Making A National Insurance Scheme More Inclusive and Accessible
Parliamentary Speech on CareShield & Long-Term Care Bill, 2 Sep 2019
Introduction
Mr. Speaker, with our ageing population, long-term care support cannot be just a luxury for some; it is a must for all. When our loved ones are cared for well, we enjoy the peace of mind to contribute productively to the economy and country.
However, this Bill must not leave out or undervalue significant groups of people as that would go against its policy intent of being universal and inclusive. Besides urging for a for a critical change in how we define disability as I have in the past, I would also like to highlight the need to better support our younger Singaporeans who may have disabilities or are in need of long-term care, and how the current policies discriminate against women. This Bill can and must go further to strengthen our social fabric and safety nets so that we truly walk the talk of being an inclusive society.
A More Inclusive Definition of Disability: Including Mental Health
The Bill defines “severe disability” as when an individual is unable to perform 3 or more of the following physical activities of daily living or ADLs: washing, dressing, feeding, toileting, walking, transferring. I commend the ElderShield Review Committee in recommending that the impact of cognitive impairments on functional ability be explicitly considered in the disability assessment framework for claims, and am glad that the Ministry of Health has accepted this recommendation.
However, “severe disability” remains too narrowly defined, as it excludes people with mental health conditions. This is especially troubling as the Ministry of Health has announced that in FY2017, we have 12.4% of Singaporeans aged 18–74 who suffer from minor psychiatric morbidity (e.g. anxiety, depression and related disorders), which is estimated to rise to close to 14.0% (or about 315,000 Singaporeans) in FY2019. These are numbers specifically for this age group, and only counts Singaporeans who suffer from minor mental health conditions. According to IMH’s latest nationwide study, “1 in 7 people in Singapore has experienced a mental disorder in their lifetime”. Given the number of Singaporeans who will be affected, there is an urgent need to examine how long-term care costs for people with mental health conditions are supported.
While people with mental health conditions may be able to perform the physical ADLs, our current policies fail to recognise that they may struggle with other ADLs which are just as essential to everyday life. These may include cognitive ADLs like communication or simple problem solving, aspects which are not recognized within our current definition but are captured in internationally-recognised assessment tools like the Functional Independence Measure Instrument (FIM). Furthermore, there is already precedence in our public policy which considers the impact of mental health conditions on daily living, like how the intake assessment for nursing home residents includes aspects of psychiatric conditions, thereby recognising that people with mental health conditions may require support as much as those who have physical disabilities. I therefore urge the government to take a more inclusive approach in the definition of disabilities, both nationally and in this Bill.
To be inclusive, we should ensure our policies and schemes provide coverage and support for long-term care for people with mental health conditions, and we can start doing so with CareShield Life. We should consider how specific mental health conditions that are highly prevalent are recognised and supported by other long-term care schemes, eventually moving to a more universal and explicit recognition of all mental health conditions in our long-term care policies. A critical start could be in how we explicitly consider mental health conditions when defining and assessing disabilities. For instance, we can include assessment of equally critical but non-physical ADLs like cognitive ADLs in functional assessments, or as doctors have advocated for regarding disability assessments, assess and score what patient actually does rather than what patients can do. This important differentiation between capacity and performance is crucial because it is what we do which actually determines care needs, and hence caregiver burden.
Severe Disability — Severe Gap For Non-Severely Disabled?
Currently, multiple schemes ranging from Interim Disability Assistance Scheme for the Elderly (IDAPE), Pioneer Generation Disability Assistance Scheme (PGDas), Foreign Domestic Worker Grant (or its replacement Home Caregiving Grant), Eldershield (or its replacement CareShield Life), Withdrawal of Medisave savings and ElderFund requires “severe disability” in its eligibility criteria for people to benefit from it.
Take an elderly who lives alone in a rental flat, I will call him Marcus who is terminally ill and unable to perform 2 physical ADLs, on top of his mental health condition which affects his cognitive ADLs. Despite his condition, Marcus will not be eligible for this network of schemes designed to support people like him. In the eyes of our system and policies, Marcus will be considered to be moderately disabled rather than severely disabled, and the result is that he will lose out on close to $1,250 worth of support [Assuming that Marcus meets all other eligibility criteria (age, income etc.), he will lose out from benefits provided by a) CareShield Life ($600), b) Home Caregiving Grant ($200), c) Medisave Withdrawals ($200), and d) Elderfund ($250)], which would have been a lifesaver financially, as that would allow him to consider a broader range of options like employing a helper, or engaging private nursing services that will enable him to pass away at home peacefully with dignity as he would have preferred. Instead of enjoying support, Marcus had to agonise over the financial difficulties, which creates stress and anxiety which adds to his mental health condition. For both Marcus (who is already suffering from multiple conditions) and his caregiver, their journey in seeking care and support and his last days were unnecessarily difficult. When we adopt such an extreme definition of severe disability, we inevitably exclude and prevent support from reaching those with more moderate or milder forms of disabilities who are inadequately covered in terms of financial support.
An ongoing research conducted by AWARE of family caregivers reveals that their care recipients who are moderately rather than severely disabled, could spend close to $866 after subsidies (or 22% of their monthly household income) on average on care-related expenses. This is 35% more than what the average household in Singapore spends on similar items, according to data from the 2017/18 Household Expenditure Survey [Department of Statistics Singapore, Report on the Household Expenditure Survey 2017/18. For this calculation, care-related expenses consist of a) Outpatient Services ($172), b) Hospital, Covalescent, and Rehabilitation services ($81.10), c) Land transport services ($174.60), d) Medical products, appliances and equipment ($69.8), and e) Domestic services and household services ($143.4)]. I am concerned how this may affect retirement adequacy of family caregivers, or foster intergenerational transfers of long-term care costs.
To prevent the cliff effect created when many schemes concentrate on severe disability as the eligibility, I urge the government to consider pursuing two areas of improvement.
- First, we can organise existing schemes such that those with less severe forms of disability would still retain eligibility to some of the support schemes so that their needs can be better-met. For example, the criteria for Medisave withdrawal for long-term care needs could be relaxed to allow those with mild disabilities to start withdrawing, while the other schemes continue to have a higher bar.
- Second, we can learn from existing schemes like Medifund and ComCare such that the level of financial support provided is tiered against the extent of care need — which in this case could be approximated by the extent of disability. For instance, CareShield Life payouts can start progressively when one is unable to complete one ADL independently, albeit with a smaller payout. Failing to do so means that CareShield Life in essence acts as a severe disability insurance — rather than the intended long-term care insurance.
In addition to relieving some financial burden, receiving financial resources earlier in a graduated approach may also allow more Singaporeans to better access rehabilitation services that could reduce the worsening of their condition, or even prevent further conditions or disabilities from developing. Furthermore, supporting these families at an earlier stage relieves caregiver stress and anxiety, and allows them to focus on other aspects of life like work, parenting and more. All of these are likely to create downstream cost-savings, and more importantly enhances the well-being of Singaporeans.
An Inclusive Insurance Policy: Regardless of Gender
Mr. Speaker, inclusivity needs to and must extend along the lines of gender. I understand that CareShield Life premiums are gender-differentiated due to actuarial assessments, but our society surely should not be defined by these numbers solely, just like how our other social and health policies are not defined along these lines. Both men and women receive fair and equal treatment regardless of statistical differences — they receive the same amount of healthcare subsidies and benefits despite the greater susceptibility of women to chronic illness and disabilities. This similar treatment for all, regardless of gender, should continue in the payment of CareShield Life premiums especially since the point of insurance, as we know, is to risk-pool.
Women may live longer than men, but they also live with less financial resources. In 2017, the average net CPF balance for females aged 60 years and over was $69,732, which was about 24% lower than that of males. In the same year, about four in 10 active CPF members who turned 55 in 2017 did not hit the Basic Retirement Sum, or BRS, of $83,000 in their Retirement Accounts [Vivienne Wee et al., “Singapore,” in Financial Security of Older Women: Perspectives from Southeast Asia, ed. Susana Concordo Harding, Mary Ann Baquero Geronimo and Supriti Bezbaruah (Singapore: Tsao Foundation, 2018), 192]. Among women, only 53% were able to reach the BRS as compared to 66% of men. [Linette Lai, Minister gives details of CPF retirement payouts, (The Straits Times, Singapore, 2019)]. Every year, many more women than men drop out of the labour force to care for their loved ones. In the 2018 Labour Force Survey, 75,000 women are outside the labour force to provide caregiving to relatives/families (this does not include children) — in other words, 80% of family caregivers who are outside the labour force are women. They suffer from loss in income, affecting their ability to save for their own retirement and healthcare needs.
Moreover, when comparing with international practices, it is helpful to consider how the European Union’s highest court banned the practice by insurance companies of gender-differentiated premiums. An EU Court of Justice Grand Chamber case ruled that multiple EU legal instruments which mandate equal treatment between men and women do not allow for the use of sex as an actuarial factor in differentiating individuals’ premiums and benefits. Article 12 of our Constitution provides that “all persons are equal before the law and entitled to the equal protection of the law”. The government has acknowledged in its latest Convention for Elimination of Discrimination against Women, or CEDAW, state report that the principle of equality for women is entrenched under this Article. Surely then women deserve equal protection and their premiums not be differentiated through actuarial factors.
I believe that designing a mandatory and national long-term care insurance scheme with a framework that discriminates based on gender will set us back a long way in pursuing gender equality. According to the Care Where We Are report by Lien Foundation, Singapore spends only 0.19% of GDP on long-term care compared to the OECD average of 1.7% of GDP. I would like to suggest that we are certainly in a position where we can afford to spend slightly more to pave the way for a more equal society.
We must not forget the unaccounted value of how much women have contributed since the independence of Singapore. Instead of recognising and compensating the vastly unequal amount of unpaid work they do, it may appear that we are now proposing to further penalise them. I believe this is not the kind of social compact we aspire to build.
In a national scheme that aims to meet the needs of all in Singapore, Mr. Speaker, I urge that premiums pricing be made gender-neutral.
A Long-Term Care Strategy That Does Not Discriminate By Age
Let me move from gender to age. Our policies apply to those who are aged 30 and above. While I understand and appreciate the need for these schemes to support our ageing populations, I must ask why do we discriminate against those who are aged below 30 because illnesses and disabilities can hit at any age.
CareShield Life covers pre-existing disabilities for all future cohorts which is laudable. But it leaves a huge gap for those who are severely disabled and requires long-term care support before 30. This is even more so for children who are diagnosed with life-limiting diseases. Studies have estimated that we have around 2,000 children [This study defined children to be between the age of 0 and 19] with life-limiting conditions in Singapore [Poh Heng Chong, What do physicians think about paediatric palliative care? A survey in Singapore, 21(2), (European Journal of Palliative Care , 2014)], who would potentially be in need of long-term care should they continue to stave off the threats on their lives brought by their conditions. My understanding from the ground is that these children and their families face immense long-term care costs, which include but are not limited to: hospitalization, surgery, rehabilitation, special school, special transport, specific aids and machines, specialized milk powder and other consumables. For example, the Enhanced Seniors’ Mobility and Enabling Fund allows for seniors to apply for up to 90% subsidies for consumables like milk and diapers, but no such policy is in place for our young ones who may be similarly disabled, where their families face similar financial pressures for long-term care costs.
Mr. Speaker, we should consider allowing children and youth to be enrolled into this national long-term care insurance, with premiums paid by their parents either through their Medisave accounts, or through government hand-outs like Baby Bonus. Other than CareShield Life, amendments to the CPF Act to allow Medisave withdrawals for long-term care should allow all to do so regardless of age. For children and youth who may not have CPF savings to tap on, we should also extend flexibility in allowing parents to tap on their Medisave accounts to support the long-term care needs for their children. While I understand that we may want to ensure that parents themselves retain adequate CPF savings for their own retirement and healthcare needs, at the end of the day, the money must come from somewhere. If it is not from their CPF Medisave account, it is likely that it has to be out of their own pockets. While we have good social safety nets, we must also consider that many of these schemes take into account the savings and assets possessed by the household. As such, retirement adequacy and savings for healthcare costs in future will remain affected.
Moreover, allowing parents to tap on their CPF Medisave savings for their children is in line with our policy of family as the first line of support. This would also ensure consistency in policy, as current rules allows for parents to pay for the hospital bills of their children using their Medisave savings. In this vein, I am glad to see that the Home Caregiving Grant would not be age-restricted. However, it only provides $200, and given the care needs and costs of our younger ones who may be equally ill or disabled, we ought to ensure that our other schemes support them adequately rather than discriminate against them. It would be sad for us to take good care of our seniors, and forget about our younger generation.
Given the lower prevalence of terminal illness and disability amongst our children and youth, we can afford to provide the same support we do for our seniors but at far less significant budget expansion, and I hope that we will do the right thing and stand in solidarity with all Singaporeans regardless of age.
Accessibility of the Long-Term Care System
Finally, Mr. Speaker, I would like to raise the issue of accessibility to an expanding and extensive web of policies and schemes, especially for the very people we designed them for. The community practitioners who work with vulnerable seniors, differently-abled and low income communities on the ground have spent countless hours trying to grasp the increasing complexity and fragmentation of our health, social and care systems and policies.
In a recent mapping exercise conducted by the Cassia Resettlement Team, they found there are at least a total of 22 schemes (including the new schemes, and excluding those which will be phased out) relevant to Singaporeans with long-term care needs. Most of these schemes have an average of 3 eligibility criteria, and these criteria differ across schemes in terms of age, extent of disability, household monthly income and more. Many of these schemes requires application through a social worker or directly to the relevant government agency, or alternatively requires a disability assessment to be conducted. On the ground, awareness of these schemes is understandably an issue, and the concern will surely be for people who are severely disabled but may not have accessed touchpoints like hospitals or social service offices such that they could be directed to access this web of schemes. Even with the support of these touchpoints, applications often take up significant portions of time for either care-recipients and/or their caregivers, as well as the social service or healthcare professional assigned to support them. The sheer number of schemes, accompanied by the number and variance in eligibility criteria, and amount of supporting documents required for the application, makes it overwhelming and exhausting for all involved. Even with the Silver Generation Office Ambassador’s work, limitations remain, especially in ensuring timely access to these schemes for those who desperately need support.
One of the cases that was shared with me is an elderly Singaporean male, let’s call him Michael, who is married to a foreign spouse and resides in a 1-room rental flat. Michael suffered from global aphasia and a stroke, and he was also diagnosed to suffer a permanent loss of mental capacity, ability to communicate and needed help in all ADLs. When the volunteers met the family after Michael was discharged, they found that the family had insufficient money to put food on the table, and was also struggling to find money for transport to the hospital for the required medical care and proposed rehabilitation services. The subsequent days was a chaotic navigation of our systems for both the family and the volunteers attempting to support them. They alerted, made referrals and continued to work closely with around 10 stakeholders, including the FSC, RC, AIC, SSO, HDB, ICA, CPF (Family Service Centre, Residents’ Committee, Agency for Integrated Care, Social Service Office, Housing & Development Board, Immigration & Checkpoints Authority, Central Provident Fund), the regional hospital, and other service providers. The volunteers had to help facilitate or lodge applications related to Eldershield, Comcare financial assistance, renewal of rental flat tenancy, medical escort & transport services, application to withdraw CPF savings, day rehabilitation services, appeal for higher means-testing subsidy level, respite care services, and extension of the wife’s social visit pass for her to continue as the full-time caregiver. Extensive support was required because the wife was new to Singapore, could not speak English, and had near-zero awareness of any of the available schemes. The entire process was made even more difficult because many of the applications required the doctors to provide their professional input on issues related to mental capacity, functional status, and details on the medical condition. There is often waiting time involved before the next medical appointment for the family to get the required memo from the doctors, and there needs to be extensive coordination and communication with the medical team such that they understand what requires their medical opinion. Michael passed on earlier this year. Without citizenship, his wife and three children moved back to her home country.
I am so very thankful for these community volunteers, Mr Speaker, but it’s clear from Michael’s story and the feedback from these community practitioners that we need to urgently do more in providing care planning, navigation and coordination services. I also urge for more centralisation and consolidation of existing schemes to provide support in a more streamlined manner.
Conclusion
A young taxi driver recently shared how his 87 year-old Ah Gong jumped to his death just outside their flat one morning a few years back, whilst the rest of the family was still having breakfast. They could only speculate that he didn’t want to be a burden to the family because now his widow-ed Ah Ma is talking about ending her own life for the same reasons. The fear of burdening family and friends was also cited by SOS as one of the main reasons for elderly suicide.
“Cheaper to be dead than be sick in Singapore” still hangs off the lips of so many ordinary Singaporeans, especially the elderly and those who struggle to make ends meet. This is despite the commendable strides that we’ve made in our healthcare schemes and policies over the years. What bothers them? What makes them feel like they don’t want to burden their family and won’t be taken care of by their country that they have contributed to? What is our social compact as a people, and with our government?
Mr. Speaker, I used my full 20 minutes because I feel strongly that this Bill tells of the social compact we aspire towards, beyond the technical policy details. While actuarial fairness and sustainability of the schemes are important considerations, we must not forget that public long-term care insurance are often designed on the bedrock of social solidarity. I believe that solidarity with all Singaporeans — regardless of age, gender or extent of disability — should be important guiding principles for a care system in a country which now ranks among the wealthiest in the world.
I look forward to the Minister’s clarifications. Notwithstanding that, I support the Bill. Thank you.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Anthea Ong is a Nominated Member of Parliament. (A Nominated Member of Parliament (NMP) is a Member of the Parliament of Singapore who is appointed by the President. They are not affiliated to any political party and do not represent any constituency. There are currently nine NMPs in Parliament.)
The multi-sector perspective that comes from her ground immersion of 12 years in different capacities helps her translate single-sector issues and ideas across boundaries without alienating any particular community/group. As an entrepreneur and with many years in business leadership, it is innate in her to discuss social issues with the intent of finding solutions, or at least of exploring possibilities. She champions mental health, diversity and inclusion — and volunteerism in Parliament.
She is also an impact entrepreneur/investor and a passionate mental health advocate, especially in workplace wellbeing. She started WorkWell Leaders Workgroup in May 2018 to bring together top leaders (CXOs, Heads of HR/CSR/D&I) of top employers in Singapore (both public and private) to share, discuss and co-create inclusive practices to promote workplace wellbeing. Anthea is also the founder of Hush TeaBar, Singapore’s 1st silent teabar and a social movement that aims to bring silence, self care and social inclusion into every workplace, every community — with a cup of tea. The Hush Experience is completely led by lovingly-trained Deaf facilitators, supported by a team of Persons with Mental Health Issues (PMHIs).
Follow Anthea Ong on her public page at www.facebook.com/antheaonglaytheng