Singapore’s Governance Is Non-Exportable
People Keep Picking the Wrong Countries to Study
I’ve spent too much time recently disagreeing with Matt Bruenig about whether or not Nordic policies can be transplanted into the United States (spoiler: they really, definitely, absolutely cannot be). However, the affliction of “Can’t we just be like this actually incomparable country?” is not a unique disease of the left. Conservatives routinely hold up hilariously irrelevant models for the United States to emulate, like Hong Kong, or Singapore, or South Korea, or Denmark, or Switzerland. Today’s example is Singapore.
The thing I really love about all this is what it really comes down to is, for everyone, there’s some little corner of the world they think Has Figured Stuff Out. But they don’t move there. Why? Because immigration laws won’t let them, or there’s no job there, or they don’t speak the language, or some other reason that proxies for “it is a small place that only caters to a carefully selected group of people.”
It’s amazing what you can do when you don’t have the burdens of being a big country. I’ll go on record and say I think there are only a few countries that can really be meaningful proxies for the United States in terms of how readily we could pick up their policy models. Australia and Canada are serious contenders, but I still have concerns about both. China, Brazil, Russia, and India are apt, as is Germany to some extent, though I prefer comparing the United States to the European Union as peer-entities (Germany, after all, cannot control the flow of people, money, or goods across its borders).
And of course, these countries aren’t usually the ones we hold up as models for the United States, because their policies have a messiness and a compromisingness that we don’t find in our small, eccentric enclaves. But of course, that messiness, those compromises, the diminished efficiency of large-scale administration across large, diverse polities is an irreducible feature of any policy to be implemented in the United States. So really, we need to compare to countries that face similar messiness: bitter regional rivalries, large power of Federal entities, ideally a Presidential and constitutional system of government, extremely geographically polarized political preferences, high levels of assortative migration, extremely low trust in government, moderate levels of representativeness of government, etc.
So with that, let me get to today’s example of a nonsense international comparison: Singaporean healthcare!
Ross Douthat has a series at the NYT where he’s making deliberately ridiculous policy proposals in the hope of broadening the Overton Window of policy debate, especially on the right. The most recent example is that he says the U.S. should adopt Singapore-style healthcare.
I don’t want to get into minutiae about whether Singapore’s healthcare model is good or not. Instead, I want to ask whether there are unique features about Singapore that enable it to spend very little on healthcare and get very good results.
Let’s start by thinking about the things that cost money in a healthcare system, from cradle to grave.
Well, cradle-costs are substantial. For many families, pregnancies will be one of the biggest medical bills they ever rack up. So a simple question is: does Singapore have a lot of births?
That’s the average lifetime births per woman in the United States and Singapore. As you can see, Singapore’s birth rate is about 1/3 lower than American birth rates. With fewer infants, fewer births, and thus fewer of the attendant costs (and thus fewer child non-workers to subsidize by transferring costs from working adults), Singapore is able to directly reduce healthcare costs.
Of course, this may be a chicken-egg situation. Douthat claims that Singapore makes patients bear the burden of their healthcare more than than U.S. Maybe the healthcare model is discouraging having kids. That doesn’t seem likely given what I know about Singapore’s other birth-related policies, but maybe!
Either way, the point is that for conservatives like Douthat, the Singapore model is deeply uncomfortable: you make healthcare cheap partly by eliminating a key societal driver of healthcare demand, which is childbirth. Pro-natalists like (given his Catholicism I assume) Douthat should have more than a moment’s pause when considering what Singapore’s healthcare system may cause or depend upon.
In the United States, immigrants are often healthier than natives. There’s debate about why this may be: selection bias of immigration, better foreign-culture eating and exercise habits, different U.S.-based cultural norms in different groups, etc. Whatever the case, it is reasonable to assume more generally that this fact might persist in other countries too: immigrants might have a health bonus over natives. So the immigrant share of the population may have an impact on overall healthiness.
Well, in 2016, about 40% of Singapore’s population was a non-citizen foreigner (I do not have data on hand about foreign-born citizens, if such exist). In the United States, non-citizen foreigners make up about 7% of the population.
If selection bias causes rich countries to get disproportionately healthy, hard-working, driven, conscientious people, then we would expect immigrants in any rich country to be disproportionately healthy. In other words: we might reasonably think about 40% of Singapore’s population has a selection-bias for marginally better health.
If the plan for lowering U.S. healthcare costs is to double or triple the foreign-born share of the population, then immigration restrictionists like Douthat may have a tricky argument facing them.
Singapore is a city state with very specific healthcare needs. For example, sickle-cell anemia is extremely rare in Singapore, thanks to a different ethnic mix. Being a virtually 100% urban country, many “wilderness” diseases are effectively eliminated (though proximity to poorer countries means many travelers contract these diseases). Being tropical of course exposes the population to different diseases, but the point is that an urban environment where the population is all facing similar conditions can yield relatively simple healthcare needs for which a healthcare system can more directly optimize itself.
It especially helps if, for example, your childhood obesity is about 1/2 in Singapore what it is in the US, as appears to be the case. Or if total population obesity rates are 1/3 lower. Or if the prevalence of death due to injury is 1/3 lower. Or if your rate of driving deaths is 2/3 lower. Or if your rate of smoking is 1/3 lower. Or if your per capita alcohol consumption is 2/3 lower.
Now, Douthat might plausibly respond that one of the reasons that Singaporeans are healthier is because their healthcare system puts more burden of their healthcare on them. Okay, fair enough: but Americans aren’t used to that. The delay between smoking and lung cancer is years and years and years; even if we implemented this system, habits wouldn’t change for at least a generation. Is an entire generation of awful habits with high levels of very expensive personal responsibility to pay for those habits really viable? Isn’t the most likely outcome in an American institutional framework that people revolt, that emergency room visits skyrocket, etc? That is, isn’t the basic problem here that you may be able to Make America Singapore, but you will never Make Americans Singaporeans?
I could go on. One reason Singapore spends a low share of income on healthcare is because they are very rich. Adjusted for purchasing price parity, Singapore’s GDP per capita is about $30,000 higher per person than the U.S.’
To be clear, if our GDP was 50–60% bigger, our healthcare spending share would be smaller too. And why is Singapore’s GDP so big?
Well, they’re a fantastically rich urban hub surrounded by an area with relatively free trade and movement. They have very pro-market economic policies. They had special relationships with the West that enabled rapid industrialization.
Oh also they have a massive oil refining sector because nearby Malaysia is a huge oil-producing country.
But hey you know. It’s not like massive oil deposits and 100% urbanization rates ever allowed a country like Norway to artificially juke its states either. Oh wait, that’s exactly what happens. High urbanization plus oil wealth plus even moderately good governance equals incredibly good outcomes every time. You won’t be surprised to learn that Bahrain and Qatar also spends a low share of GDP on healthcare. Among developed, Western countries, which ones spend the least on healthcare as a share of GDP? Luxembourg! Ireland! And among the Nordics, the lowest-spenders are Norway and Iceland: both of which have massive natural resource and energy endowments. For Luxembourg and Ireland, it’s urbanization or GDP-juking via corporate profit reporting.
Singapore’s healthcare system may be the cat’s meow for Singapore, but there is no reason to believe it could function in the United States. Douthat, of course, is broadly aware of this: he views his proposal as deliberately ridiculous, and openly questions whether Americans would accept Singaporean paternalism. Fine. But he fails to notice that’s not the end of the problems. Singapore’s low expenditures are also a product of a fundamentally different population: one that self-selects for healthiness, is culturally and structurally predisposed away from many expense-boosting behaviors, and one that avoids the numerous expenses and subsidies of high rates of childbirth. Plus, their expenses are themselves artificially suppressed by the fact that Singapore has the unique advantage of being a phenomenally wealthy city-state boosted by a local oil refining industry. Maybe if Salt Lake City had oil, Utah could implement SingaporeCare. But it doesn’t, and certainly the US on the whole is incredibly unlike Singapore.
Check out my Podcast about the history of American migration.
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I’m a native of Wilmore, Kentucky, a graduate of Transylvania University, and also the George Washington University’s Elliott School. My real job is as an economist at USDA’s Foreign Agricultural Service, where I analyze and forecast cotton market conditions. I’m married to a kickass Kentucky woman named Ruth.
My posts are not endorsed by and do not in any way represent the opinions of the United States government or any branch, department, agency, or division of it. My writing represents exclusively my own opinions. I did not receive any financial support or remuneration from any party for this research.