First, Singaporeans do not spend money voluntarily saved in health-savings accounts. Under their Medisave program, they spend money saved in mandatory health-savings accounts, to which employers contribute as well. Second, their catastrophic insurance doesn’t come from a bevy of competing health insurance companies, but from a government-run single-payer system, MediShield. And then the government maintains a further safety net, Medifund, for patients who can’t cover their bills, while topping off Medisave accounts for poorer, older Singaporeans, and maintaining other supplemental programs as well.
So the Singaporean structure does not necessarily minimize state involvement or redistribution. It minimizes direct public spending and third-party payments, while maximizing people’s exposure to what treatments actually cost. And the results are, again, extremely impressive: By forcing its citizens to save and manage their own spending, the Singaporean system seems to free up an awful lot of money to spend on goods besides health care over the longer haul of life.
This is the point in a normal column where I would note the insuperable political obstacles to getting a Singaporean plan through Congress even if Republicans embraced it. (And for the record, I am quite certain that making America Singapore wouldn’t generate quite the same cost savings for cultural reasons alone: A sprawling empire of free spenders is never going to be as disciplined as a city-state ruled for 30 years by Lee Kuan Yew.) But I’m dealing in political implausibilities these days, and if you simply wish away the hurdles, there is a stronger case by far for trying to get to Singapore than for the jerry-built, incoherent thing that Paul Ryan is struggling to maneuver through the House.