Health Minister Khaw Boon Wan gave some interesting statistics the other day: 9 per cent of the patients in Class C wards, and 13 per cent of those in Class B2 wards, are in the top 20 per cent in terms of per capita household income.

The 2005 General Household Survey gives $2,830 as the average per capita household income from work for those in the 81st to 90th percentile. This is almost three times the median per capita household income.

I doubt if the 9 and 13 per cent mentioned by Mr Khaw are the high earners themselves, more likely their elderly parents who wish to stay in non-air-conditioned wards.

On what will the means test be based? Suggestions abound: income tax returns, properties owned, housing type, even car ownership.

Mr Khaw has indicated that it will most probably be something simple, such as the individual patient's income, or, if he is not working, his housing type.

But things won't be that simple in practice, because there are many other variables, the biggest of which is the number of dependants a patient has.

Hence the cries from the middle class, especially those with young families, who fear that hospital bills will now be a bigger cost item in their already tight budgets.

For the 'middle class' in Singapore is really not that rich. According to 2005 figures, the average monthly household income in Singapore is $5,400. However, the median is much lower - $3,830. That means half the households in Singapore make less than that per month.

For a family of four, with two working parents, it means each parent makes less than $2,000 - or $1,915 to be precise - each. That is not very much in this age of escalating costs.

The means test would have to be set above that line in terms of individual income if these families are not to be adversely affected.

Other alternatives? One is to liberalise Medifund, which in 2006 paid out a record $39.6 million to more than 20,000 subsidised patients in public hospitals. But this too is not a bottomless pit. The capital amount in the fund is currently $1.4 billion, and income from it is what is used for payouts. That income would wax and wane with prevailing interest rates.

My suggestion is to set up an additional avenue of funding - a temporary loan, like a bridging loan, which can be paid back when the family is in better financial shape, as most middle-class families must be after their brush with illness is over.

Call this Medicaid or Medibridge. Means testing is not the fourth M of health care. This is.

leehoong@sph.com.sg