Making CareShield Life and long-term disability care more inclusive

Published by TODAY on 9 Sep 2019. See published article.

It has been said that the longest distance to travel in the world is the 12 inches from the head to the heart. I would argue that it may also be that impossible gorge between actuarial science and inclusivity in our national long-term care insurance.

The CareShield Life and Long-Term Care Bill, which was passed in Parliament on 2 September 2019 establishes a mandatory public insurance scheme for long-term care. Its policy intent of being universal and inclusive is admirable. I’m heartened that my concern raised in Parliament for mental health illness to be included in the definition of severe disability has been allayed — that disability assessments will include cognitive impairments, and be based on what the patient actually does rather than what patients can do. Yet significant groups of people are still undervalued or left out in the policy design.

Why start a gender-based policy now?

The Government has explained that the higher premium pricing for women is based on the actuarial assessment that generally women live longer as well as fall into disability and require support for a longer period of time. In other words, for a typical woman, the payouts will last for longer than that for a man hence the differentiated pricing to keep the design and terms of the scheme actuarially consistent. It also says that premiums for ElderShield are also currently gender-differentiated yet ElderShield is run by private insurance companies and not a universal national scheme. (Note: EU’s highest court banned the practice by insurance companies of gender-differentiated premiums in 2011.)

Surely, we must go beyond the actuarial rhetoric. Our social and health policies are not defined along gender lines, so why start now? Men and women receive the same amount of healthcare subsidies and benefits despite the greater susceptibility of women to chronic illness and disabilities. 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. Among women, only 53% were able to reach the Basic Retirement Sum as compared to 66% of men. In the 2018 Labour Force Survey, 80% of family caregivers who are outside the labour force to provide caregiving to relatives/families (this does not include children) are women, all 75,000 of them. They suffer from loss in income, affecting their ability to save for their own retirement and healthcare needs.

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 appears that we are now proposing to further penalise them. I don’t believe this is the kind of social compact we aspire to build.

Article 12 of our Constitution also 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.

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. We are certainly in a position where we can afford to spend slightly more to pave the way for a more equal society, especially if we are concerned that men may not come on board CareShield Life if we make the premiums gender-neutral. It might also be helpful if we know how much more would men have to pay beyond their actuarial assessment and if this increment is significantly material in this actuarial defence.

If we use gender now, what is to stop us from using race and other genetic factors in the future to determine pricing with the advent of precision medicine as challenged by my fellow NMP, Irene Quay? I agree with her because we are opening a Pandora’s Box in social equity. Besides, of the 5 OECD countries that offer national long-term care insurance — Japan, Germany, Luxembourg, Netherlands and South Korea, none opted for premiums to be differentiated by gender. Somehow, they managed to put aside the actuarial science to design the premium pricing by income instead.

Should we not protect our children and young persons who need long-term care?

Studies have estimated that there are around 2,000 children with life-limiting conditions in Singapore, who would potentially be in need of long-term care should they continuously manage to stave off their life-threatening conditions. These children and their families require support for significant long-term care costs, including for hospitalisation, surgery rehabilitation, special aids, among other expenses.

We should consider allowing children and young persons 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. Medisave withdrawals for long-term care should allow all to do so regardless of age.

“Cheaper to be dead than be sick in Singapore” still hangs off the lips of so many ordinary Singaporeans, especially those who struggle to make ends meet, 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 won’t be taken care of by this extensive web of well meaning policies? What is our social compact as a people, and with our government?

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 gender or age should be important guiding principles for a care system in a country which now ranks among the wealthiest in the world. Because surely the head can follow the heart, sometimes.

Anthea Ong is a Nominated Member of Parliament, a social entrepreneur and Author of ’50 Shades of Love’. www.antheaong.com