Make standard B1 coverage available for all Singaporeans


Adding B1 layer to MediShield Life insurance will cater to rising expectations

Last December, I spent a Saturday afternoon closeted in a room with about 30 other Singaporeans talking about a subject very close to our hearts and wallets: health-care cost.

In particular, the review of MediShield Life, the improved national health insurance plan that offers coverage to all, including those with pre-existing medical conditions, and for life.

I cover such discussions on public issues all the time as a journalist. But this time, I signed up as a citizen because I wanted to give views on a specific area: allowing people with pre-existing medical conditions to be covered under higher ward class plans.

The proposed new MediShield Life offers universal coverage - but for B2 and C class wards only.

Those of us with pre-existing medical conditions cannot buy insurance cover for B1 or A class wards, since insurers have every right to reject us.

As it turned out, I didn't even have to raise the topic in my small-group discussion.

A woman in my group brought it up. I've since learnt that it was actually a common concern among the 1,200 participants in focus groups who gave views to the committee.

One group concerned about this are those already on private Integrated Shield Plans (IPs). They say insurers are jacking up premiums as they get older (some premiums doubled last year) and they feel at the mercy of these commercial providers.

If they can't afford the premiums, they end up back on basic MediShield Life, and will have to go to Class B2 and C wards: no air-conditioning, no choice of doctor, and access to a more restricted and cheaper range of drugs and treatment options.

Their call: Could the Government step in to offer a MediShield Life option that lets people get treatment at B1 wards? Premiums can be higher than for B2 or C class wards, of course.

For this group, the concern is over-insurance. About 60 per cent of Singaporeans buy IPs. But many don't utilise their benefits fully. Of those with plans meant for A class wards in public hospitals, seven in 10 chose to stay in lower ward classes when hospitalised. For those with plans meant for private hospitals, six in 10 chose lower class wards.

In other words, many people are paying premiums for benefits they don't need or want. Many told the committee they would like to downgrade to B1 coverage but aren't sure how this would affect their benefits. Health Ministry data also shows that premiums for B1 plans have seen sharp hikes from 2008 to 2013.

Another group of Singaporeans is concerned with under-insurance.

I belong to this category.

We will be covered by basic MediShield Life, which excludes no one.

But because of our medical conditions, private insurers will not cover us under private Integrated Shield Plans. They don't offer coverage at higher premiums. They simply turn us down flat.

The result is that many of us with pre-existing medical conditions are under-insured.

I am fortunate now to be employed by Singapore Press Holdings, which has generous medical benefits by Singapore standards. But the day I quit is the day I will fall into the category of the under-insured.

Those with savings can self-insure, meaning we make sure we have enough for our needs if we want to go to private wards. Those without employer benefits and with scant savings, depend on family or friends. Or they just choose B2 or C wards.

If they do the latter, they risk clogging up already crowded subsidised wards.

This was an issue on which the over-insured and the under-insured could agree on: Add on a B1 tier under MediShield Life.

After all, expectations are rising. Class C and B2 wards may have been fine 20 years ago, but may have become a less than optimal choice today.

When my parents were hospitalised, in the 1990s and 2000s, Class C was the preferred ward for many elderly people - and not always because of the cost. They belonged to a generation who disliked air-conditioning and found single rooms deathly quiet. That made Class B2 or C wards, with fans and open windows, and rows of cubicle beds per ward, the optimal choice.

For those of us in our 40s, perhaps the optimal choice is B1: with air-conditioning and a few people around for company, but not too many. And we can choose our doctor, and have access to the new drugs or treatment our Internet searches tell us are promising for our ailment.

Yet, the MediShield Life default remains at the B2 and C classes. To be sure, keeping premiums low and affordable is paramount, and this is probably the main reason the committee has not recommended adding on a B1 layer to MediShield Life.

Even then, committee chairman Bobby Chin and his colleagues must be credited for taking the IP bull by its horns and trying to wrestle with it. IPs now offer a daunting range of plans and benefits.

The committee wants the Government to work with private insurers to come up with a standardised B1 Integrated Shield Plan that will be available to all. Those with higher-class plans can downgrade to this. Those on basic MediShield Life plans can choose to add on this B1 tier as a private insurance plan.

For those with pre-existing medical conditions, the committee says private insurers should be allowed to treat them differently and add "risk loading" - which means charging higher premiums to compensate for their potentially high claims.

So far, the Government has been careful in its response.

The Ministry of Health press release issued on Friday said the Government "accepts all the recommendations" on the design of the MediShield Life scheme. But it merely "welcomes" the recommendations on IPs and other related issues, "and will study how best to implement them".

I wish the committee had been bolder and taken a firm position. Top choice would be if it had said MediShield Life should offer a B1 plan run by the Government. If that's too difficult to administer, it could have stated categorically that every Singaporean should be assured of coverage under its standard B1 plan. This would put the onus on insurers and the Government to work together to come up with premium tables that make sense actuarially and also ethically.

Without that assurance, private insurers can simply risk-load to unconscionable levels. This means that those of us who developed medical conditions later in life remain second-class citizens in the much-vaunted MediShield Life new world.

Yes, we get coverage under B2 and C class wards like everyone else.

But unlike our healthier peers who can buy health insurance for B1 and higher class wards - and have a choice of doctors and more options for treatment - we can't.

The new MediShield Life umbrella covers us all equally but when it pours - really pours - the healthy stay dry in a waxed raincoat while those already sick get soaked.