Health insurance in Singapore: who's not included and why?

INTRODUCTION Health insurance and the consequent risk pooling are believed to be essential components of a sustainable healthcare financing system. We sought to determine the profile of Singaporeans who had not procured health insurance over and above MediShield, the national government-spearheaded health insurance program and the factors associated with insurance procurement. METHODS A total of 1,783 respondents were interviewed via telephone and asked to rank their agreement with statements pertaining to healthcare cost, quality and financing on a fivepoint Likert scale. RESULTS Respondents were representative of the general population in terms of ethnicity and housing type, but lower income households were over-represented. Respondents also had a higher education level compared to the general population. Data on 1,510 respondents, with full information on household (HH) income, education and insurance status, was analysed. HH income below S$1,500 per month (odds ratio [OR] is 5.66, 95 percent confidence interval [CI] is 3.9-8.3, p is less than 0.0001) and a secondary education and below (OR is 2.05, 95 percent CI is 1.5-2.8, p is less than 0.0001) were associated with not procuring insurance over and above MediShield coverage. Respondents with insurance were less likely to agree that healthcare was affordable and that the "3M" framework was sufficient to meet healthcare needs. CONCLUSION Singaporeans with a lower HH income and a lower education level were less likely to possess health insurance. This may be related to a stronger belief that healthcare is affordable even without insurance. Educational efforts to encourage the more widespread use of health insurance should be targeted toward lower income groups with less formal education and should be complemented by other interventions to address other aspects of insurance procurement considerations.