CareShield Life and Long-Term Care Bill

Order for Second Reading read.

2.03 pm

The Minister for Health (Mr Gan Kim Yong): Mr Speaker, I beg to move, "That the Bill be now read a second time."

Population ageing is a global phenomenon. For Singapore, the good news is that we are living longer, and many of our seniors live fulfilling and active lives, well into their silver years.

However, ageing also comes with related illnesses and disability. To enable more of our seniors to age well with dignity and purpose, we need to prepare ahead of time. We need to look at how we can better organise social and health care, how we can enable our seniors to stay healthy, age-in-place, and continue to contribute to the community, and how we can support them in their medical and long-term care needs.

We have made significant progress in these areas over the past few years.

In 2015, we implemented MediShield Life to provide universal health coverage, with better protection for all, so that all Singaporeans have peace of mind for their hospitalisation bills, and for life, so that older Singaporeans are covered too, regardless of their age.

That year, we also developed the Action Plan for Successful Ageing with various stakeholders, which now has over 70 initiatives underway to empower our seniors to live well, even as we live longer.

Earlier this year, we announced the Caregiver Support Action Plan to strengthen the support for care-giving for our seniors. These include the Home Caregiving Grant, respite care services, and care-giver empowerment and training.

More recently, we introduced the Merdeka Generation Package, to thank the Merdeka Generation for their contributions to Singapore and provide more support for their healthcare and long-term care needs in their silver years. This follows the Pioneer Generation Package that was introduced in 2014.

One important area we need to address is long-term care financing. In 2016, the ElderShield Review Committee was set up to look into how we can provide greater financial support for Singaporeans who become severely disabled during old age. After rigorous deliberation and extensive public consultation, the Committee submitted its report to the Government last year with the following key recommendations.

First, universal insurance coverage for Singaporeans born in 1980 or later, regardless of their health, disability and financial status, so that our future generations will have basic protection against the costs of long-term care.

Second, higher payouts that increase over time and are for life, so that Singaporeans are better supported for as long as they remain severely disabled; and simpler claim processes, so that severely disabled Singaporeans and their care-givers can apply for claims more conveniently.

The Government accepted the recommendations made by the Committee and the report was debated in Parliament in July last year. We announced our plan to introduce CareShield Life. The risk-pooling approach through the universal insurance coverage for CareShield Life reflects our desire to nurture an inclusive and caring society. I am glad that it had received support from Members of this House. Once again, I would like to thank the Committee for their work.

Financing our long-term care is a shared responsibility. We come together as a society to pool our risks through insurance, CareShield Life and ElderShield, to address the variability of long-term care costs. Individuals and their families also play a part through their own savings; and the Government provides significant support through subsidies and assistance schemes, particularly toward the lower income.

All these three pillars are essential – insurance, savings and Government support – and achieving the right balance among them is crucial in keeping our system inclusive, affordable and sustainable. Therefore, in addition to strengthening insurance, we have concurrently reviewed how other financing sources of long-term care can complement CareShield Life and ElderShield to better support Singaporeans with disability.

We will enhance Government support for long-term care through the establishment of ElderFund in January 2020. ElderFund will be a discretionary Government assistance scheme for low-income, severely disabled Singapore Citizens who are aged 30 and above. It will provide up to $250 per month especially to those who are unable to join CareShield Life, have low MediSave balances and face financial difficulties in meeting their long-term care needs.

This is in addition to existing subsidies of up to 80% for long-term care services, such as nursing homes, and various other Government disability assistance schemes.

Around mid-2020, we will also be extending the use of MediSave by allowing Singaporeans to withdraw cash from their own and spouses' MediSave for their long-term care needs. Severely disabled Singaporeans who are at least 30 years old will be able to make cash withdrawals of up to $200 a month, from their own and their spouses' MediSave Accounts to support their long-term care needs.

This CareShield Life and Long-Term Care Bill provides the legislative framework for the establishment, governance and administration of the CareShield Life Scheme, and also facilitates the implementation of other long-term care financing measures for the severely disabled I mentioned earlier.

Mr Speaker, I shall now highlight the key provisions of the Bill.

First, clause 5 of the Bill provides for the establishment of the CareShield Life Scheme. It provides for the CPF Board to administer CareShield Life and be responsible for the issuance and servicing of the insurance policies, premium collection, payment of benefits and management of the CareShield Life and ElderShield Insurance Fund.

I will talk about the Fund in a short while.

We will also be appointing the Agency for Integrated Care (AIC) as the Administrator. AIC will be responsible for the assessment of an individual’s eligibility for the claim by ascertaining his or her disability status. This division in administrative roles between CPF Board and AIC allows us to tap on the expertise of the respective agencies. In particular, as AIC administers all of MOH's disability schemes, AIC will be the natural touchpoint for seniors. They are best placed to advise disabled seniors and their care-givers on the various forms of long-term care services and financing schemes they can tap on.

Clause 6 of the Bill defines the groups of individuals that will be covered under the CareShield Life Scheme.

In line with our vision for inclusivity, the Scheme will apply to all Singapore Citizens and Permanent Residents born on 1 January 1980 or later. Those who are at least 30 years old will be covered when the Scheme is launched. Subsequent cohorts would be covered on their birthday when they turn 30 years old. This provides universal coverage for future generations of Singaporeans, ensuring CareShield Life coverage for them regardless of their health, pre-existing disability or financial status.

However, the Scheme will be optional for older cohorts of Singapore Citizens and Permanent Residents born in 1979 or earlier, and they can join the Scheme if they do not have pre-existing severe disability. The ElderShield Review Committee had recommended to keep the scheme optional for them because their circumstances and their needs could vary widely.

To encourage participation of younger cohorts of this group, we will auto-enrol those born between 1970 and 1979, who are ElderShield policyholders and are not severely disabled. This makes it more convenient for them to join and they can still choose to opt out before 31 December 2023, if they wish to do so. So, they will be auto-enrolled, but they have the option to opt out of the Scheme and they can do so up to 31 December 2023.

The new CareShield Life Scheme will be launched around mid-2020 for Singaporeans born in 1980 or later, and we aim to progressively launch the Scheme for Singaporeans born in 1979 or earlier, from mid-2021, about a year later.

The Bill also provides for CareShield Life to cover all individuals who become Singapore Citizens or Permanent Residents after the Scheme commences. These are the new Singapore Citizens and Permanent Residents. This way, all new Singapore Citizens and Permanent Residents will participate in this national scheme and benefit from better support for their future long-term care needs, just like all Singapore Citizens and Permanent Residents today. The only exception is if they are born in 1979 or earlier, the older Singapore Citizens and Permanent Residents, and are severely disabled. Like Singapore Citizens and Permanent Residents in those cohorts who are already severely disabled at the launch of CareShield Life, they will also not be able to join the scheme.

Next, let me touch on ElderShield. Part 3 of the Bill provides for Government administration of the ElderShield Scheme. As announced earlier this year, we are transferring the ElderShield scheme, which is currently administered by private insurers, to the Government. This will be done in mid-2021, together with the launch of CareShield Life for older Singaporeans born in 1979 or earlier.

The transfer allows ElderShield to be administered on a not-for-profit basis, with CPF Board and AIC as the Government's key administrators. This will facilitate a smooth upgrading from ElderShield to CareShield Life for those who choose to do so. This Bill will dis-apply the Insurance Act to the transfer, as otherwise the ElderShield portfolios cannot be transferred to the Government because the Government is not included in the definition of "transferee" in the Insurance Act. However, in practice, we will take reference from the requirements MAS has put in place, in governing the transfer to protect policyholders. This includes appointing an independent external auditor to audit the transfer and providing MAS with the full audit reports.

Those who choose not to upgrade to CareShield Life will remain covered by their existing ElderShield policy. I would like to assure ElderShield policyholders that the terms and conditions of their ElderShield policy will remain. In addition, they will also benefit from the improvements to the claim process that will be implemented for CareShield Life.

Now, let me move on to the benefits and payouts of the schemes. CareShield Life and ElderShield will remain as basic schemes to benefit severely disabled policyholders, as provided in clause 12 of the Bill. This keeps premiums affordable, which is crucial for a national scheme like CareShield Life that caters to a broad segment of Singaporeans.

Policyholders who prefer higher coverage or better benefits can buy Supplements from private insurers. Existing Supplements administered by the private insurers will not be transferred to the Government.

Clause 16 of the Bill provides for claims to be made for CareShield Life or ElderShield payouts. We recognise that being severely disabled can be a stressful situation for policyholders and their care-givers. Hence, we want to make the claim process more convenient. To this end, we plan to double the number of disability assessors to about 300 by the launch of CareShield Life, and we are working with healthcare institutions to progressively expand the types of disability assessments that can be accepted for claims, so that policyholders need not undergo another disability assessment if we already have similar data on their disability status.

To further provide convenience to policyholders, Part 8 of the Bill will enable CPF Board and AIC to access an individual’s disability-related health information and allow the information to be disclosed to authorised persons approved by the Minister, for the administration of prescribed public schemes, or provision of support to disabled persons for prescribed purposes. These provisions allow us to proactively reach out to disabled individuals to inform them of their eligibility for claims, not just for CareShield Life and ElderShield, but also for other Government disability schemes, using disability assessments already performed at our healthcare institutions.

These provisions also allow us to access and use disability assessments already done at healthcare institutions to assess the eligibility of those born between 1970 and 1979 for the auto-enrolment exercise into CareShield Life without having to get them to be assessed again.

Nonetheless, individuals can opt-out from the access and disclosure of such disability-related health information, and we will release more details on how individuals can do so nearer the launch date. But I should point out that if they do so, if they do opt out of the access and disclosure, they will lose some convenience. For example, severely disabled individuals will not receive any proactive outreach to apply for claims because we do not know their disability status, and they may need to go for a separate disability assessment even if they had been assessed for disability recently at a healthcare institution. In addition, individuals born between 1970 and 1979 will not be auto-enrolled and may need to go for a disability assessment in order to join CareShield Life.

Part 8 of the Bill also enables CPF Board and AIC to access, subject to certain safeguards, an individual’s confidential information in the possession of another Government department or public authority for the administration of CareShield Life, ElderShield and prescribed social or healthcare-related public schemes. Again, this is meant to increase convenience for policyholders.

The Bill makes the wrongful access, use, or disclosure of any information collected an offence. If convicted, a person may be liable for a fine of up to $5,000, or imprisonment of up to 12 months, or both.

Overall, we want to strike a careful balance between facilitating access and convenience for Singaporeans with the safeguarding of health and confidential information.

Mr Speaker, another key feature of CareShield Life and ElderShield is that payouts will be in cash. This gives claimants the flexibility to decide on their preferred care arrangement, so that they can remain at home or in the community if they wish and still receive the cash payouts. However, it is important that these cash payouts are safeguarded. We will balance between such flexibility and the need for safeguards in several ways.

First, some severely disabled policyholders may lack mental capacity and are unable to manage their cash payouts, or even apply for claims in the first place. In this case, a donee or a deputy can act on their behalf to apply for claims and receive and manage the payouts.

In the absence of a donee or deputy, clause 16 of the Bill allows certain family members or care-givers to be authorised applicants to make claims on behalf of such policyholders, and receive payouts as approved payees so as to support the care of the policyholders.

However, to safeguard against the risk of misuse or fraud, the classes of persons who can make or receive claims will be a tight list approved by the Minister, and generally limited to those who are care-givers for the policyholder. They can only receive the payouts for a limited period of one year, subject to appeals for an extension, if necessary, to give them time to apply to be appointed as a deputy for the policyholder.

Second, we will allow policyholders or their authorised applicants to nominate healthcare institutions caring for the policyholders, such as nursing homes, as approved payees under the Bill. This will ensure the continuity of their care.

Third, we will require third-party payees to first apply the payouts for the policyholder’s care, as provided in clause 50 of the Bill. Not doing so without reasonable excuse is an offence. If convicted, the penalty is double that for the offence of false declarations or wrongful access of information under clause 48 of the Bill, given that these are offences against vulnerable persons. This ensures that payouts are prioritised for the care of the policyholder.

Further, we will protect the payouts from creditors. Clause 20 of the Bill protects CareShield Life and ElderShield payouts from creditors, with two tight exceptions. First, the Bill allows premium debt to be netted off from the payouts, and we will use this only in the case of wilful defaulters who do not pay CareShield Life premiums, but have made claims to benefit from the Scheme. We will do so in a calibrated manner and will cap the amount of debt netted off from the payouts each month to ensure that policyholders will continue to receive the bulk of the payouts to meet their long-term care needs. The second case is where there are monies owed by the policyholder to a healthcare institution, for instance, a nursing home, arising from the care provided to the policyholder, if the policyholder or authorised applicant has already directed the payouts to this institution. This ensures that healthcare institutions providing care to the policyholder can continue to be adequately resourced to do so.

Sir, I will now move on to premiums.

Clause 14 requires that CareShield Life and ElderShield policyholders pay their premiums in a timely manner. This is so that the schemes will remain solvent and sustainable, and to be fair to other policyholders who have dutifully paid their premiums.

For those who need help with their CareShield Life premium payments, we will put in place measures to ensure premiums remain affordable. There will be means-tested premiums subsidies of up to 30% to help lower to middle-income Singaporeans with their premiums. Transitional subsidies will be given to Singapore Citizens born in 1980 or later for the first five years from CareShield Life’s commencement to ease their transition into the Scheme. For Singapore Citizens born in 1979 or earlier, they will be given participation incentives of up to $2,500, if they join CareShield Life in the first two years after the Scheme is available for sign-ups from mid-2021. This is to encourage early participation in the Scheme. In addition, seniors from the Pioneer Generation and Merdeka Generation will receive additional participation incentives of $1,500, so that they receive a total of $4,000 in participation incentives. The participation incentives will be netted off their premiums payable over a period of 10 years, thereby reducing the amount of premiums that the policyholders will need to pay.

Policyholders who need further help with their CareShield Life premiums even after premiums subsidies and support measures can receive Additional Premium Support. This is similar to MediShield Life, and is the Government’s commitment to ensure that premiums remain affordable and that no one loses CareShield Life coverage due to his or her inability to pay.

However, there may be a small group of wilful defaulters who refuse to pay their CareShield Life premiums despite having the means to do so, even after reminders have been sent to them.

Any CareShield Life premiums defaulted that cannot be recovered is a burden that will be shouldered by other policyholders in the form of higher premiums eventually. To be fair to the other policyholders, we need to take a strict stance against these wilful defaulters. Therefore, Part 7 of the Bill provides for a premium recovery framework that is similar to the approach for MediShield Life. Penalties and interest can be imposed on outstanding premiums, and we intend to similarly appoint IRAS as a recovery body to recover outstanding premiums. Let me reiterate that for those who genuinely need help, we will help them with the premium payments.

For ElderShield policyholders who do not pay their premiums, their ElderShield cover will lapse after the grace period, similar to their current terms and conditions.

Premiums collected under CareShield Life and ElderShield will flow into the CareShield Life and ElderShield Insurance Fund that will be established by clause 35 of the Bill. The insurance fund will be a self-sustaining fund, supported by the premium collected under both schemes.

The CareShield Life and ElderShield Insurance Fund will be managed by CPF Board in a not-for-profit manner, for the benefit of policyholders. The Fund moneys can only be used for policyholders’ benefit and scheme administration. The Government or CPF Board as the Fund administrator cannot remove any Fund moneys for its own use, except for the cost of operating the schemes.

Let me now touch on the issue of governance.

I want to assure Singaporeans that there are safeguards in place to ensure proper scheme governance for both CareShield Life and ElderShield. These include safeguards over the scheme parameters and administration, the collection of premiums and payment of claims, and management of information. Let me elaborate.

First, the governance of scheme parameters and administration will be overseen by an independent CareShield Life Council, to be appointed by the Minister under clause 37 of the Bill. The Council will review and make recommendations on policy and scheme parameters, to ensure that the schemes provide protection for Singaporeans in an affordable and sustainable manner. This includes reviewing CareShield Life's premium and payout increases beyond 2025. For the first five years of CareShield Life's implementation, until 2025, both premiums and payouts will increase at 2% per year. Adjustments thereafter will be reviewed by the Council.

In addition, the Council will review the administration of the schemes and advise on matters related to the investment of the CareShield Life and ElderShield Insurance Fund.

The Council will be appointed by the time the CareShield Life Scheme takes effect. It will comprise members with various professional expertise and a wide range of experience to perform the key functions of the Council. We are in the midst of setting up the Council, and will share more information later.

Second, the Bill aims to ensure proper collection of premiums and payment of claims to protect the interest of policyholders. Clauses 48 and 49 of the Bill make false declarations and fraudulent disability assessments offences, with penalties to deter such offences.

As mentioned earlier, the Bill will also enhance the role of personal and family savings, and Government support in helping the severely disabled with their long-term care costs. These measures will help older Singaporeans who are not covered under ElderShield or CareShield Life.

Severely disabled Singapore Citizens and Permanent Residents who are at least 30 years old will be able to make cash withdrawals from their own and their spouses’ MediSave Accounts to support their long-term care needs. Clause 66 of the Bill will amend the CPF Act to allow for this.

To ensure that members have sufficient MediSave balances for other medical treatments, the amount that can be withdrawn for long-term care will be based on their prevailing MediSave balance, and up to $200 a month for each severely disabled individual. These cash withdrawals will supplement the CareShield Life or ElderShield payouts that they may be receiving. This will enhance the role of personal and family savings in supporting long-term care needs.

Like CareShield Life and ElderShield, similar safeguards will be in place for those who lack mental capacity.

Apart from allowing withdrawals from MediSave for long-term care, the Government will also play a part in helping Singaporeans with their cost of long-term care. The Bill provides for the establishment of a Government fund called the Long-term Care Support Fund in clauses 38 and 39. This Fund will be administered by MOH; $5.1 billion will be set aside in this Fund, as announced by the Deputy Prime Minister during Budget 2019. Monies in the Fund will be used to fund premium subsidies and participation incentives for the CareShield Life Scheme and to provide financial support for severely disabled persons under prescribed public schemes, such as Elder Fund, which I mentioned earlier.

ElderFund is a new discretionary Government assistance scheme that will be implemented in January 2020.

The Long-Term Care Support Fund is in addition to existing Government subsidies for long-term care services such as nursing homes, home care and centre-based care services, existing Government assistance schemes, as well as the new Home Caregiving Grant.

I would like to emphasise that the Long-Term Care Support Fund is a completely separate fund from the CareShield Life and ElderShield Insurance Fund. The Long-Term Care Support Fund, or the support fund, holds the $5.1 billion of Government monies and is used to provide Government support, while the CareShield Life and ElderShield Insurance Fund – we call the insurance fund – holds the premium monies collected and are used for CareShield Life and ElderShield payouts and expenses. So, just to repeat, the support fund holds the Government funding to help the Scheme through premium subsidies and so on, whereas the insurance fund holds the monies from premium payments which is used to fund payouts from the schemes. So, the two Funds are separate. Both Funds will be accounted for and managed separately and the accounts of each Fund will be made public.

Mr Speaker, let me conclude. Our society is ageing and we need to prepare for this ahead of time. CareShield Life is a major step in expanding the role of insurance in the long-term care financing landscape. But the CareShield Life and Long-Term Care Bill goes beyond long-term care insurance. The Bill also enables enhancements to be made to the other two pillars of our long-term care financing system through the withdrawal of MediSave for long-term care and ElderFund. With the strengthening of the roles of insurance, savings and Government assistance, Singaporeans can have better protection and greater assurance for their long-term care needs. This way, Singaporeans can live long and with greater peace of mind. Mr Speaker, I beg to move.

Question proposed.

2.32 pm

Dr Chia Shi-Lu (Tanjong Pagar): Mr Speaker, Sir, I stand in support of the Bill, and my views are essentially unchanged from those I expressed during the debate on CashShield Life in this very House in July last year.

I thank the Ministry for accepting most of the recommendations that were put forward by the Government Parliamentary Committee (GPC) for Health in our paper on Enhancing ElderShield, which was presented to Minister Gan Kim Yong in January last year. I am also reassured by some of the additional provisions in this Bill, such as ElderFund, which seek to strengthen the framework of long-term care in Singapore, because although CareShield Life aims for universal coverage, there are necessarily some situations where it is not scoped to address.

But now that we are here at the business end of things, I have several clarifications for the Minister:

CareShield Life will be mandatory for all Singaporeans born in 1980 and later, but will be optional for those who are born earlier. I understand that enrolling older Singaporeans into the expanded benefits schedule of CareShield Life would be costly, but would the Government consider further measures to financially support older cohorts to encourage them to either enrol or switch over from ElderShield to CareShield Life?

And how will the Government support older Singaporeans who are unable or unwilling to enrol in CareShield Life, should they become significantly disabled in the future? For instance, how can disbursements from the soon to be established ElderFund be calibrated to support these disabled seniors and will payouts from ElderFund be also adjusted according to medical and cost of living inflation.

To quote from the GPC's recommendations on CareShield Life, we noted that, and I quote, "a careful balance has to be struck between increasing and expanding benefits so that the programme remains relevant and useful, and yet keeping the scheme both affordable and sustainable for the long term.

If ElderShield is to be universal with mandatory enrollment, then the GPC believes that the Government will have to provide targeted financial assistance to ensure that all Singaporeans will be able to participate in this social security programme, which is designed to increase peace of mind in the event of severe disability."

Hence, I would appreciate clarifications from the Ministry as to how it intends to maintain premium affordability for CareShield Life, while ensuring that Singaporeans are suitably buffered against rising long-term care costs, particularly when they are only either mildly or moderately disabled and thus requiring financial support?

What are the criteria for granting additional premium support?

I note that the Minister just mentioned that the criteria would be the same as for MediShield Life Additional Premium Support. But my question is should the criteria be the same, given the fact that the operational circumstances for CareShield Life and MediShield Life are fundamentally different?

The GPC also supports that Supplemental Plans from Private Insurers continue to be offered for CareShield Life and I am glad that a mechanism is built to provide for that as it was the case for ElderShield. This will certainly grant flexibility and meet the needs of Singaporeans who feel that they would be willing to purchase additional coverage.

Would the Ministry be able to comment whether private insurers will indeed be prepared to provide such Supplements for additional coverage for CareShield Life, and whether Singaporeans will be able to use their MediSave to purchase or to cover such additional coverage?

I would also like to ask if the Ministry is aware of any of the private insurers is currently planning to introduce a Supplement whereby, perhaps, payouts can be activated at a lower threshold, specifically when a policyholder has two instead of three affected ADLs. This was the feedback that has come up here and there, and there were questions on why three instead of two ADLs. The GPC actually felt that there could be scope for private insurers to meet these gaps. And if not, what are the reasons that this is not being considered by the private insurers?

Finally, I have several clarifications regarding the administration of CareShield Life itself. I am happy that the Ministry is taking steps to facilitate functional assessments in regard to qualification for payouts. There has been some feedback in the past about the claims process for ElderShield, that the pool of disability evaluators was limited and the process of evaluation and re-evaluation was both onerous and unwieldy. For instance, there was feedback that for claimants, the requirements for re-evaluation could be too frequent.

So, I would appreciate clarifications regarding how the claims process for CareShield has indeed been streamlined, while at the same time I would also like to know how we can guard against fraudulent claims and ensure that the payouts actually reach their intended targets.

The proposed introduction of a National Electronic Health Records system and, of course, the recent incidents of data leaks and hacks, notably the hacking of SingHealth's IT system have thrown the issue of data integrity and security into sharp focus.

And so I would like to ask how would the administrators of CareShield Life safeguard policyholder data that is being collected and also that is being used for the purposes of the scheme?

The GPC has acknowledged in our paper that there were concerns regarding the adequacy of payouts, related to uncertainties regarding the pace of cost of living increases and also medical inflation. Thus, we had urged that the quantum of payout be reviewed at fixed intervals, and revised according to a formula that takes into account both general consumer and medical inflation. We had further proposed that there be a framework for periodic review of the premiums, to ensure that the scheme remains both sustainable and affordable.

The Minister has touched briefly on how this would be done but I would like to understand a little bit better as to exactly how and how often, does the Ministry intend to review and adjust payouts and premiums.

In concluding, I would like to ask the Ministry to what degree information will be released to the public regarding the administration of CareShield Life, and whether the Ministry would be transparent about how the fund is managed and how the premiums are priced and how payouts are disbursed. For instance, in the early years of ElderShield, it was found that claims were in fact below what was essentially projected, and rebates were, of course, duly given back to policyholders as a result. This should certainly be happy news to policyholders at that time, but it also led to questions about whether the premiums and calculations were in fact overly conservative, and secondarily, whether this could have led to excessive profits gained by the private insurers who were then underwriting the scheme.

I look forward to the clarifications from the Ministry and I support the Bill.

2.40 pm

Dr Lily Neo (Jalan Besar): Mr Speaker, Sir, I stand in support of the CareShield Life and Long-Term Care Bill. This Bill is timely because one in two healthy Singaporeans aged 65 today could become severely disabled later in their lifetime; family units are becoming smaller; life expectancy is increasing; and population is rapidly ageing.

I view the CareShield Life and Long-Term Care Bill as the finishing piece of an encompassing "medical safety net" that includes the CHAS, MediShield Life and MediFund. This Bill has its good points but also some minus points in several areas which I shall elaborate.

I shall start with this Bill’s plus points.

One, the lifetime pay-out is welcome as severely disabled individuals require life-long assistance with their daily living.

Two, the setting-up of the Long-Term Care Support Fund (LTCSF) which sets aside monies for premium subsidies and incentives, capital injection and other public schemes that provide support for disabled persons. This fund will ensure that the CareShield life premiums will be affordable for the majority. May I ask the Minister if there are any postulation calculations done on the amount required for subsidies and long-term care support and how long will the $5.1 billion last to serve its intended purpose?

Three, those eligible severely handicapped presently will receive CareShield Life payout immediately for life after paying their first premium. It is rightly so that we can show benevolence to this group of Singaporeans with this immediate payout.

I consider the following as minus points for this Bill.

One, the monthly payout of $600 is inadequate for severely handicapped individuals in long-term care basic costs. While I can understand that higher payout will require higher premiums, the purpose of insurance is to give peace of mind on future unforeseen needs. In view of its inadequacy, there is a need to depend on personal savings or family help should the need arises. For better piece of mind and coverage, individuals can take extra insurance for higher payouts with private insurers. May I ask Minister whether Government can administer these "riders" for those who want better payouts, rather than dependence on profit-orientated private insurers?

On MediSave withdrawals for Long-Term Care of $200 per month for the severely disabled who are above 30 years old and subject to a minimum MediSave balance of $5,000, can they tap their children’s or siblings’ MediSave once their own MediSave have been exhausted?

New assistance scheme from 2020 will provide lower income Singaporeans who are severely disabled and need additional support for Long-Term Care costs of up to $250 per month. May I ask Minister what is the income eligibility for this assistance scheme? May I also ask whether they are still eligible for this assistance if they are tapping on their MediSave accounts or on their home care-giving grants of $200 per month in lieu of Foreign Domestic Worker Grant?

For Pioneers, can they also receive this assistance on top of the $100 per month PG Disability Assistance Scheme and the use of MediSave of $200 per month?

May I ask Minister whether the Home Caregiving grant of $200 can be made less onerous in its criteria of disbursement, such that, the assessment requirement can be done by applicants’ own doctors, instead of stipulated stringent assessors, for convenience and easier access? Can the criteria be made less stringent, for example with two ADLs instead of three ADLs to qualify?

Two, the three ADLs criterion for CareShield Life eligibility claim is challenging. While I agree that there will be a lot more claimants with two ADLs instead of three ADLs, thus resulting in higher premiums, my contention is that many, if not all, afflicted with two ADLs cannot continue to work as before. They would need to depend on personal savings or family members. Thus, better awareness on long-term care financing and long-term care insurance should be raised so that people can better plan ahead for possible eventualities.

Three, claimants of CareShield Life payouts must go through the stringent assessment by stipulated assessors. May I how many of such assessors are available presently and how many more will be required going forward? May I ask how often are claimants required to go through assessments to enjoy confirmed payouts? Will Minister exempt those newly discharged from hospitals from assessment by stipulated assessors once specified by their own public hospital doctors to be having three ADLs? Can public doctors looking after their own patients endorse the three ADLs, since they know their patients well? This will greatly convenience the claimants.

Will the Minister consider setting up a one-stop assistance channel or centre for mobility afflicted Singaporeans to tap on the various available schemes – for example, patients on discharge from hospitals can be assisted to claim for Home Caregiving Grant, MediSave withdrawal, Elderfund, Pioneer Generation Disability Scheme, Senior Mobility Fund, ADAPE and so on? The reason is that many Singaporeans do not know the various schemes available or how to apply for them. This is especially useful and convenient for those low-income patients who are already applying Medifund to pay for their hospital bills. They have already given all the eligibility information to hospitals for Medifund assistance.

Will the Minister make it easier for relevant Ministries to share information, so that claimants do not need to submit the same documents multiple times for various subsidies? Many seniors with three ADLs living in the community will also benefit from the one-stop assistance channel for referrals to various Ministries to claim insurance or to apply for subsidies. Will the Minister assist in identifying and facilitating this group of Singaporeans?

Sir, many Singaporeans shared that they would prefer to live at home with their families as they grow old. Home care is an important component of Long-Term Care services. It is a good alternative to institutional care setting for many reasons. But our home care in Singapore is presently inadequate. This is worrying with our fast-ageing population and the fast increasing need of home care. May I ask Minister how does he plan to expand and better equip on the availability of home care?

May I request Minister to prioritize home care for seniors, especially those living alone at HDB rental flats? The number of Singaporeans aged 65 and above living alone, or with their spouse but without children, has grown by more than 50% from 2010 to 2015 or from 94,000 to 148,400. This number may increase in future. Could Minister expand home care quickly with the tenets of prevention of further deterioration of physical frailty and mental disorder such as depression? Ageing Gracefully at Home programme at Chin Swee supported by Agency of Integrated Care (AIC) is a good home care programme. This home care provides the seniors living alone at HDB rental flats with medical, social and daily needs, nursing care, mental wellness and so on.

I hope MOH will continue to support this programme and to expand it to other constituencies. This home care programme emphasizes on prevention of further deterioration of medical conditions or frequent visits to hospitals.

We also need to expand other home care programmes for complex long-term care needs in the community. I hope Minister can look into the requirement and supply of personnel for such home care as soon as possible to expand this sector. This will facilitate many Singaporeans to age gracefully with their loved ones in the comfort of their own homes.

2.50 pm

Mr Png Eng Huat (Hougang): Mr Speaker, anyone who has aged parents or loved ones to look after would know that providing long-term care for the elderly, especially those who need help with Activities of Daily Living (ADLs), is a very daunting task. In a small family environment, the burden of care for the elderly would fall squarely on one or two members of household. For a family with no children, such burden would exacerbate rapidly when the couple grows old and neither one of them is able to care for one or the other.

At our Meet-the-People Sessions, we would have heard stories of the struggles and challenges faced by our residents in looking after the elderly, while trying to raise a family of their own and having to make ends meet all at the same time.

We heard in this Chamber last year that this Government intends to focus on building an inclusive society where no Singaporeans, young or old, healthy or sick, gets left behind. The CareShield Life and Long-Term Care Bill is a step in that direction.

In the debate on the motion on ElderShield and CareShield Life in the middle of 2018, the Workers' Party Members spoke in support for the rationale to strengthen our social safety net for the long-term care needs of Singaporeans. CareShield Life, as the Minister had stated then, would be a basic protection scheme for Singaporeans against severe disability during their old age and the scheme would be inclusive, affordable and sustainable.

On the point of inclusivity, I would like to ask the Minister what would happen to the fate of Singaporeans who are currently disabled, mild or severe, when CareShield Life kicks in?

Under Clause 6 Subsection (4)(b) of the proposed bill, the CPF Board may determine that an individual who is severely disabled currently may be covered under CareShield Life, but only if the individual satisfies such conditions as may be determined by the Minister in any particular case where the Minister considers appropriate. Such case by case basis assessment at the sole discretion of the Minister does not provide any assurance that CareShield Life is going to be inclusive for Singaporeans who need the basic protection most. And what about Singaporeans who are unable to do one or two out of three ADLs currently? Would they be able to enrol into CareShield Life or be assisted by Elderfund only as highlighted by the Minister earlier?

Sir, there are also Singaporeans who withdrew from ElderShield not by choice but by the fact that they had nothing left in their MediSave accounts to service the premiums and they had no ability to pay the premiums in cash. I happy to note that the Minister will find ways to enrol these vulnerable Singaporeans into CareShield Life since the scheme is going to be made compulsory for all over time.

Next, on the point of affordability, I would like to ask the Minister to share with the House on the impact of the introduction of CareShield Life on the adequacy of the MediSave accounts for future cohort of Singaporeans who would be enrolled into the compulsory scheme upon attaining the age of 30.

Take the case a young father who is servicing the MediShield Life premiums for his children and himself, and perhaps, even his spouse, using his MediSave account. Would this person have enough in his MediSave account to pay for CareShield Life as well or when the transitional subsidies for the scheme expires?

The affordability of CareShield Life needs to be considered in context with MediShield Life, since both schemes are made compulsory for Singaporeans. Is there any impact study done on the adequacy of the MediSave accounts of our young working class Singaporeans with the introduction of such mandatory insurance schemes?

On the same issue of affordability, may I ask the Minister again, are the premium calculations for CareShield Life heavily influenced by the MOH estimates that one in two Singaporeans aged 65 and above could become severely disabled in their lifetime? If we were to strip away the international data from the MOH estimates, how would the percentage look like?

Sir, the international data cited by the Minister that 52% of Americans turning 65 in 2016 would develop a disability serious enough to require long-term care – does not even apply in the context of CareShield Life as these people may not even qualify to claim under the scheme unless they cannot do three out of six ADLs. Would the Minister not agree that, using data that may not even trigger a claim under the proposed scheme to help calculate the corresponding premium to pay for an insured person would not be meaningful to begin with?

So, in the interest of transparency on the affordability and sustainability of the scheme, would the Minister be able to publish a brief of the factors and assumptions made in the premium pricing model for CareShield Life? The Senior Minister of State had mentioned some of these factors in passing his speech on the subject last year. Factors such as the disability mortality rate, recovery rate, disability incidence and risk profile for various cohorts, to name a few, are important information for the public, not just to determine whether Singaporeans are being charged baseline premiums or way above it, but to spur them to make informed choices to live healthy.

Mr Speaker, this Government should also see considerable savings in the administration cost for CareShield Life when it takes over the respective pool of insured persons from the three private ElderShield insurers. What is the projected savings from this exercise and did the Ministry work this savings into the premium calculations? And what would be the projected profit and loss for the CareShield Life scheme under the sole administration of the CPF Board assisted by AIC?

Although this is a not-for-profit insurance scheme, it does not mean that there is no profit generated. I am sure the Ministry would have crunched the numbers in the run-up to the introduction of CareShield Life. It is in the public interest that the Ministry should release such information. I am also sure that the Ministry can easily illustrate the technical details of the actuarial model for CareShield Life in simple graphics or something easy for the general public to digest.

2.57 pm

Prof Fatimah Lateef (Marine Parade): Mr Speaker, the Organization for Economic Cooperation and Development (OECD) defines long-term care as "the care for persons needing support in multiple facets of living over a prolonged period of time". Sustainable long-term care requires the following three elements: first, financing; second, delivery and this is where we need the three "Cs" – capacity, capability and coordination; and thirdly, regulation of some form.

In many countries today, the distribution of care is shared between the public, private and people sectors. In Singapore, co-sharing between the Government, the individual and the family; and it is a model that we are quite used to.

Essentially the following four modes of funding are utilised for healthcare: (a) Government subsidies in different forms; (b) MediSave; (c) Basic healthcare insurance, which is our Medishield Life; and (d) Medifund for those who really cannot afford and have no other sources of assistance.

For long-term care, ElderShield is the scheme and now, with migration to CareShield. The demands for long-term care will increase significantly with the ageing population, the coming of age of our baby boomers and of course, the population and others who may develop complications of chronic illnesses which we have a lot of. Financing will always put a high demand on governments on various platforms. In this aspect, I have a few queries and clarifications pertaining to the Bill.

Firstly, starting off with a fundamental question. The CareShield Life Scheme, which is a migration from the ElderShield, is compulsory for all citizens and PRs of Singapore born on or after 1 January 1980 and are at least 30 years of age. Can the Minister explain on the decision and rationale for the cut off at 30 years? There is because, with ElderShield, we earlier saw that it started at 40 years. This is a difference of 10 years and it would be useful for us to understand the difference of 10 years and why we are starting a lot earlier with CareShield Life. From a medical perspective, I can certainly understand that, but, perhaps, maybe from a financial perspective and an administrative perspective, we can get a better understanding of this.

Secondly, what happens with a person who is eligible for CareShield Life but lives or works long-term overseas? What type of processes do they have to go through? Can the Minister also outline the steps and requirements for those who are alone and in nursing homes and for those with no next-of-kin support? Pertaining to the disability assessment, on what grounds can the assessment fees be waived? Are there steps or application forms, that the applicants will have to pay for such waiver? Please also review the process and make sure that it is simple enough because many of them can be illiterate or they may not be able to understand what is being asked. They may not even have next-of-kin.

On the same matter of assessment, some of these people with disability are still in the process of review. That means that disability has not reached a stable stage and they will need regular review in our healthcare institutions to make sure that it is not progressing further.

The Minister did mention that we can have data obtained from our healthcare institutions for those people who need regular reviews, but then, again, is this sufficient or would they have to pay every time they need to have an assessment done by one of the appointed assessors? So, that part is something that most elderly, those with disability and members who have disabled in their families are concerned about.

One new change is that, with effect from 2020, there is a possibility of withdrawal of $2,400 per year from the MediSave Account, subject to having a minimum of $5,000 in the account. The Minister did mention that patients or the disabled person himself as well as the spouse's account can be used. How about parents, siblings and children's accounts? Can these also be tapped on because I think most family members would want to support the disabled member in their family?

Can I also ask the Minister on: what are our plans moving forwards, for long-term care at home? We can do so much more in this area, which is an option besides institutionalisation. What kind of further support at home, in terms of training, respite for care-givers at home who need a break from the care-giving process – are we able to assist families with?

Also, on the issue of capacity, even in the step-down care area, whether it is at home or in institutions, how are we planning to cope with the supply of manpower? Today alone, we are highly dependent on foreign nursing and care-giving workforce in this area. So, how sustainable is this and what are the supplementation and injections we are planning, moving forward?

Finally, with the definition of disability in this Bill, it does not really categorically cover mental and psychological incapacity and disability. We know that for people who have very severe psychological or psychiatric problems, they may not even be able to perform their activities of daily living (ADL). Therefore, perhaps, there is also a need to review and align this with MSF and other Ministries and see how we can assist these families as well, because the number of people with psychological disability and severe forms of psychological and psychiatric disabilities are increasing and bound to increase further.

There has been some issues raised about the number of activities of daily living (ADL) that we can actually include under our consideration for certain schemes, whether it is one, two, three or four. Perhaps, I would like to urge the Ministry to consider, even for people who have less than three, perhaps two activities of daily living (ADL) that they cannot fulfil, perhaps, we can give them a case-by-case consideration because, in considering ADL, it is a spectrum. It can be from the most minor to the more severe. Therefore, perhaps, for those with two disabilities, but they are relatively severe, at the most severe end of the spectrum, we could consider giving them the assistance or enrolling them in the scheme as well. Sir, in Malay.

(In Malay): [Please refer to Vernacular Speech.] In 2016, the WHO stated that long-term quality care is related to two factors; first, the type of care provided and, second, the lack of integration between different healthcare services.

Therefore, I would like to ask the Minister whether we can focus on these aspects in the forward planning for this sector because this sector is a very important one.

Until today, although there are many schemes administered by the Government and the Ministry, in terms of long-term care, many people are still unfamiliar or unsure about what these schemes are. So, even more messages, educational information and advertisements are needed. Therefore, we had to conduct more dialogue sessions and discussions, such as case studies, where we can show our families, especially those from the low-income groups, how to obtain assistance from the good schemes made available by our Ministry.

CareShield is a scheme that can provide help to families and the amount is not insubstantial because it starts at $600 per month and will increase gradually. Therefore, if we know how to make use of this assistance, we should use the grants and scheme for our needs as well as our families' needs, because the expenditure for long-term healthcare is certainly high.

Finally, I would like to ask the Minister, in Budget 2019, it was announced that $5.1 billion will be provided for the Long-Term Care Support Fund. How long is this amount expected to last to meet the needs of Singaporeans? On that note, I support this Bill.

3.05 pm

Miss Cheryl Chan Wei Ling (Fengshan): Mr Speaker, I stand in support of the Bill. When a friend of mine turned 40, she received a letter informing about the ElderShield scheme. She shared some thoughts that crossed her mind when she first saw the letter. Soon, CareShield Life (CSHL) scheme will be compulsory for those turning 30. I can imagine what many at that age would be thinking as they read the collaterals. Why the need for such scheme at this age? They are healthy, have an active income and ageing is certainly a distant concept for them. But, what many fail to think of is health issues can take many forms and impact anyone regardless of age, in particular, when one suffers disabilities as a result of illness or become mentally incapacitated. The real challenge is what happens if one is not financially prepared or does not have the means to take care of themselves in the long term. This burden inevitably falls on the family and not on themselves.

Take dementia as a classic example. Dementia does not impact only the elderly. One can be physically normal, not disabled, but simply fails to get about their daily activities once dementia sets in. I came across a resident who, unfortunately, suffered dementia at the age of 52. Fifty-two years old in today's context is not old age, especially not so given the longer life expectancy. However, this resident who had dementia will have to depend on another person to manage his daily activities for the rest of his life. Having to care for him not only raise concerns about the cost of care on the long run, but also whom in the family would become the primary care-giver from then on.

In other encounters with people who needed long-term care, it is those children or youths who are born with physical disabilities or lack the mental capacity to care for themselves. Parents that I met with children of special needs are genuinely concerned. The parents are worried that if they themselves grow older, physically and financially taking care of their children will become a significant task. It is a worry they grapple with constantly. What more can they do to have a peace of mind that their children will not be left to fend for themselves when they are unable to care for them in the long run. Thus, I believe the CareShield Life and Long-Term Care fund will play a pivotal role in bridging at least some aspects of the care-giving.

While the Bill provides details around the implementation and governance of the funds in the interest of the beneficiaries, I wish to raise a few areas for consideration and some questions for further clarification.

First, for those who are automatically covered under CareShield Life from 2021 onwards, is there a concurrent requirement for them to also apply for the Lasting Power of Attorney (LPA)? Whilst the financial aspect of their care-giving may be taken care of through CareShield Life, but if they do not have an LPA in place, in the event that they become unable to make decisions for themselves, there presents a risk that their family members will have to fork out additional legal fees to act on their behalf. While clause 16 provides option for the family members to act on their behalf if a donee or a deputy is not in place, but would it not be better if they have a LPA from the onset of joining the scheme? This would mean less likely a potential lapse in their coverage if the family is unable to afford the legal fees.

Second, under clause 6(b), it specifies that for all Singaporeans and Permanent Residents born before 1980 who are not severely disabled before becoming citizens or PRs will automatically qualify for CareShield Life. I would like to ask if the Ministry can consider including coverage for all individuals in this age group, who by birth, have physical disability and/or lack the mental capacity to function in their daily activities. This group of individuals in Singapore are not the bulk of the population. However, a universal insurance coverage of this nature will form a necessary and central support for them and, financially, it is more manageable for their families.

Earlier in the speech, the Minister just mentioned about the Long-term Care Fund that will provide them the access to their own MediSave or that of their spouses. But we should also be cognisant that these individuals may unlikely to have worked by that age or they might not even have sufficient funds in their CPF to have this coverage and may not even have a spouse or a spouse who have that fund to help them.

Third, when a compulsory insurance scheme is implemented, it is understandable for low-income families to be anxious about whether they can reasonably afford the annual premiums. Since details of the premiums are not yet announced by MOH, can the Minister share how and what may be done to address the concerns of these low-income families, as the CareShield Life premium adds on to other premiums like MediShield Life that the individuals must afford.

Fourth, for schemes that look into the long-term needs of individuals, it is judicious for strong governance process to be established. This Bill addresses several aspects and clause 50 seeks to focus on preventing the misuse of funds. However, clause 20 does indemnify the healthcare institutions or service providers to those with disabilities, wherein they can have access to their patients' funds after providing the service. On this note, I hope more clarity can be offered if any audit process will be instituted to verify the sums charged by the healthcare institutions or service providers are within affordable range. Also, that their services rendered are duly monitored to ensure the vulnerable is receiving proper care, especially if the vulnerable does not have a next-of-kin.

Fifth, when the need arises for an assessment of an individual's condition of disabilities, it is stated that the charges will be based on per type of disability assessed. Will the Ministry then provide the public with a reference cost range for each disability assessment service and are there any requirements that prevents an individual from being fully assessed by the same doctor for all conditions on activities of daily living (ADL)?

And lastly, apart from those who are turning 30 and would be automatically enrolled in CareShield Life scheme, there are Merdekas whose age is between 60 to 65 that hope to enrol for CareShield Life as well. Can the Minister provide more information on how the Merdekas can enrol for CareShield Life and what are the criteria for them to qualify if they had previously opted out of the ElderShield scheme?

Sir, having these long-term care scheme and funds are a progressive step forward in ensuring that our population will have a safety net. It is pertinent that we implement the schemes well and provide reprieve for families who may face untimely and unfortunate health conditions in any of their family members. I look forward to more details on the scheme and clarifications on the points raised.

3.12 pm

Mr Leon Perera (Non-Constituency Member): Mr Speaker, Sir, I declare my interest as the CEO of an international research consultancy that undertakes studies in the field of products and services for the elderly, among other industries.

Sir, the CareShield Life and Long-term Care Bill seeks to establish the CareShield Life scheme and the ElderShield scheme under Government administration to provide long-term care financing support for severely disabled persons. The Bill also amends the CPF Act to make provisions for CPF withdrawals for long-term care. Most of the key provisions for this Bill were debated in this House last year as part of the debate on the White Paper expressing recommendations for the ElderShield Review Committee.

Subsequent to that debate in the House last year, the Government announced the ElderShield scheme will be administered by the Government from 2021 and not-for-profit basis. The insurers will transfer to the Government the liabilities and corresponding assets backing these liabilities to for all policies under the ElderShield scheme.

During Budget 2019, Deputy Prime Minister Heng Swee Keat announced that a total of $5.1 billion will be earmarked for the Long-term Care Support Fund.The Bill also establishes this Fund.

Sir, all these changes are steps in the right direction. Worker's Party Members debated most of these provisions in the House last year and supported the general move towards risk-pooling for financing elder disability while raising a number of questions and suggestions. I shall make a number of points at this stage to reiterate the views we had expressed earlier.

Firstly, we reiterate our call that premium should be set at equal levels for men and women as the advantage of sending the signal of gender equality in major public policy formation are ways to disadvantages explained by the Government.

Secondly, will the Government publish the actuarial model behind the setting of premiums such that Singaporeans can assess these assumptions and can be aware of how these assumptions track against future realities as the years go back. This kind of transparency will ensure greater public buy-in by providing some assurance that premiums have not been set at too high a level that will tend to over reserve funds that may either need to be disbursed by way of future premium rebates or which may be retained for the benefit of future cohorts. Such transparency will also pre-empt the spread of misinformation and ill-informed speculation about the CareShield Life scheme, as Member Mr Pritam Singh argued last year.

Thirdly, will transparent policy guidelines be given to the CareShield Life Council to determine the extent to which excess funds, if any, are to be disbursed via premium rebates as opposed to reserving those funds for future cohorts so that the system can be seen to be inter-generationally fair?

The ElderShield Review Committee Report in the context of the existing Eldershield scheme states that the premium rebate as a feature that provides for the three insurers that administer ElderShield return 50% for the accumulated surplus to existing ElderShield policyholders, if the actual claims experience turns out to be better than what was projected. Premium rebates are considered once every five years. CareShield's acceptance would benefit from similarly transparent guidelines binding on the CareShield Life Council rather than the Council simply having discretion to make such decision and inform the public after the fact.

Fourthly, will the Government consider reducing the onerous three ADLs test to two ADLs test using the Long-term Care Fund to administer premium subsidies to defray and defer increment hikes that may be necessitated by this change.

Next, moving on from points made in the 2018 debate in this House, I would like to raise several new points and questions.

Firstly, holders of ElderShield supplements will continue to be served by their existing ElderShield supplement insurers. Does the Government envisage that a competitive CareShield LIfe supplement scheme market will emerge providing competitive premiums and supplements in exchange for higher or less onerously determined payouts? And, if so, are there any steps being taken to facilitate this?

Secondly, clause 15 states that in the event of premium rebates been given, refunds for grant will be recovered. Just to clarify the mechanism for this – does this mean that if the state has provided the grant to reduce the premium and future premium rebate is given to that CareShield Life policyholder, the grant plus interest will be deducted from the premium rebate and returned to the Long-term Care Fund?

And, lastly, because the changes to this Bill concretise the optimum effects of our ageing society, we should work towards the creation of a vibrant eco-system that supports many different pathways for the rising number of Singaporeans embarking on their ageing journey. In the past, the mantra for ageing was that the family members should take care of their elderly, but with our demographic pyramid looking the way it does now, where the ratio of younger people supporting elderly people in more or less every family is much lower than it was, say, 30 years ago, it is no longer possible to view the question of an ageing society solely through the prism of family responsibility alone.

What would such a vibrant eco-system look like? It should, of course, include employment for those who want to continue to work. This group has the right to employment opportunities unscarred by the stigma of ageism. And it should include social support for high levels of activity and social engagement for all older Singaporeans, whether working or not. The eco-system we strive for should include strong capacity for institutionalised care in nursing homes and step-down care facilities to provide care at harmonised and high levels of quality, not to mention elder-friendly facilities in existing and new HDB flats where some progress has been made. It should include pathways for ageing in place – home-care and day-care should be widely available geographically, with a variety of providers offering an environment that is competitive and rich in variety and experimentation.

Fifthly, it should include options for assisted living. Facilities which allow a high degree of autonomy for residents, with shared activity programmes, round-the-clock medical support available on demand, and proximate mixed facilities catering to various age groups so that older Singaporeans do not feel cut-off.

How does the system living differ from nursing homes? Please allow me to quote a short passage from Atul Gawande's moving book "Being Mortal", where he talked about one of the founders of assisted living Keren Brown Wilson in the US state of Oregon in 1980 in a concept she championed. I quote, "The services were in most ways identical to the services that nursing homes provide, but here the care-providers understood they were entering someone else's home and that changed the power relations fundamentally. Her philosophy was to provide a place where residents retained their autonomy and privacy of people living in their own homes including the right to refuse strictures imposed for reasons of safety or institutional convenience."

For all pathways, financial assistance should be available that is means-tested and also automatically inflation-indexed based on inflation trends and fiscal resources. Facilities catering to a range of budget should be nurtured. The Korean Silver Town model, which I have spoken about in this House, includes a range of facilities, offering different prices and the different degrees of government support from government-run facilities to purely private profit-driven facilities. The facilities in such an eco-system should be provided by companies, not-for-profit VWOs and where necessary government agencies. Not all Eldercare services should be provided by or paid for by the government.

Where fiscal cost is required, it should be seen in the context of not providing such assistance. It could lead to elderly people living alone, becoming cut-off and gaining access to medical services only when it is too late when catastrophic conditions set in, for example. And this could have amount to a far greater drain on the state's coffers downstream in terms of hospital subsidies, MediShield Life, premium subsidies, Medifund disbursements and so on.

The cost of providing financial assistance should also be seen in the context of the opportunity cost of not providing it. If older Singaporeans lack help to age with purpose and dignity, we could lose out in the vital role of elderly Singaporeans as contributors to the workforce and to the economy as employees, entrepreneurs and customers. Let us not forget the significance of older Singaporeans as role models, mentors, counsellors and care-givers, even when not working. When elderly Singaporeans cannot afford to leave the house because he or she cannot afford a mobility device, for example, he may be unable to work, he may be unable to be a customer for a neighbourhood business, he may be unable to help his family.

As we move towards a future where one in four Singaporeans will be aged over 65, let us strive for successful ageing, both for older Singaporeans and those of us not yet old.

Having said this, I have a few questions and suggestions regarding our whole-of-society approach towards successful ageing, that is of indirect but nevertheless unmistakable relevance to the concerns that underlie this Bill.

Firstly, what is the progress towards launching assisted living facilities? It seems that other countries are far ahead of Singapore in this respect to the concept dates back to the 1980s. During the COS Debate this year, Minister Lawrence Wong said "typically, in such assisted living apartments, there will be more communal and shared spaces for residents to interact with each other. As the assisted living model is new, we will conduct focus group discussions to seek views on the proposed concept for assisted living in public housing. We will take in feedback and views from the discussions and I am sure seniors will welcome such an option where the model will be sustainable for the service providers. We will work towards a launch for an assisted living pilot site for public housing in Bukit Batok next year."

Sir, the assisted living model is new to Singapore but far from new abroad. In advanced countries like Finland and Japan, assisted living facilities (ALFs) are growing faster than nursing homes. A 2016 survey by the Lien Foundation and Income found that nearly 50% of almost 1,000 respondents were willing to stay in ALFs. I would urge the Government to accelerate the launch of new sites. Assisted living at its best and to be sure not existing ALFs in the world present that best, by any means, but at its best, assisted living promises to marry autonomy with good quality medical care and social connectedness. It could be a key pillar for successful ageing. In building this pillar, we have the opportunity to work with local enterprises and start-ups to develop know-how in operating ALFs in the Southeast Asian cultural context. Know-how that could be exported to the region in future – where ageing is a major challenge in countries like Thailand and Malaysia – to the benefit of our economy.

And, secondly and lastly, eldercare is a field that has seen a good deal of innovation through the application of technology and new business models to increase choice, reduce cost and raise productivity. In fact, productivity is a key challenge for this traditionally labour-intensive sector. Social robotics, wearable technology and other innovations are being used in the eldercare sector globally including in some countries in the region like Japan, Korea and China. What efforts are being made by the Government and non-governmental players to study these innovations and aim to bring them to Singapore by way of engagement with companies and not-for-profits, both at home and abroad.

3.24 pm

Assoc Prof Walter Theseira (Nominated Member): Mr Speaker, Sir, in 1994, Prof William Kissick defined the set of three trade-offs that any health care system faces: cost, access and quality. We all want a health system that is low-cost, grants timely access to all who need care and ensures that healthcare is of high quality. But all three at once is impossible to achieve, so we need to choose between difficult trade-offs.

We have, by international standards, solved the health system problem better than most. In 2000, the World Health Organization ranked Singapore sixth in the world in overall health system performance. Because this ranking was so controversial – the United States ranked 37th behind all the Western European countries – the WHO has never updated the ranking since. But if you look at more up-to-date figures we are doing well. The most recent WHO World Health Statistics 2019 reported that Singaporeans enjoy a healthy life expectancy at birth of 76.2 years – the best in the world. We also have a correspondingly high total life expectancy at birth of 82.9 years. And our healthcare is delivered efficiently. Health expenditure as a percentage of GDP was 4.5% – in the bottom quartile of countries worldwide by expenditure.

But there are still gaps. The CareShield Life and Long-Term Care Bill will create a universal, prefunded long-term care insurance plan, at least for younger cohorts. Because CareShield Life is universal and will be supported by subsidies for low-income Singaporeans, I believe this will provide genuinely universal access to long-term care if we become severely disabled. A mandatory universal plan is particularly important because the likelihood that we will become severely disabled is quite high. As the ElderShield Review Committee Report states, one in two Singaporeans aged 62 today could become severely disabled within their lifetime.

So, CareShield is not really an insurance scheme in the sense of protecting Singaporeans against a low risk, high cost event. It is really a pre-funding scheme for care needs that are part and parcel of old age. The mandatory nature of CareShield Life will ensure that no Singaporean – or their families – will be in desperate want for financial assistance to cope with care needs in old age. Cost effectiveness and quality will also be important, but they will have to be addressed another day.

I wish to examine how we propose to use the MediSave system to pre-fund CareShield Life and what the implications are for our broader health care financing system.

Sir, at the risk of exaggeration, let me suggest the chief concern among many Singaporeans if they were to get sick is how they will manage their medical expenses. This is ironic, given our excellent health outcomes and our comprehensive medical financing system. Our top healthy life expectancy ranking worldwide is surely not a sign of a people who cannot afford quality healthcare. But it is not so difficult to understand once we appreciate that a fundamental policy lever we have used to manage the cost, access and quality trade-off is to emphasise individual responsibility whenever possible. It appears Singaporeans have internalised this policy principle of individual responsibility quite well. And individual responsibility has been made practical through our MediSave medical savings scheme which gives Singaporeans a nest-egg to spend on their future medical needs.

Mr Goh Chok Tong, then Second Minister for Health, said in the debate on the MediSave Scheme in 1983, and I quote: “We must therefore save when we can, put a few dollars aside every month when we are working, save as an individual, save as a nation. This is the basic idea of MediSave – to provide funds for our citizens to pay for their future health needs, for them to buy an umbrella when it rains; and even before it rains.”

But MediSave has a policy objective that extends beyond pre-funding. If the policy problem was only pre-funding for future healthcare costs alone, it would not matter whether MediSave was collected as individual accounts or whether the Government created an endowment fund for future healthcare spending. The policy objective of MediSave was also to encourage efficiency in healthcare utilisation. MediSave achieved this by giving each Singaporean an individual financial stake in their healthcare decision-making.

Mr Lee Kuan Yew, in the book, "Lee Kuan Yew: Hard Truths to Keep Singapore Going", said of MediSave, "My major objective in the early days was to make sure that nobody derails the idea of having individual accounts for CPF and MediSave. Whatever you earn, it is yours. It is yours and if you don't use it, you can leave it to your children or relatives or whoever you like. Why should you put it into a common pool and everybody draws out at your expense, which is what is happening in some Western countries. The system has collapsed."

As in many other matters, Mr Lee was prescient. I suspect many Members dealing with appeals from constituents feel that the problem with individual accounts is holding the line against requests to use MediSave for all types of personal medical and other expenses.

Since 1983, there have been dozens of Parliamentary Questions and "cuts" that appeal for the use of MediSave to be extended to many non-hospitalisation healthcare expenses. For example, when Mdm President was a Member in this House, she filed cuts in the Budget 2006 debate to call for greater flexibility in the use of MediSave, particularly for long-term chronic illnesses. The Government has generally held the line, although MediSave's scope has generally been expanded.

In isolation, I think holding firm to the policy is admirable provided that Singaporeans who appeal to access their MediSave funds are given other means of financial assistance. But if you were to read Mr Lee’s statement on MediSave carefully, you will see that the other problem with individual accounts is holding the line against the Government itself. The risk is that policymakers will appropriate the funds in MediSave to finance healthcare expenditures on a universal basis, or indeed, meet any other healthcare expenditure need.

Sir, we have expended considerable effort to ensure that individuals cannot use their MediSave as they please, because we want to protect them against the risk of exhausting their medical savings prematurely. Yet the same discipline that the population is expected to exercise in using MediSave wisely, must also apply to the policymaker. The policymaker has tended increasingly to see the MediSave account as a convenient source of healthcare financing. And why should she not? As of the first quarter of 2019, the CPF Board reported that aggregate MediSave balances stood at $97 billion dollars, or about $25,000 on average, per CPF member's account. This is enough to fund the operating expenses of MOH for about 10 years.

What will be the impact of CareShield Life on our MediSave system? The illustration given in the ElderShield Review Committee report states that total estimated premiums, paid from age 30 to 67, for a non-subsidised 30-year-old male policyholder, will be about $11,300. If you take this as a lump sum premium, this would amount to nearly half of the aggregate MediSave balances currently existing.

Of course, the plan is for CareShield Life to be funded over the decades, through premium payments amounting to a few percentage points of a member's monthly MediSave contribution. But the total amount collected under CareShield Life – and paid out – will be staggering over the next few decades, just as the sums collected and paid out for MediShield Life have been.

The problem I have outlined goes beyond just the creation of schemes such as MediShield Life and CareShield Life, which have greatly improved access to healthcare. The MediSave account has become a source of funds that the policymaker can use to adjust the balance of subsidies in healthcare financing. As average balances in MediSave increase, it will become more feasible to propose higher basic rates of coverage in MediShield Life, and in CareShield Life, with the accompanying higher premiums. Hospitalisation and long-term care subsidies as well, can be adjusted if MediSave balances are robust.

The ElderShield Review Committee report states that the Government today plans to subsidise about 60% of the cost of nursing home care for a lower middle income severely disabled Singaporean. But of course, this subsidy level could fall in the future if CareShield Life payouts became more generous. I think there is nothing sinister in this. It is just a matter of whether payment is taken through the MediSave pocket or the taxpayers' pocket. But we may come to a point where we can reasonably ask if the individual ownership of the MediSave account remains a meaningful policy principle.

Mr Speaker, Sir, a hallmark of this Government is the willingness to solve problems pragmatically rather than ideologically. I respect this principle tremendously, but as we adapt our healthcare policies to address the challenges of an ageing society, we should take a hard look at some of the ideological principles behind healthcare financing. I would urge that we examine carefully our assumption that individual responsibility through paying from MediSave and cash, actually reduces moral hazard – the excess consumption of healthcare.

As a matter of health economics, this is an empirical and not a theoretical question. It is true in theory that when healthcare coverage is provided free at the point of treatment, there will be increased demand and over-consumption. But the extent and magnitude of these effects are not settled, and the policy question is often too narrowly framed as one of medical cost management only. An array of studies from healthcare insurance coverage experiments in the United States suggests that other social outcomes matter as well, such as financial and psychological stress, and early detection and management of chronic diseases.

Second, I would urge that we also recognise that the MediSave account must be protected from the policymaker, just as it must be protected from the account owner. The issue, I think, is not the misuse or abuse of MediSave funds. I am quite sure that this Government poses no such risk. The issue, rather, is the use of MediSave to alter how healthcare financing is structured without a full and frank examination of how we should be balancing payments between pre-funding and current payments, between the individual and the taxpayer. CareShield Life, while a great innovation that will substantially increase access to long-term care, has changed the structure of healthcare financing in Singapore. We should not let this policy decision pass unexamined. Mr Speaker, I support the Bill.

Mr Speaker: Mr Yee Chia Hsing.

3.36 pm

Mr Yee Chia Hsing (Chua Chu Kang): Mr Speaker, Sir, sickness and death comes to all. Old age too, but only to those who are lucky enough to see old age.

This Bill establishes and provides for the CareShield Life scheme and other measures to provide for long-term care financing support for severely disabled persons. CareShield Life will feature higher payouts that increase over time with no cap on payout duration, to provide better protection and assurance against the uncertainty of long-term care costs if a person becomes severely disabled.

Over the recent years, I noted that both MOH and CPF have allowed more flexibility on the withdrawal of CPF funds to assist with the care needs of the elderly or disabled as well as provide additional assistance for their maintenance.

I applaud the move to allow cash withdrawals of up to $200 per month from MediSave accounts to pay for expenses for the severely disabled. This allows greater flexibility for those who may have informal care arrangements. CPF members can also apply to withdraw their CPF savings on medical grounds.

I would also like to acknowledge the designation of the Agency for Integrated Care (AIC) as a one-stop agency to assist families on matters relating to our seniors. The work of the AIC is wide and diverse and often very difficult. These include coordinating the work of the Silver Generation Office to assigning subsidised nursing home vacancies and assessing the need for motorised wheelchairs.

One aspect which I especially like to highlight is the provision of a monthly cash grant of $120 to families which need to hire a foreign domestic worker to take care of a family member who requires permanent assistance with three or more activities of daily living.

Mr Speaker, Sir, while much has been done to help families which need to take care of their elderly, I would think that families that need to hire a foreign domestic worker or put their parents in a nursing home will still face substantial financial pressure. While CareShield Life addresses this problem going forward, as Singapore citizens and Permanent Residents born in 1980 or later automatically join this scheme in 2020, most of the elderly today are not even enrolled in ElderShield and thus have very little financial support when it comes to their long-term care needs.

As such, I hope MOH can do more to help this group. As our population ages and long-term care costs continue to rise, we will face increasing challenges to tackle these issues in the future. I noted that the ElderFund will be set up to provide cash payouts of up to $250 per month but this is unlikely to be sufficient for the hiring of a foreign domestic worker or to put an elderly in a nursing home.

Over the past few years, we have seen the introduction of the Pioneer Generation and Merdeka Generation packages which are cohort-based and not means-tested. It is my suggestion that if the Government should have sufficient fiscal surplus in future, it should move away from cohort-based packages, to set up a long-term care package which will provide low to middle income families with additional assistance to take care of their elderly. Mr Speaker, Sir, I support the Bill.

Mr Speaker: Ms Anthea Ong.

3.40 pm

Ms Anthea Ong (Nominated Member): 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 also 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.

The Bill defines "severe disability" as when an individual is unable to perform three or more of the following physical activities of daily living (ADLs): washing, dressing, feeding, toileting, walking and 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 MOH has accepted this recommendation.

However, "severe disability" remains too narrowly defined, as it excludes people with mental health conditions. This is especially troubling as MOH has announced that in FY2017, we have 12.4% of Singaporeans aged 18-74 who suffer from minor psychiatric morbidity, for example, anxiety, depression and related disorders, which is estimated to rise to close to 14%, 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, "One in seven 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 recognised 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 care-giver burden.

Currently, multiple schemes ranging from Interim Disability Assistance Schemes for Elderly (IDAPE), Pioneer Generation Disability Assistance scheme, Foreign Domestic Worker Grant or its replacement, Home Caregiving Grant, ElderShield or its replacement CareShield Life, withdrawal of MediSave savings and ElderFund require severe disabilities 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. He is terminally ill and unable to perform two 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, 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 care-giver, 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 on-going research conducted by AWARE of family care-givers 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 2017/2018 Household Expenditure Survey. I am concerned how this may affect retirement adequacy of family care-givers, or foster inter-generational 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 care-giver 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.

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 be continued 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 above 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. Among women, only 53% were able to reach the BRS as compared to 66% of men. 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 care-giving to relatives and families. This does not include children. In other words, 80% of family care-givers 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 therefore 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.

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 population, 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 with life-limiting conditions in Singapore, 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: hospitalisation, surgery, rehabilitation, special school, special transport, specific aids and machines, specialised 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 allow 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.

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 three 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 care-givers, 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 the amount of supporting documents required for the application, makes it overwhelming and exhausting for all involved. Even with the Silver Generation Office Ambassadors' 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 us 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, 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 and transport services, application to withdraw CPF savings, and extension of the wife’s social visit pass for her to continue as the full-time care-giver. 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. Michael passed on earlier this year. Without citizenship, his wife and his three children moved back to her home country.

Mr Speaker: Can you wrap up in the next few seconds?

Ms Anthea Ong: Yes, I am just finishing up. It is clear 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.

Mr Speaker, I used my full 20 minutes because I feel strongly —

Mr Speaker: Any more?

Ms Anthea Ong: Yes, I know. Thank you for that. I feel strongly that this Bill tells of the social compact we aspire towards, beyond the technical policy details. "Cheaper to be dead than to 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.

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 of 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. Thank you, Mr Speaker, for your indulgence.

Mr Speaker: Mr Chen Show Mao.

4.02 pm

Mr Chen Show Mao (Aljunied): (In Mandarin): [Please refer to Vernacular Speech.] Mr Speaker, in helping Singaporeans prepare for long-term care, the CareShield Life Bill that is being discussed today is a step in the right direction.

People say that you have children to prepare for old age. In Singapore today, just depending on our children for old age is not enough. In future, as the population ages, preparing for old age will be increasingly challenging. Last year, during the Parliamentary debate on the CareShield Life Committee Report, I said that the programme itself is self-sustaining but the implementation details need to be actively planned out. For example, how do we assist those who cannot afford the premiums and include them in the programme, so that no one is not left behind? The Bill tabled today has addressed this.

Mr Speaker, why do I say that the CareShield Life Bill is a step in the right direction? What is the right direction for our social policies? What is our vision?

There is an ancient saying that in great harmony the aged are provided for till their end, the disabled are cared for and people treat each other like their own kin. By pooling risks we are able to pool resources together to assist the elderly and the disabled who are unable to care for themselves. By pooling risks we can pay relatively low and affordable premiums to get comparatively high and meaningful payouts when needed.

The Bill today has provided a partial framework that is feasible and reasonable for our vision to care for the aged and disabled. But aside from the Bill, the entire package should be carefully planned out. For example, if an elderly is unable to carry out three out of six daily activities due to old age, stroke or dementia, including bathing, taking medicine, changing, going to the toilet, moving around and moving from bed to chair or to a wheelchair, they can file claims and they will be able to receive $600 in cash every month for the rest of their lives to pay for long-term care until they are fully recovered.

However, Mr Speaker, how much can $600 buy in terms of life-term care – be it home care, full-time domestic helper, nursing homes, community day-care or other arrangements? If you have $600 in your pocket, do you have enough suitable options? Are the fees affordable for those who require long-term care? Mr Speaker, Sir, that is why I say that we can move another step forward.

Mr Speaker: Order. I propose to take a break now. I suspend the Sitting and will take the Chair at 4.25 pm.

Sitting accordingly suspended

at 4.06 pm until 4.25 pm.

Sitting resumed at 4.25 pm

[Deputy Speaker (Mr Lim Biow Chuan) in the Chair]

CareShield Life and Long-Term Care Bill

Debate resumed.

Ms Jessica Tan Soon Neo (East Coast): Mr Deputy Speaker, disability can occur at any time to anyone, young or old. None of us can anticipate when we could be hit by a sudden illness or sustain an injury that could affect our ability to go about essential daily activities and to work. If we are not financially prepared, this will have serious impact on our life and our families. While we would not wish for anyone to be severely disabled, we cannot predict when and who it will impact.

I have a resident who in his early 40s suffered a stroke. He was severely disabled as a result of the stroke. Before the stroke, he was gainfully employed and the dual income that he and his wife made was more than sufficient to comfortably support his family and their three young children. Not only has the stroke rendered him unable to be work, he needs to be assisted in his daily living activities. His wife’s single income is now supporting his on-going care needs as well as their children. His family does also receive financial assistance. However, financing his on-going care needs as well as supporting their family's expenses has been and continues to be financially challenging for his wife and the children. If he had had coverage similar with benefits like CareShield Life, while it would not cover all the cost required for him, the monthly payout of $600 a month for as long as he is severely disabled would have provided some financial relief.

I have also had several residents seek financial assistance for the long-term care needs of their parents who become severely disabled and need to stay in a nursing home. For some in the lower middle-income group, even with Government subsidies they still have to pay about a $1,000 a month for their parent's nursing home care. For middle income families that do not qualify from Government subsidies, the cost is a few thousands monthly. I have witnessed many families that are not financially prepared for such expenses and face difficulty in making these payments. If their parents had coverage for the disability similar to that of CareShield Life, the monthly payout would help alleviate some of the cost.

I am supportive of the Bill to provide long-term care financing support for severely disabled persons, but I do have some clarifications and feedback on CareShield Life and Long-Term Care.

The Bills seeks to make CareShield Life compulsory for those born on or after 1980 and those 30 years old on or after 2020. Those in this age group are in their 30s to 40s and are at the stage of their life when they have many responsibilities and financial demands, for example, if they are married and have children, they would need to support their young families, pay the mortgages on their homes. They may also have to take care of an aged parent.

As enrollment into CareShield Life is compulsory and not an option for this group, how can they be assured that CareShield Life Premiums are fair and competitive as compared to premiums of other similar insurance covered by private entities? With the scheme being compulsory, the risk pool will be large and it would be expected that premiums will be affordable. What assurance is there for Singaporeans that premiums will be kept low and affordable? As it has been stated that payouts will increase about 2% each year to adjust for the higher cost of long-term care in future, premiums will be expected to increase in tandem. So, will the transitional subsidies and means-tested subsidies be sufficient to keep premiums affordable?

Can MOH assure them that for our people and these age group that taking on long term care coverage at a young age, that they would be better off than delaying that to a later time? Given that the various healthcare coverage plans and schemes that are already in place, more information should also be shared to show how CareShield Life complements and is not a duplication. Feedback from the ground, is that there are so many schemes and eligibility criteria for these schemes and understanding the various schemes and objectives can be quite confusing.

While MediSave funds can be used to make payment for CareShield Life premiums, with the changing employment trends and disruption in jobs and employments, income contributions to MediSave may be affected. This may impact ability to make payout for CareShield Life and other premiums like MediShield Life and Integrated Shield Plans. So, what are the implications if an individual loses his job and will his coverage lapse, if he is unable to pay for his CareShield Life premiums? What help, if any, can he get to assist him during this period when there is disruption?

In terms of qualifying for payouts and disability assessment, the First Schedule in the Bill outlines the definition of a person with severe disability to be his or her inability to perform three of the six Activities of Daily Living (ADLs) set out for CareShield Life. Feedback, as we have heard from many other Members in this Chamber, is that the criteria for at least three ADLs may be somewhat strict. But, regardless, when one is already in the unfortunate position of being afflicted with disability, what help will there be to ensure that the process for disability assessment and eligibility will not be onerous? For those with two ADLs on the CareShield Life scheme, who do participate in the CareShield Life Scheme and they are not eligible for the claim payouts when they do get disabled, do they need to continue to pay future premiums for CareShield Life if they are unable to work or to continue to work? This will affect their ability to afford premiums in the future if they are already unable to do the two ADLs. Could Minister share how this group would be treated if they do have ADLs but are not able to qualify for the payouts?

For older Singaporeans born in 1979 or earlier, CareShield Life is not compulsory and they have a choice to decide on whether they wish to participate. I am going to ask some operational and procedural or practical questions with regard to CareShield Life. Can MOH share how and when this cohort of older Singaporeans will be informed of the details of eligibility and the amount of premium they need to pay to participate in CareShield Life, if they choose to do so? The reason why I am asking is that, during the briefings that I conducted with our Merdeka Generation (MG) seniors, it was quite interesting because many expressed interest to participate in CareShield Life. They do, however, need to have more information to help them understand CareShield Life, most importantly to assess if they can afford it and how to participate. Some of the MG seniors I met – unfortunately, I have to say this – but many that I met were not sure whether they are on the ElderShield or not, because they said "I do not know whether I opted in or whether I opted out". So, they do need some help to also check on that.

I do want to take the opportunity at this point to also give feedback because the information online with regard to CareShield Life has been actually quite comprehensive. At the same time, the Online Calculator for CareShield Life premiums is very easy to use and very simple. The only problem is you need to have certain information, like whether you have ElderShield or not. So, for some of our seniors, they could answer all the other questions except that, so they could not estimate. I think these are very practical but important matters that I hope more clarity can be provided to our seniors soon.

With regard to the definition of disability, I also want to touch on the point of mental health condition because CareShield Life's definition of severe disability today is based on the Activities for Daily Living (ADLs) with emphasis on physical disabilities. How will mental health conditions and dementia, for example, be assessed? Mental illness and dementia can significantly impair cognitive and behavioural functioning and interfere with normal activities and relationships. These can be as disabling as any other physical disabilities. Dementia and mental illnesses are sometimes called invisible disabilities and may impact an individual's ability to do essential daily activities. So, I hope that we can look at how mental illness and conditions like dementia could be treated or would be assessed together with the ADLs.

Based on the report on "The Burden of Disease in Singapore between 1990 to 2017", Singapore faces a challenge shared by many developed countries. While life expectancy has increased, the number of years that is spent in poor health has not decreased. Lifestyle and habits increase the risk of disabilities. The leading risk factors affecting health in Singapore in 2017 were dietary risks, tobacco, high blood pressure and high blood sugar. The leading causes of Years Lived with Disability (LYD) in Singapore were musculoskeletal disorders, mental disorders, unintentional injuries and neurological disorders.

So, it is important that we leverage on the data that we have on our healthcare trends, assess the risks together and also encourage regular health screening as I believe that this will help support early detection and enable appropriate and timely interventions. This may help mitigate some of the risks of severe disability associated with chronic diseases and enable Singaporeans to live better quality lives. Mr Deputy Speaker, notwithstanding my clarifications and comments, I support the Bill.

4.31 pm

Ms Joan Pereira (Tanjong Pagar): Mr Deputy Speaker, Sir, the establishment of the CareShield Life Scheme and the ElderShield Scheme under Government administration is an excellent and necessary move. We can expect the centralisation of expertise in the management of the schemes to yield the benefits of economies of scale, consistency and reduce running costs. The schemes are intended to provide long-term care financing support for severely disabled persons. With our rapidly ageing population and longer lifespans, many of our frail elderly will tap upon this assistance towards the end of their lives.

The Bill also seeks to establish the Long-Term Care Support Fund (LTCSF). MOF had announced in March this year that the $5.1 billion fund will provide Government support for CareShield Life premiums and support various long-term care financing schemes for disabled persons, such as ElderFund.

May I ask the Minister about the eligibility criteria for LTCSF and measures to increase publicity and awareness of this scheme? My concern is that some elderly and their families may not be aware of such assistance and do not know how to apply for help. We need to reach out to this group of vulnerable Singaporeans.

Next, I would like to comment on a related amendment to the CPF Act, which is to make provision for MediSave withdrawals for long-term care for severely disabled persons. I would like to ask if this would be sustainable in view of longer lifespans as well as shrinking family sizes with more and more elderly depending on fewer younger family members. Would this result in the latter's MediSave being depleted, leaving them little for their own use when they themselves become older? Sir, in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] I would like to ask about the eligibility criteria for the Long-Term Care Assistance Fund and its publicity measures. The department in charge must ensure that vulnerable Singaporeans know how to apply for assistance.

Another concern for me is that MediSave can be used to pay for long-term care for people with severe disabilities. As life expectancies increase and family sizes shrink, would the younger generation's MediSave accounts be depleted such that they would not be able to tap into the funds in their own old age?

(In English): I am also concerned about the security of personal data in MOH's electronic databases. Would the Minister share an update on the measures to fortify protection of this information?

Finally, may I take this opportunity to ask the Minister to consider allowing popular non-generic drugs to be subsidised. For those commonly reported to be more effective than their generic cousins, please kindly review the demand for these drugs and consider subsidising them. I would like to conclude with my support for the Bill.

4.39 pm

Er Dr Lee Bee Wah (Nee Soon): Mr Deputy Speaker, Sir, the average lifespan of Singaporeans is on the rise. According to a study by the Institute for Health Metrics and Evaluation, average lifespan would be 85.4 years in 2040. But the number of years spent in poor health would also correspondingly increase. The Government has been enhancing policies and investing in resources to promote active, healthy living among Singaporeans. This should help to prolong the duration of healthy years. On this note, I would like to thank HPB for bringing in all kind of exercises – Zumba Gold, stretchband, yoga and so on – free of charge to our community, all the parks, pavilions and condominiums. The residents not just keep themselves healthy; in the process, they also improve their bonding. I have residents who go to exercise and later they arrange overseas trips together – one-day Batam trips, three-day Malacca trips and so on.

Nevertheless, chronic health and mobility problems are inevitable for most who are in old age. It is important, therefore, for one to be self-sufficient. This is especially so when one is retired or unable to work.

Looking at current global trends, more people are likely to stay single or choose not to have children. So, relying on the younger generations for financial support is not always an option. In fact, those who have children would typically not wish to burden them. Hence, we have CareShield Life to help Singaporeans to be self-sufficient with the support from the Government. Moreover, it is not only the elderly who may find themselves with mobility impairment. Younger people, too, may require long-term care due to illness or accidents. Hence, it is a good move to have citizens and permanent residents automatically enrolled into the scheme once they reach 30 years old.

I note that those born before 1970 will not be automatically enrolled and those born from 1970 to 1979 are only automatically enrolled under certain conditions.

My question is: how many would not qualify for automatic enrolment and how would we get them onboard? This is quite worrying because some within this group would be those who do not have ElderShield or any form of insurance coverage. There are additional subsidies for Pioneer Generation and Merdeka Generation citizens. However, I have spoken to older residents and they are unmoved by the subsidies. They are retired or do not have a full-time job and the idea of having to commit a sum of money each month to an intangible concept is daunting to them.

Unfortunately, many healthy, mobile people have the "it will never happen to me" mentality. So, they do not see the necessity of making a small investment to insure themselves against possible severe disability. In fact, there is a sizeable percentage of young people, adults included, who still do not understand how MediShield works. And they would only call up CPF to ask for clarifications when they are hospitalised.

So, when one does not understand the full benefits of a scheme, they are far less likely to put faith and their money in it. We have to go beyond subsidies to encourage a wider take-up rate. Otherwise, the people who stand to benefit most from the scheme will be left out. Thus, hopefully, the Ministry would have some education campaign to reach out to this group to explain the different schemes so that people fully understand the schemes and they can reap the benefits when they need them. In Chinese, please.

(In Mandarin): [Please refer to Vernacular Speech.] CareShield Life will look after people with disabilities. However, those born before 1970 will not be automatically enrolled and those born from 1970 to 1979 are only automatically enrolled under certain conditions. How do we encourage these people to join this scheme?

Although there are additional subsidies for Pioneer Generation and Merdeka Generation citizens, however, many citizens told me that they are retired and there is no need to commit a sum of money each month to prevent something that is unlikely to happen. They also do not know whether they will be eligible for claims even if they, indeed, develop some kind of disability.

In addition to subsidies, I urge the Government to do more public education so that people know the benefits of this scheme and more Singaporeans will be protected.

4.45 pm

Ms Irene Quay Siew Ching (Nominated Member): Mr Deputy Speaker, Sir, I thank the Minister for this timely Bill as we prepare ourselves for the silver tsunami.

The introduction of the new $5.1 billion CareShield Life as universal healthcare insurance to ensure lifetime coverage and higher monthly payouts is definitely moving in the right direction.

While I understand that CareShield Life aids to subsidise the cost of long-term care for adults above age 30 with severe disability, what about patients below than 30 years old, such as paediatric patients with severe disability?

Though I am aware that the topic of differential premium for men and women introduced for CareShield Life was widely debated previously, I would still like to state my stand and hope that MOH can review its position. The principle underpinning insurance is risk pooling. Hence, I do not agree that our society should go the route of differential premium by gender, causing gender divide. Otherwise, we may start the trend of potentially differentiating premiums in future by race or other genetic risk factors as we advance into precision medicine.

Lastly, as the Nominated Member representing the professional bodies in Singapore, I hope to bring awareness to the House, the Singapore Actuarial Society, a governance body for the actuarial profession in Singapore. The Singapore Actuarial Society (SAS) was established in 1976. Fellows of the SAS are in most cases Fellows of the Society of Actuaries in the USA, the Canadian Institute of Actuaries, Institute and Faculty of Actuaries (UK) or Institute of Actuaries of Australia.

Like other professional bodies, the SAS requires Fellows to maintain and disclose annually a minimum level of continuing professional development. An actuary with a statutory role such as the Appointed Actuary of a Life Assurance Company or the Certifying Actuary of a General Insurance Company is also required to have a Practicing Certificate awarded after attending relevant courses run by the SAS locally.

Hence, with regards to section 37 of the Bill regarding the CareShield Life Council, can I propose that when the Minister appoints the Council, can the Minister consider to include a Fellow of the SAS who is conversant with the financial management of long-term care insurance in the Council?

The viability and sustainability of the CareShield Life Scheme is highly dependent on the appropriateness of the premiums and the adequacy of the assets in the CareShield Life and the ElderShield Fund to support the benefits promised under the scheme.

CareShield Life is a long-term insurance programme. There may be uncertainties in how the experience will unfold and there is a lack of long-term care historical experience to guide an actuary in pricing and valuations.

To carry out the work, the consulting actuary has to transfer and adapt experience from other countries and draw up assumptions of future experience such that the likelihood of having to adjust the premiums to be kept at an acceptable level, keeping in mind frequent adjustments to premiums leads to loss of confidence by the public in the scheme

While I understand that MOH has appointed an actuarial consultancy to compute the premiums and in time to conduct an evaluation of the liability of the scheme, having an independent actuary on the CareShield Life Council can help by evaluating the robustness of the actuarial analyses and computation methodology in light of this scarcity of data, validating the conclusions drawn from the analyses, probing for the safeguards the consultant actuary has built in to avoid having to change premium rates too frequently.

As the proposed Council member will be providing actuarial advice, a Fellow of the SAS, who is governed by the standards and code of conduct of the SAS, will be most appropriate for this role. Notwithstanding the clarifications and proposal above, I stand to support the Bill.

4.50 pm

Mr Christopher de Souza (Holland-Bukit Timah): Sir, this Bill does not just implement the CareShield Life scheme, it also enables the ElderShield scheme to be administered by the Government instead of private insurance companies, it provides for the withdrawal of MediSave funds of persons who are severely disabled, it establishes the Long-Term Care Fund and puts in place offences and penalties. I will speak in favour of all these four aspects of the Bill successively.

Firstly, this Bill transfers the ElderShield scheme from private insurance companies to Government administration, similar to how CareShield Life is also Government administered. This has several advantages. The not-for profit administration increases the affordability of premiums. The centralisation of administering the scheme will streamline the application for payout process. It also allows for smoother transition for those who choose to shift from ElderShield scheme to CareShield Life scheme. It also allows for the funds to be combined into a single CareShield Life and ElderShield Insurance Fund. This allows for more flexibility in investing. Even as the monies are consolidated into a single fund, how will the Minister ensure inter-generational equity in how the schemes are administered? That is one question I have.

In relation to the transition from ElderShield to CareShield Life, will the Minister provide an indication as to when and how sign-ups can begin? Also, will Supplement Schemes for ElderShield be affected by the transfer of ElderShield to become Government-administered and change of coverage to CareShield Life instead of ElderShield should the policy-holder choose to shift over to CareShield Life?

Secondly, Sir, clause 66(5) provides for the withdrawal of MediSave funds of persons who are severely disabled. Because healthcare can come in many forms, this flexibility is valuable for families to have yet another place of resources to tap into to care for the severely disabled. But even as there is increased flexibility, it should not deplete from MediSave funds to the extent that MediSave is no longer useful for its intended purpose. This is especially acute where a child’s MediSave funds is used to pay for a parent's medical expenses, and the child has his or her own medical expenses to cover and, as a result of not marrying, the child does not have anyone else’s MediSave account to tap onto in the future.

Therefore, would the Minister address these concerns? Furthermore, the new section 16B(1)(a) of the Central Provident Fund Act found in clause 66 indicates that there is a minimum sum in the member’s account in order for cash withdrawals for long-term care to be allowed. From news reports, the minimum sum that is being looked at is $5,000. Would the Minister explain how this figure was derived such that it ensures that the account-holder still has money to pay for other healthcare needs?

Thirdly, part 10 establishes the Long-Term Care Support Fund which is used for premium subsidies and other long-term care related assistance as set out in clause 39. Would the Minister share with us what are some of the plans that the Ministry has in utilising the Funds for purposes other than subsidising CareShield Life premiums? In particular, what kind of assistance will there be for those who are severely disabled but have utilised the six years under the ElderShield scheme, those who were unable to purchase the ElderShield scheme because they had been severely disabled, and those who are low-income and do not have much in their MediSave account? How does the Minister seek to address these perceived gaps?

Fourthly, this Bill introduces offences and penalties for the administration of this scheme. Clause 49 criminalises the act of an assessor making a fraudulent disability assessment. As the integrity of the administration of CareShield Life and ElderShield schemes rests primarily on the disability assessor, this offence places a safeguard against fraudulent claims facilitated by disability assessors.

Clause 50 criminalises the act of not applying the funds for the insured person first. The new section 16B(10) of the Central Provident Fund Act also has a similar offence. This offence ameliorates the risk of cash payouts being misused. Because the person directly harmed by the act criminalised by this offence is the insured person or member, why is it that a portion of the penalty be returned to the insured person himself or herself instead of having the whole penalty be paid into the CareShield Life and ElderShield Insurance Fund?

Because the penalty is possibly more than the amount misused by a four to eight times, requiring the offender to pay the insured person or member would not remove the punitive quality of the penalty.

An exception to the offence is reasonable excuse. Because different households structure their expenses differently such that it may not be very clear whether the payout was used for the insured person or member first, would the Minister give some examples of what a reasonable excuse might be?

Even as this Bill seeks to provide some financial support for long-term care, financial support is only one side of the equation to ensuring that long-term care remains affordable. Another side of the equation is to expand the supply of long-term care services. This is especially important as the number of persons who are severely disabled is projected to increase to 69,000 in 2030 compared to 29,000 in 2014. That is about 140% increase in demand for long-term care services or long-term care care-giver training.

Would the Minister elaborate on the plans to ensure that we have sufficient personnel and facilities for this increase in demand?

Because technology can help caring for severely disabled persons less physically demanding, how has Singapore been investing in such technology to reduce the reliance on foreign manpower and to allow those who work in this physically demanding field to enjoy a longer, meaningful career? Also, what efforts have been made to make certain assistive technologies more accessible to families who may need it to care for their loved ones?

Sir, during this debate, there have been a number of broad criticisms against our healthcare system. In my view, however, we have, in broad terms, a good system in place. Is there room for improvement? Sure. But let us also acknowledge the merits.

Where the provision of fiscal measures to support a sustainable healthcare model is concerned, where good quality doctors are concerned, where professional and hardworking nursing population is concerned, I think Singapore ranks well and does well. Singapore has been independently assessed as being second in the 2018 Bloomberg study on most efficient healthcare systems – that is good outcomes but reasonable costs. So, I hope we can put things in perspective in this debate.

In conclusion, Singaporeans have been fortunate, some may say blessed, with long lives, with our life expectancy one of the highest in the world. But often with long lives, though not necessarily so, comes with it some loss of the kind of life as we knew it. Needing to rely on others to carry out activities of daily living does not just affect the elderly but also affects people from all ages. Through it all, the recipient of help is still valued and valuable.

This CareShield Life and Long-Term Care Bill helps support them and their families. By pooling the risks among many in society, they may be able to receive more than they would have in their savings otherwise. By allowing spouses to tap onto each other's MediSave account, another resource to support each other through the difficult time is opened. By setting up the Long-Term Care Support Fund, there can be more support for those who need more help in financing long-term care options, whether it be through subsidising premiums or through other schemes. Because this Bill implements and commits to the caring for those who are severely disabled, and for the reasons I have stated, I support it.

5.00 pm

Ms Tin Pei Ling (MacPherson): Deputy Speaker, Sir, I have spoken on the importance of CareShield Life in 2018. Today, I renew my support for it and I am glad that this Bill does not focus solely on CareShield Life but long-term care as well. CareShield Life has to be viewed within the frame of Singapore's long-term care plan.

Sir, we all know that Singapore has an ageing population and we need to be ready for it. But how ready are we, really?

The Government invested significant amount of resource and effort to build up our system, policies and infrastructure to cope with the needs of a rapidly ageing population, strengthening them as we progress. Government spending has also increased by multiple folds. Public healthcare expenditure, for instance, more than doubled in the past six years, and will continue to increase. How we can sustain this is serious business.

Ageing is a multi-faceted issue, covering physical, financial, psychological and social aspects of our lives. Given the growing silver population and longer lifespan, it is imperative that we have in place a comprehensive and effective long-term care system for Singaporeans. In fact, we need a good eco-system to do so.

The Government cannot monopolise the care for our seniors. We will need community partners and Singaporeans too to address the challenges and needs of an ageing Singapore successfully. We will also need to plan early and act pre-emptively.

Some of the challenges faced in our old age may have their roots in our younger days. Likewise, what we do right in our youth can also offer ourselves better protection when we become old. One such instance is insuring ourselves against calamities such as severe disabilities in our old age

Today, one in two healthy Singapore residents aged 65 could become severely disabled in their lifetime, not that rare after all. The number of severely disabled Singapore residents aged 65 and above is expected to increase from 29,000 in 2014 to 69,000 in 2030, more than double.

Severe disabilities can also be long drawn. The median duration for which Singapore residents remain in severe disability is about four years. Yet, about three in 10 can remain in severe disability for a decade or more.

These are not insignificant numbers, especially since severe disabilities can seriously strain one's psychological, physical and financial well-being. Yet, not everyone is protected.

Therefore, similar to the philosophy underpinning MediShield Life, it is important that we consider and support CareShield Life. Through a public insurance such as CareShield Life, we pool our risks and money to help fellow Singaporeans in need, sustainably. We are a society that believes in compassion and inclusivity. Schemes, like CareShield Life, translate such beliefs into real actions.

Despite the clear imperative for CareShield Life, it is, nonetheless, a very complex scheme to understand, even for younger Singaporeans. Different age groups start in different years and even within the same cohort, there can be sub-groups. For example, there are those who enrol in CareShield Life and those who remain in ElderShield. If one thought MediShield Life was complex, CareShield Life topped it.

Hence, effective communications to address the "why" and "how" are critical to a successful implementation of CareShield Life.

In the first part, I would like to talk about the "why" – persuading the young. From 2020, all Singaporeans born in 1980 or after will automatically be enrolled into CareShield Life, regardless of pre-existing conditions or disabilities.

Despite the high probability, our young today question the need for the scheme to be made mandatory for all. This is, understandably so. Many, who are still in the prime of health, do not anticipate severe disabilities when they age. Many also do not see the urgency in planning for the possibility of age-related disabilities at this point. Hence, they want to preserve their autonomy in choosing whether and when to enrol themselves in a universal public insurance scheme.

Furthermore, the sense of importance for risk pooling is diminished when they observe that the total claim of $100 million is only a small fraction of the total premium collection of $2.6 billion as at end 2015. "What happens to the huge sum of money remaining in the pool?", they ask. "Who pockets the rest?", the more cynical amongst them may also ask.

To be fair, these concerns were answered before. But such concerns remain today. Perhaps, people missed it and the message bears repeating. But I think it is also because there are too few stories of "success" in the case of ElderShield and too many stories of difficult claims that breed scepticism. Hopefully, with CareShield Life to be managed fully by the Singapore Government, Singaporeans' confidence in the scheme will be boosted.

Interesting to note, private life insurance hardly needs persuasion, despite events qualifying for claims being relatively rare. As at 2018, life insurance sales grew at 7%. Yet, the total claim amount due to deaths and disabilities in 2018 was about 0.1% of the total sum insured. There is strong awareness of the need for life insurance, and credit goes to the army of insurance agents who actively educate the population on the ground face-to-face – a point worth pondering.

Next, talking about supporting women. Women policyholders are expected to pay a higher premium than men. This stands out starkly. The main reason articulated was that women have a longer life span on average and risks being disabled for a longer period of time.

Arguably, however, the idea of a public insurance plan is to pool risks and resources to help one another. Thus, should women not be allowed to pay the same amount of premium as the men in their respective cohort?

Moreover, women tend to "lose out" to men in earnings and savings, in part due to them exiting from the workforce early to care for their families. Many sacrificed their prime years to stay home and care for their loved ones. The years away from work mean they may have little or significantly less savings in their MediSave. These women may also not come from well-to-do families, who have little to contribute to their MediSave even if they wish to. There is also no guarantee that their spouse or children, if they have any, will pay for their extra premiums.

How then we ensure fairness and equity in the system? For women who may have lost out to their male peers at work or who have made financial sacrifices for their families, what help can they look to receive? Could older and lower-income women receive more premium rebates so that they do not lose out even more?

Next, I would like to talk about communicating the "how" – "customer" experience. CareShield Life will see different years of commencement and impact on different age groups. Premium payments also differ across age groups and possibly within cohorts. These different ways of "slicing" ensure as many people are covered as possible, but it can be highly confusing and soliciting buy-in will also be much harder. So, again, well-planned and targeted communications are imperative to a successful implementation.

If the scheme cannot be simplified, the claim experience must certainly be simplified, and it must not disappoint. A straightforward claim process comprising a one-stop solution without the need to approach different agencies for different documents will be useful and avoid the accusation of CareShield Life being a sinister plan that takes money from the people without the sincerity of giving back when needed. More importantly, when a person is already severely disabled, he or she cannot withstand complex processes.

Overall, we could benefit from communicating how our Long-Term Care works in Singapore better and clearer. This Bill specifically covers the establishment of the Long-Term Care Support Fund. This is useful but we know Long-Term Care is more than just a fund. As we improve the Long-Term Care system over the years, we have been making announcements in piecemeal fashion. This is understandable as we communicate whenever a new initiative becomes available. But the general public may not remember every initiative and consciously piece everything together.

Therefore, may I humbly suggest the Government consider the following.

Firstly, consistently educating and publicising how we deal with ageing in Singapore, specifically the principles and mechanics of our Long-Term Care system. This could be done in schools as part of national education, through common touch-points in the course of our lives and, of course, the usual mass media.

Second, high touch method of engaging target groups when implementing and communicating complex schemes such as CareShield Life. For example, akin to how insurance agents make complex insurance schemes easy to understand, could there be a network of trained policy agents who would reach out to Singaporeans at the workplace or at home to explain complex schemes to them? Even the most well-meaning policies can fail if we fail to help Singaporeans understand and solicit their support.

Finally, discussions so far focused on passively dealing with the challenges of old age and severe disabilities. We should also explore prevention and ways to minimise the risk. In a 2015 report by the United Nations Department of Economic and Social Affairs, it stated that there is a growing body of research literature underscoring the importance of fostering good health and habits in life to prevent or postpone the onset of morbidity at older ages. This should apply to age-related disabilities as well.

Therefore, we must continue our efforts in encouraging healthier lifestyles and to do so from young. Healthy outcomes are not just important from a financial burden perspective, but because we love life. And therefore, for those who have proven to engage in healthy activities and maintained good health past, say, 60 years old, could their premiums be reduced or could rebates be given as a way of encouragement to reinforce this very positive behaviour?

Next, may I please continue in Mandarin?

(In Mandarin): [Please refer to Vernacular Speech.] Mr Deputy Speaker, in 2014, we had a vigorous debate on MediShield Life in Parliament and passed the Bill. The purpose of passing that Bill was to provide universal healthcare insurance coverage so that all Singaporeans can enjoy basic healthcare protection. Besides Government subsidies and our own MediSave savings, MediShield Life can help us cope with unforeseeable circumstances. The concept behind it is risk-pooling whereby everyone’s money is pooled together to allow people in need to pay for massive medical expenses. Everyone has an equal chance.

In principle and theory, CareShield Life and MediShield Life are the same.

Our population is now ageing rapidly. Our family size is also shrinking. It is inevitable that Singaporeans must support each other through thick and thin. Moreover, statistics show that one in two Singaporeans aged 65 years and above will become severely disabled later in life. This is a very high probability. Therefore, the implementation of MediShield Life and CareShield Life is to prepare people not just for their own but others' future as well.

I am sure we are all clear about the importance of CareShield Life after last year's and today's debate. In my view, the key to the successful implementation of CareShield Life lies upon whether the Government can communicate it well, how it can explain the scheme in a targeted manner and address queries from different groups. When MediShield was introduced, many people felt that it was a very complex policy. In truth, CareShield Life is even more complicated. Therefore, we must communicate it well. Otherwise, if people do not understand, they would not support it. If they do not support it, unhappiness may occur.

Hence, I hope that while we promote CareShield Life, we must also focus on communication and engage the people wholeheartedly. And this should not be limited to CareShield Life alone. We must let Singaporeans, young and old, to understand the concepts and methods of our eldercare system within the overall picture of the long-term care framework.

Here, I have some humble suggestions.

Firstly, the Government can consider using the various mass media channels to publicise the concepts and mechanisms of our long-term care system. For example, we can, through civic education or ways that do not require exams, allow Singapore students to understand how we cope with the challenges of ageing and how we care for the aged, so that they are prepared at a young age.

Secondly, the Government can also consider setting up a network of volunteers who are familiar with public policies to reach out to workplaces and the community to explain complicated policies to Singaporeans. Through such face-to-face in-depth explanations, I believe Singaporeans will be able to understand those important but not necessarily popular policies.

Frankly speaking, the Government has taken a great deal of pain to look after the elderly. We all can see that. In the past, the Government has introduced many eldercare schemes and programmes, including CareShield Life. Earlier this year, we introduced the Caregiver grant worth $200 every month; and in the Pioneer Generation Package, we provide additional support to the disabled among the Pioneer Generation worth $100 per month. All these various subsidies and support packages are aimed at better looking after the elderly and giving them long-term care.

Earlier on, the esteemed Member Mr Chen Show Mao mentioned that the care given under CareShield Life is not enough and that $600 can only pay for part of the expenses of the severely disabled. I am curious to learn from Mr Chen in what way can the Government do better. On a macro level, we have many different packages and subsides, I would like to know from Mr Chen what are the areas that we can improve on.

In fact, there are many suggestions raised in Parliament, not just from Mr Chen, for the Government to consider. However, when we raise these suggestions, we must be aware that after all, someone will have to pay for it. The government need to allocate precious resources to the things we ask for and it must balance different interests and trade-offs to formulate the best possible policies to help Singaporeans. The efforts that the Government has made is not simple at all.

Lastly, when we are looking at issues pertaining to long-term care and ageing, we tend to be a bit passive. We should adopt more proactive measure, such as encouraging Singaporeans to pay attention to their diet when they are young, stay fit, so that they can have a healthy foundation as they grow old and be able to enjoy a happy retirement life. To encourage people to stay healthy, can the Government consider emulating private insurers and offer CareShield premiums rebate or discount to those who actively exercise and stay healthy after 60?

(In English): Sir, in English. Sir, there is a real need for Singapore to get ready for the consequences of an ageing population. My sincere hope is that we will all enjoy good health, lead a full and fulfilling life, and rather than having to spend on our care needs, are able to spend on things that we enjoy. But we can never be sure of what will happen to us in the years to come.

It would be too late if we only start to worry or find ways to finance our care needs later in life when our familial obligations intensify; or worse, when we suffer disabilities. It is also unsustainable and unfortunate if we have to burden future generations – which is by the way shrinking because of our ageing population – to fund our own care needs.

Very importantly, CareShield Life provides better long-term care and protection for all Singaporeans. This does not mean that the Government can cut back its support; this does not exonerate individuals from exercising personal responsibility, but this does enable us to pool our risks and help our fellow countrymen through times of need. In a society that expounds the importance of compassion and inclusion, all of us will need to contribute, in ways big or small, in one way or other. With that, I support the Bill.

Debate resumed.

5.20 pm

The Senior Minister of State for Health (Mr Edwin Tong Chun Fai): Thank you, Mr Deputy Speaker, and I thank the various Members in this House for having spoken up in support of the Bill – Members from all sides of this House. I will round up this debate on behalf of Minister Gan.

As Minister Gan has outlined, Singaporeans are living longer and healthier. However, many of us will face the risk of severe disability and require long-term care at some point in our lives. Therefore, it is important that we protect ourselves and our families. I would like to assure Members that even as we enhance our long-term care financing system, implement the CareShield Life Scheme, we are and have been enhancing existing infrastructure and the eco-system for care. We have been rolling out services to support Singaporeans in old age and we have more than doubled in this respect the home care and day-care places since 2011. We continuously look at key aspects of ageing and also the related issues around successful and active ageing, including, as Mr Perera has exhorted, the use of technology.

I thank the Members for the various suggestions, questions and queries in the course of this debate. I will like to use the opportunity to round up the debate and address those queries by focusing on the core principles behind the design of this financing scheme. I will anchor the response around the key principles of inclusiveness, affordability and sustainability.

Let me start with inclusiveness. An inclusive long-term care financing system is one that supports all Singaporeans and enables them to afford essential basic long-term care. The design architecture of the Scheme must be to achieve that goal – to support Singaporeans and be able to do so while keeping premiums affordable.

First, in terms of coverage, the Bill reinforces and strengthens inclusiveness by making CareShield Life universal for future cohorts of Singaporeans born in or after 1980. Such a design is essential to protect vulnerable groups, such as the lower income and those with pre-existing disability.

For older existing cohorts of Singaporeans, which are those born in 1979 or earlier, we have kept CareShield Life optional for them as we acknowledge that the profile of this cohort, this group, is a lot more diverse. Many have previously decided to opt out from ElderShield, or may have made other long-term care financing arrangements of their own. In addition, the older cohorts would also have fewer economically active years left to spread out their premiums, and hence face higher entry premiums. Given that the Scheme remains optional for these cohorts, members of these cohorts will need to assess their own preparations, their own provisions for long-term care, when deciding whether or not to join CareShield Life.

To address Dr Chia Shi-Lu's point, we will provide ample Government support and incentives to encourage their participation in CareShield Life.

I would also like to assure Mr Png that those who are not severely disabled in existing cohorts can still join CareShield Life when it is launched in 2021. Mr Png also sought clarifications on clause 6(4). Let me explain that. This clause is used to cater for exceptional situations such as when someone had submitted an application for CareShield Life and it is being processed but, in the interim, fell into disability before the Scheme was effected or valid for this person. This clause allows the Minister to use flexibility to still provide CareShield Life cover on compassionate grounds. So, it is used in those limited exceptional circumstances and certainly not to be used arbitrarily.

As CareShield Life remains optional for existing cohorts, we will not be able to cover those in the existing cohorts who are already severely disabled, and I think Mr Png understands this point. Miss Cheryl Chan had raised this as well and I also hope that this addresses the point because if you cover everyone who is already severely disabled, that has an immediate impact on the premium that has to be borne by the remaining persons who subscribed onto the Scheme at that stage.

These individuals with pre-existing severe disabilities will be able to make claims immediately under the Scheme and so it is going to impact on the way in which you price the premiums for the rest of the members and also have an impact on whether their peers decide to join the Scheme or not. This is not a sustainable insurance scheme design. However, we will assist these Singaporeans with pre-existing disability in other ways and I will elaborate on them.

Prof Fatimah Lateef and Mr Christopher de Souza asked how ElderShield and ElderShield Supplement coverage will be affected. As Minister Gan has explained, ElderShield policyholders who decide not to join CareShield Life will remain covered by their existing ElderShield policy. I would also like to clarify that ElderShield Supplements will continue to be administered by the private insurers. ElderShield Supplement policyholders will remain covered by their existing Supplement policy, regardless of whether they upgrade to CareShield Life or not.

Dr Lee Bee Wah asked about encouraging existing cohorts who would not be auto-enrolled onto CareShield Life to join CareShield Life. I will reiterate what Minister Gan has shared, individuals born between 1970 and 1979 who are ElderShield policyholders and are not severely disabled will be offered the convenience of auto-enrolment. For those born in 1969 or earlier they will not be auto-enrolled, as their individual circumstances are far more varied, as I have explained.

In particular, there is a significant number of ElderShield 300 and uninsured individuals in the older existing cohorts, who will have to pay a catch-up component to join and get onto CareShield Life. They may thus prefer to have the option to choose to join CareShield Life at their instance instead of being auto-enrolled and that is the thinking behind the scheme mechanism.

Nevertheless, I agree with Er Dr Lee’s point that it is important to outreach to these groups too to help them understand, to raise awareness and certainly we are of the view that if we design a scheme that is good and well, it is of no use if people do not understand it and do not know it. So, I accept Er Dr Lee's point and I also in return urge all Members of this House to use opportunities that you have on the ground in your events to explain the policy, to explain the scheme design and to reach out and explain and deal with queries that your residents may have.

Ms Irene Quay and Ms Anthea Ong have asked about the schemes available to help younger severely disabled Singaporeans, in fact below the age of 30, including newborns and whether it is possible to extend CareShield Life to these people. CareShield Life is primarily designed to provide financial support for Singaporeans who become severely disabled during old age, which is when Singaporeans are most likely to need long-term care and support.

Notwithstanding that, we have other schemes available which are outside the scope of the current Bill but let me just outline some of them to help the younger severely disabled Singaporeans.

First, MediShield Life will help to support their bills for inpatient and selected outpatient treatments. They can also benefit from other assistance schemes such as the Assistive Technology Fund and the new Home Caregiving Grant, which I think Ms Ong mentioned, which does not have an age criterion. In addition, hospitals such as KKH and NUH offer programmes such as subsidised therapy services to help parents with children who need that specialised care. Finally, Government-funded safety nets such as MediFund and ComCare will also continue to provide additional assistance to needy Singaporeans.

On that score, I would like to assure Prof Fatimah that overseas Singaporeans can avail themselves of CareShield Life. They will be able to file CareShield Life claims from abroad wherever they may be, and to receive payouts to support their care costs in those chosen countries.

The second aspect of inclusiveness lies in making the claims process accessible and as seamless as possible, which several Members have raised queries and concerns about. Let me give Members a broad sense of the measures that we will be taking or have taken.

Beyond what Minister Gan has mentioned about increasing the number of accredited disability assessors to about 300, progressively expanding the types of disability assessments that can be accepted for claims and also proactively reaching out to disabled individuals to inform them of their eligibility for claims, we will also be waiving the first assessment fee for CareShield Life claims to further reduce any hesitation or reluctance that an individual policyholder might have in making the claim.

I would like to also assure Miss Chan that only one assessment is required, and furthermore, the same assessment can then be made for other schemes as well; other different multiple schemes.

In addition, policyholders need not pay for assessment fees for periodic disability reviews. Such periodic reviews are, however, important to ensure that we continue to make payouts only to policyholders who are and remain severely disabled, but to address Dr Neo's concern, we will be adopting a more targeted approach for periodic disability reviews. For example, policyholders who have been assessed to be clearly permanently disabled may then be exempted from further reviews.

I would like to assure Ms Ong that we understand and we accept her suggestion that we should indeed be assessing what an individual does, instead of what an individual can do. So, the focus is on the ability or inability to do something.

In particular, we have been working with experts to improve the disability assessment framework, to explicitly recognise the impact of cognitive impairment on physical ability. This is in line with requests from a number of Members for CareShield Life to also assist those who may have that mental condition or the cognitive impairment.

To elaborate on this, a policyholder may well be physically able to perform the various Activities of Daily Living (ADLs), but requires significant prompting or reminding as he is unable to remember what those steps might entail or how that is to be done. Under the current framework, assessors who may not be sure how to assess this policyholder might well classify him as not being disabled, being able to perform the ADLs since he can physically complete them.

Under the new framework and revised training curriculum, assessors will be guided with more information, more teaching and learning, and will be more explicitly guided on the aspects that should be taken into consideration if a policyholder is suspected to be cognitively impaired, including whether the policyholder's problem-solving ability and memory impacts his or her ability to actually carry out the physical acts of the ADL. This will result in cognitively impaired policyholders being able to more consistently qualify for CareShield Life claims.

Members have expressed concerns about vulnerable Singaporeans who may not be able to navigate the long-term care financing and social support landscape on their own. Again, as I said earlier, we understand this and we want to ensure that Singaporeans know and understand the schemes well – know how to make the claims, know when it applies to them and know what kind of claims to make.

AIC, which administers all of MOH's disability schemes, and in particular the Silver Generation Office under AIC, will be our key partner in providing Singaporeans with guidance on the disability schemes they are eligible for, and also how to apply.

To embed more touch-points in the community, we will create four more AICare Link touch-points co-located at Silver Generation satellite offices, and this will be done by end-2019.

At the same time, we will improve our coordination with the Social Service Offices and other Government touch-points within the community, so that our support for vulnerable Singaporeans is more cohesive and also resides more closely to where the residents and the policyholders might be. We will also continually review our various initiatives to consolidate and, as far as possible, simplify them. We encourage Members to continue to refer needy individuals – and I think we heard some stories earlier – refer them to us, give us some specifics and we will reach out and see how we can assist.

Third, we recognise that not everyone can afford or will be covered by ElderShield or CareShield Life. Members have asked for more to be done to help such seniors who need financial support for their long-term care needs.

The CareShield Life and Long-Term Care Bill facilitates this by providing for cash withdrawals from MediSave for long-term care. That is a more recent advent and one which we believe strikes the right balance.

The Bill also sets up the Long-Term Care Support Fund, which the Minister for Finance has committed to set aside $5.1 billion to service this Fund. ElderFund, the discretionary scheme for the lower income who are severely disabled, will be supported by this Long-Term Care Support Fund. Dr Lily Neo asked for more details on the eligibility criteria.

As Minister Gan has explained, this Scheme is targeted especially at Singaporeans who are unable to join CareShield Life, have low MediSave balances and also face financial difficulties in meeting their long-term care needs.

We recognise that individuals' circumstances from person to person may vary widely, and hence ElderFund is a discretionary scheme designed to take into account different circumstances as being applied to different persons. Singaporeans who are unable to meet their long-term care needs even after relying on other sources of financing can be considered for ElderFund.

In response Dr Chia's query on how we review ElderFund, we will review the adequacy of ElderFund payouts over time as we have more experience and we will also look at it in conjunction with several other factors that we determine the adequacy of the payout.

These new schemes and initiatives provided by this Bill should, however, not be seen in isolation, but instead, should be seen as complementary to the existing Government subsidies and assistance schemes. I have outlined a few such as ComCare and MediFund earlier.

Our system is designed to support all Singaporeans, regardless of their income levels. So, it is that to which I now turn on the question of affordability, the second key principle behind the design architecture of the Scheme.

Affordability involves keeping CareShield Life premiums affordably priced, whilst at the same time also providing premium assistance to those Singaporeans who need it.

There are several points. First, to ensure that CareShield Life premiums remain affordable, the ElderShield Review Committee had recommended that the CareShield Life Scheme focus on providing basic coverage for Singaporeans’ long-term care needs.

One of their recommendations was to keep the existing ElderShield claim criteria, which is the inability to perform at least three out of six activities of daily living (ADLs), a point that we have heard many Members touch on earlier.

Ms Ong, in particular, asked if CareShield Life payouts could be tiered based on the extent of disability. We have previously considered this. I think Ms Ong would also know that lowering the claims criteria to two ADLs would immediately increase the CareShield Life premiums of a 30-year-old policyholder by about one-third. That is anything in the order of 25% to 33% of increment, just by dropping down to two ADLs.

The premium increase for CareShield Life would likely be significantly and also exponentially higher if the claims criteria is then further lowered to one ADL, given the higher incidence and length of disability. Not only will there be more persons with one or two ADLs, as opposed to three, but the period of support, which is for life, will also be for longer. Both will have an impact on the amount of premium that will have to be collected.

The Committee had also recommended that CareShield Life payouts start at $600 per month, and increase over time. Dr Neo asked, and I think many others as well, such as Mr Chen Show Mao, if the payouts could be higher.

CareShield Life payouts already start at an amount which is, at present, significantly higher than the current ElderShield scheme. Increasing the starting payouts from $600 to, say, $800 a month would also increase premiums for a 30-year-old policyholder by around a third. So, recall I said at the start that we have to find a design architecture for the Scheme that is affordable and that meets the interest of basic long-term care of Singaporeans.

In addition, as Members would know, CareShield Life payouts are set to increase at 2% per year for the first five years of scheme implementation. Assuming a continued increase of 2% per year after that – so that is 2% thereafter after the five years – a 30-year-old joining the Scheme in 2020 may receive around $1,200 per month should he become severely disabled at age 67 or later. So, that is the projection that we take into account and also to keep up with the value of money over time.

So, for those reasons, we have kept the focus on basic long-term care needs, and looked at other ways to provide additional support. And I urge Members to remember that the payout from CareShield Life is intended and it is designed to be complementary. It complements the other pillars of financing support, not replace and not take over, and also not put in place and reduce others; it is to complement as an add-on. Lower and middle income Singaporeans, including those with moderate disabilities, will be supported with subsidies of up to 80% for residential and non-residential care services, and can also receive other disability grants.

For example, the existing Pioneer Disability Assistance Scheme and the new Home Caregiving Grant, which will be launched at the end of this year, will provide support for persons with moderate disability. So the threshold will be different from what is otherwise required in the CareShield Life Scheme.

In response to Dr Neo's query on the disability criterion and assessment process for the Home Caregiving Grant, I should explain that the Home Caregiving Grant is targeted at precisely that, the moderately disabled Singaporeans who require some assistance with at least three ADLs. This is less stringent than the severe disability claims criteria for CareShield Life and the current ElderShield, where a higher level of dependence is required for each ADL.

Dr Chia and others in this House asked about the type of Supplements that will be offered by private insurers and whether MediSave can be used to purchase the Supplements.

Singaporeans can purchase Supplements from the private insurers which currently provide coverage starting from two ADLs, and also a higher payout. So you can choose either one or both of these Supplements.

As with ElderShield Supplements, Singaporeans can use up to $600 of their MediSave annually, per insured person, to pay for CareShield Life Supplement premiums.

Dr Neo asked if the Government could administer these Supplements. As I explained earlier, our approach for the Government in this Scheme is to provide basic coverage, whilst at the same time allowing the private sector to innovate in the provision of supplementary coverage. We believe that there are benefits to be reaped, for instance, in the diversity and type of products that are being offered, by allowing private insurers to compete in this space beyond the basic tier.

Second, in response to Prof Fatimah's query, we keep premiums affordable by starting earlier. So, that is one principle behind why 30 and not 40, which is ElderShield. A 30-year-old would have been working for some years at that age, and starting premium payment at that stage lengthens the payment duration and also reduces the annual premium payable, making CareShield Life premiums more affordable and more within reach, including for a person who has started work for some time at around 30.

Third, we allow the use of MediSave for CareShield Life premiums, similar to the approach for MediShield Life and ElderShield today.

In response to Prof Walter Theseira's point, we allow the use of MediSave but judiciously, because we recognise that it may be difficult for individuals to save and plan ahead for long-term care.

We facilitate them starting these preparations early, by allowing individuals to tap on their existing savings in MediSave as another financing source, instead of requiring them to use only cash which, as the Member knows, will cause a strain in their cashflow. This also helps to buffer individuals against the vagaries of life, sometimes from unintended or temporary unemployment.

As a safeguard, we only allow MediSave to pay fully for basic healthcare and long-term care insurance. For additional coverage, we have set withdrawal limits to protect MediSave adequacy. This is in line with the discipline that Professor Theseira spoke about in the way in which we use MediSave to fund these schemes.

Mr Png also asked whether permitting MediSave uses for CareShield Life premiums would affect adequacy. The current MediSave contribution rates allow most working households in future cohorts and auto-enrolled existing cohorts to pay for CareShield Life, MediShield Life premiums and other healthcare needs from their monthly MediSave contributions.

Fourth, I would like to assure Members that the Government is committed to keeping the premiums affordable through the provision of subsidies. This includes permanent premium subsidies for lower and middle income policyholders. Ms Jessica Tan, Miss Cheryl Chan and Dr Chia Shi-Lu asked some questions about this. In addition, we will also provide incentives to encourage existing cohorts to join the scheme, and these incentives are netted off against their premiums. Younger cohorts will also receive transitional subsidies.

While at Mr Leon Perera's point, I would like to clarify clause 15 of the Bill that allows the offsetting of premium subsidies from premium refunds, for administrative ease. So, let me just illustrate it with a scenario. For example, if an auto-enrolled policyholder decides to opt out before the deadline of end 2023, which Minister Gan outlined, the premiums he had paid will be fully refunded and the mechanism that is being used is designed in clause 15. Any premium subsidies and incentives he received previously will then, of course, also be offset from this refund. So, you do not retain the subsidies whilst at the same time choosing to exit from the Scheme.

Separately, if the Council considers at its regular adjustments to consider premium rebates, for instance, in that situation, if there is a premium rebate to be paid to a policyholder, the rebate computation will not take into account the subsidy that has been given. So, if part of what you have been paying as a premium is assisted through the subsidy, then, the rebates that are given will not take that into account in giving the rebate to the policyholder. Instead, the rebate will be retained in the fund, for the benefit of all the other policyholders; and that, we believe is the fairest arrangement.

Mr Png also asked if the savings from Government administration have already been reflected in the CareShield Life premiums. Let me confirm that the CareShield Life premiums from existing cohorts are based on the expected expenses under Government administration and would thus have also reflected the savings that we expect to see from such administration.

In any case, any further savings will be fully returned to policyholders such as in the form of higher payouts or the premium adjustments that I just spoke about. In short, the Fund is not for profit and should there be any surpluses, it will be put back into the Fund for the benefit of all policyholders.

Next, I would like to assure Members that no one will lose coverage due to his or her inability to pay, but it has to be a genuine inability to pay, not just a refusal.

The Government will provide Additional Premium Support to Singaporeans who cannot afford CareShield Life premiums even after premium subsidies, MediSave and family support.

Dr Chia had a question about Additional Premium Support criteria for both CareShield Life and MediShield Life and whether we intend for it to be the same. An individual's additional premium support status will be shared across both CareShield Life and MediShield Life so that an individual would not be put through the task of having to apply for Additional Premium Support twice over.

Let me turn now to the third key principle which is that of sustainability. I think Members would agree that we must ensure that the long-term care financing system that we put in place must remain sustainable and must work in the long term. This is so that our children and the generations beyond that will not be unnecessarily and unduly burdened by the needs of the current generation. Let me elaborate with reference to a few points.

First, CareShield Life and ElderShield are designed to be self-sustaining schemes. So, that again is in the policy design. It is in fact hard wired when into the design of the schemes. So, as a result, these schemes are heavily pre-funded, with CareShield Life premiums payable until age 67 or spread over 10 years for older existing cohorts, and ElderShield premiums payable until age 65. This means that each cohort saves up for their own long-term care needs, and taps on these savings in their senior years, thereby minimising inter-generational transfers across cohorts. CareShield Life and ElderShield premiums are set based on this pre-funding principle, and in line with internationally-accepted industry standards and principles.

Several Members – Ms Anthea Ong, Ms Irene Quay and Ms Tin Pei Ling – have asked about gender-differentiated premiums. In particular, Ms Quay expressed concern that gender-differentiated premiums could start the trend of potentially differentiating premiums in future by reference to other factors, such as race and so on. We have explained this previously the actuarial basis for this feature, but we do recognise there are other factors at play. Let me just quickly recap it and address the points raised by Members.

Actuarially, it is recognised that women live longer, are more likely to experience severe disability, and live longer in severe disability. Let me just outline this with reference to some statistics and numbers using Singaporean-based profile and information.

In 2017, the average life expectancy at birth for women is 85.2 years as compared to 80.7 years for men. As individuals are more likely to become severely disabled in old age, women have a higher probability of becoming severely disabled in their lifetime. Three in five healthy women at age 65 are expected to become severely disabled, compared to two in five healthy men at age 65.

In addition, when disability happens, women are also likely to remain in disability for a longer period of time than men. Women aged 60 are expected to spend 7.8 years requiring assistance with any of the ADLs, compared to 2.6 years for men. And those are based on a study done in Singapore of Singaporean numbers. This means that women stand to receive more benefits from CareShield Life if you look at it across the spectrum, and hence, their actuarially priced premiums are higher.

We could average out the premiums across genders. I think some Members have alluded to that. But this only works if it was a fully universal scheme where there is no option.

As CareShield Life is optional for existing cohorts, gender-neutral premiums could well encourage male policyholders to stay on ElderShield and buy gender-differentiated Supplements from the private insurers, which may now then appear cheaper. As Members know, the ElderShield premiums are gender-differentiated. Conversely, female policyholders would now find CareShield Life a much better deal than the existing gender-differentiated ElderShield. This increases the risk of gender skewing in the risk pool as more women than men would join the CareShield Life Scheme. The gender-neutral premiums would become increasingly unsustainable and premiums would have to increase, possibly approaching the level women would have had to pay anyway under a gender-differentiated scheme, but without covering a significant proportion of men.

In response specifically to Ms Irene Quay's query, I should explain that actuarial differences in claims experience by gender is well-established both locally as well as globally. However, there is limited data to support such differences based on other factors such as race or genetic factors, which is why we look at this as an actuarial factor. So does ElderShield and ElderShield is supported by a series of other private insurers. In addition, I would also like to note that ElderShield Supplement premiums are not differentiated by race or genetic factors, the same factors that Ms Quay has outlined. And my Ministry will not allow insurers to do so. Hence, the concerns I have just explained with regard to gender would not apply, and there is no impetus for us to differentiate CareShield Life premiums using these factors.

Nonetheless, Members have raised fair concerns about affordability for women, and I think those are fair points, and the need for greater inclusiveness for a national scheme. But let me explain it this way. If you have seen the numbers that I have outlined, I would suggest that greater inclusivity also means ensuring that the actuarial integrity of the scheme in itself should be the proper basis for designing the scheme's terms and that in the long term ensures a fair long-term sustainable outcome.

We will, however, address affordability separately, including the points raised by Members, through the provision of means-tested premium subsidies and Additional Premium Support. The means-tested premium subsidies are intentionally designed to be based on a percentage of premiums so that lower and middle-income women will receive larger dollar quantum. So, in absolute dollar terms, the Government subsidises women more compared to the men in their age cohort and of the same income levels.

I would also suggest to Members in this House that a gender-neutral premium, or gender-neutral scheme design, might at first blush appear inclusive. But if you take into account the factors that I have outlined, looking at that in terms of the payouts and the expected payouts and for the period of those payouts, then in the longer term it would likely lead to women from existing cohorts opting into CareShield Life, and men choosing to stay away. We would then have a gender-skewed coverage, and this would have the unintended effect of further worsening national solidarity over the Scheme, in the longer term.

Dr Chia Shi-Lu, Mr Png Eng Huat and Mr Leon Perera amongst others asked what information about the administration of CareShield Life, the management of the insurance fund, and the premium pricing methodology – what information will be available. Let me assure Members that the Scheme will be transparent. Minister Gan has explained earlier, the accounts of the CareShield Life and ElderShield Insurance Fund will be made public. We will also publish relevant information on the premiums collected and payouts made for the CareShield Life and ElderShield Insurance Fund on an annual basis. The public can be assured that the information shared will be similar to that for MediShield Life, and the CareShield Life Council will also consider what other information might be useful having regard to industry norms.

As we explained in Parliament in July last year when we debated the White Paper, premium pricing is an extremely complex exercise, and, in coming up with a scheme design, MOH has engaged professional actuarial consultants to construct an actuarial model to do so. For example, underlying assumptions include mortality and morbidity assumptions, and how these change over time and over age for the population. Given these complexities, instead of just publishing a large number of actuarial tables, it is a lot more meaningful to release relevant information in a manner that can be easily understood and reviewed by a layperson.

I think Mr Png had a query on the US numbers; he had the 52% numbers. The query, I think, centred on the statistic that in the US, 52% of elderly would require long-term care assistance and asked whether this was taken into account. This along with information coming out from the UK and Japan was not taken into account in computing the premium in this case. On the assumptions backing one in two that was shared previously – and I think that was the point Mr Png also raised – MOH had engaged the professional advice of actuaries to compute this estimate, using the assumptions, parameters and the model that I spoke about earlier.

The projections are based on ElderShield claims experience but also draw information from a wider range of cross-sectional and longitudinal sources, given the limited experiences at older ages. As shared previously, the actuarial pricing data we look at includes insurance schemes in the US, Taiwan and South Korea. It does not mean we used their data wholesale. It looks at the models they have there, looks at our claims experience with ElderShield, draw them together, use the models and get the expertise of the actuaries and provide the scheme design.

At the end of the day, I should emphasise that if the actual claims experience was better than expected – in other words to take Mr Png's point – if we were more conservative with designing the scheme, that if the premiums collected are more than what is needed, then any surpluses from any of these excess premiums will be fully returned to policyholders, for their benefit. The Council could recommend for the surpluses to be returned in a number of ways such as higher payouts over the years, reduced premium increases over the years, or premium rebates. We intend to give the Council the flexibility to study factors and to make recommendations so that they adequately respond to changing circumstances and the needs on the ground.

I should also outline that there is a publication by the Singapore Actuarial Society that is now available publicly. It provides a broad explanation of the key pricing assumptions and risks for long-term care insurance, the challenges for pricing long-term care insurance, the concept, the thinking behind the models and also, advantages of pre-funding for long-term care insurance. If Members are interested, this technical paper was recently released by the Singapore Actuarial Society.

Mr de Souza asked about inter-generational equity given that monies for both CareShield Life and ElderShield schemes will be placed in the same insurance fund. Let me assure the Members that moneys for the schemes are placed in a common insurance fund for capital and administrative efficiency. For example, Government capital injections into the insurance fund, which are meant to support tail-end risks, can benefit the capital needs of both schemes. However, monies maintained for CareShield Life and ElderShield will be tracked and accounted for separately. I would like to emphasise that monies collected for one scheme will not be used to fund the other scheme.

Secondly, we will establish the CareShield Life Council as a key safeguard over scheme sustainability in the long term. The CareShield Life Council will be independent and will review and make recommendations for both the CareShield Life and ElderShield schemes.

As Minister Gan had explained earlier, one key role of the Council will be to make recommendations to the Ministry on the adjustments to CareShield Life premiums and payouts to ensure sustainability. In response to Dr Chia’s question on how often the premiums and payouts will be reviewed, let me assure Dr Chia that the Council will monitor the disability trends and claims experience of the schemes closely and on a regular basis. Let them decide how regular they feel they need to and it is possible that the review regularity may be more in the earlier years, as we start the administration of the scheme. We will then determine the exact cycle for the adjustments thereafter, in consultation with the Council.

To enable the Council to perform its functions, the Council will comprise individuals with different, diverse backgrounds, ranging from healthcare practitioners, medical social workers, auditors, investment professionals, union members and also, an actuary who is a Fellow of the Singapore Actuarial Society, as Ms Quay has suggested. The Council will also be supported by independent, external actuarial consultants.

Third, again similar to MediShield Life, the Bill also includes provisions for premium payment enforcement to enable us to take action against wilful CareShield Life premium defaulters.

The principle behind this is clear. You have to be fair to all policyholders and individuals do need to play their part by keeping up with and paying the CareShield Life premiums. Enforcement provisions are therefore necessary to ensure that wilful defaulters pay their premiums, instead of having their premiums unduly borne by other policyholders.

Fourth – and Mr de Souza raised this point – we intend to take a strong hand against fraudulent assessments and misuse of payouts. The Bill provides that maximum fines and penalties for the offences of fraudulent assessment and misuse of payouts will be twice the maximum fine and penalty for the offence of false declaration. This is commensurate with the more severe nature of these offences and also having regard to the fact that a nominated payee is acting on behalf of someone who is disabled.

To Dr Chia’s query on how we can further guard against fraudulent claims, let me assure Members that regular audits will be conducted. No audit will be 100% foolproof, but audits will be done, patterns will be studied, to sieve out potential fraudulent claims. So, for instance, we might look at cases where a claimant who was assessed to be severely disabled and then subsequently assessed not to be not disabled at all, within a short period of time. These markers will allow my Ministry to look into further cases and investigate them.

To Miss Chan’s query on whether we will audit nursing homes or service providers who have access to their patients’ payouts, let me first clarify that these providers generally only have access to the payouts if the policyholder or the care-giver had nominated these providers to receive the payouts on their behalf.

Where the policyholder lacks mental capacity to do so or/and is destitute, the nursing home can act on his behalf to apply for payouts, but this will be on very exceptional circumstances. Let me assure Miss Chan that we will audit providers who receive these payouts to ensure that they are using the payouts in the interest of the policyholder and towards the policyholder's care.

We would like to make clear that the audit and enforcement framework is not intended to penalise bona fide assessors or care-givers. Sometimes, genuine bona fide mistakes are made, and sometimes, to answer Mr de Souza, what might be a reasonable position. One could consider a situation where a care-giver living with a policyholder who uses part of the benefits for household expenses of the policyholder’s family, when the policyholder's needs are already well taken care of. So, in other words, part of the same household, needs are already taken care of, and the funds which are fungible are applied for another reason when the basic needs of the policyholder are already taken care of. So, in those situations, we do not intend to penalise the care-giver.

To Mr de Souza's other query, it is indeed our intent to return payouts to policyholders in the event of misuse.

The fines and penalty structure meted out under clause 50(2) of the Bill is to be paid to the Consolidated Fund – the fines go into the Consolidated Fund. However, clause 50(3) provides for the Courts to order the errant payee to refund payouts he or she has received into the CareShield Life and ElderShield Insurance Fund. So, those wrongfully received payouts will be put back into the Fund for the administrators to consider giving to the proper payee.

These monies can then be paid to that person or a nominated payee at the directions of the policyholder or the policyholder’s care-giver.

Like Ms Joan Pereira and Dr Chia, we do take a serious view on data confidentiality and the safeguards in the Bill reflect this, as Minister Gan has elaborated upon earlier. Some Members were concerned about the security of the CareShield Life IT system. We will design and build the system to stringent security standards, for example, by restricting system access to only approved users, encrypting data sent across organisations, and also monitoring and tracking system activity.

Fifth, we must ensure that MediSave monies remains adequate to meet an individual’s healthcare needs in old age. We all want to do a lot; we all want more payouts; we all want less premium, and we want there to be lower ADLs. That I think is a summary of the debate that we had today. But remember what I said at the outset, it must be designed for a broad majority of Singaporeans and kept affordable, and I think that has to be the design intent. I would also like to borrow Prof Theseira's point, so eloquently put, that we do have to use these schemes judiciously, we have to have an internal discipline to what can or cannot be used out of MediSave.

Members have raised several queries on the withdrawals from MediSave for long-term care. And some have also asked for the criteria to be relaxed and so that we can extend the withdrawals to that of severely disabled children, parents or siblings. And yet others in this House have expressed concerns over the sufficiency of MediSave, given the increased flexibility.

It is important to remember that MediSave's primary purpose is to help Singaporeans save up during their working years for their healthcare needs in the old age. As a general broad proposition, I think that would find no quarrel. Expansions or increases in MediSave usage will obviously impact adequacy for other healthcare needs, and they have to be considered carefully, as Prof Theseira has outlined.

As a first step, MOH has extended MediSave cash withdrawals to the severely disabled in view that their care needs are typically higher – more intensive and higher. As we recognise that the amount withdrawn can be significant depending on the length of the disability, we have started by proceeding cautiously by limiting the use of MediSave withdrawals for long-term care to the member or the member’s spouse only. This ensures that the MediSave adequacy of the severely disabled member’s children and their ability to afford current and future healthcare expenses are not impacted. So, that is also a cross-generation issue that Mr de Souza alluded to earlier.

Singaporeans who are in financial need and have low MediSave balances may apply for other Government schemes, such as ElderFund, to obtain additional support for their long-term care costs.

Mr de Souza, I think, asked about $5,000 – why $5,000 as a floor for MediSave withdrawal. It has been set to ensure that Singaporeans have some savings to help pay for their other healthcare bills, whilst at the same time allowing immediate access to MediSave for long-term care needs. It is really about striking the right balance between the two competing interests.

Next, we have planned ahead, with the Minister for Finance, setting aside the monies for the Long-Term Care Support Fund in advance.

Let me just respond to Dr Neo's and Prof Fatimah's question on how long the monies in the Long-Term Care Support Fund is designed to last for. I would like to explain that the majority of the monies in this Support Fund will be directed to existing cohorts as they are older and they are expected to form the majority of CareShield Life policyholders at the start. The majority of ElderFund beneficiaries are also expected to be in these cohorts given the higher prevalence of disability in old age.

This Support Fund is sized to be more than adequate for these cohorts as they age into their silver years. So those are the parameters, and this is the cohort that we intend to look after with this Fund. Nonetheless, as we progress and as there are more information and more claims experience, we will review the adequacy of the Long-Term Care Support Fund on a regular basis.

Sir, I have covered the three key principles undergirding the design of our long-term care financing system and the various safeguards and supporting provisions in the Bill. All three principles are essential for us to deliver a financing support system that can benefit all Singaporeans, regardless of income levels or disability status, for generations and, we hope, generations to come.

Let me turn now to the last topic on communication and outreach efforts. Members have asked about our communication and engagement efforts on the new schemes, and our efforts to explain the importance of planning ahead for long-term care.

Since May 2018, we have in fact been busy engaging the public on these enhancements to our long-term care financing system.

The Ministry has held over 60 public briefings and engagement sessions to-date and will continue to do more and spread information on this and educate the public, explain queries and help them with looking at their own landscape and deciding whether or not CareShield Life is suitable for them. This is on top of the numerous briefings which I am sure all of us in this House would have diligently done at our grassroots events over the weekends and so on. And I ask as I did earlier, that this continue.

As the Minister has mentioned earlier, CareShield Life will be launched around mid-2020 for Singaporeans born in or after 1980. Given that these cohorts are younger, our engagement efforts for them will also have to be tailored to media platforms that are typically used by that generation of people. So, social media, for instance.

We aim to progressively launch CareShield Life for existing cohorts born in 1979 or earlier from mid-2021.

We will commence engagement efforts for these cohorts closer to the launch in 2021.

Other than mass outreach in this fashion, the Silver Generation Ambassadors will also conduct face-to-face engagement with older Singaporeans in the existing cohorts. I hope this assures Members that the Ministry's efforts to ensure that Singaporeans from the existing cohorts are aware of the scheme’s benefits and will be able to make a considered decision on whether to join CareShield Life.

Of course, in all of our engagement efforts, we will not just be explaining the features of CareShield Life.

As Ms Tin pointed out, we will need to address the "why", and that I think is equally important. We have to explain why this is useful, and why planning for long-term care is important.

We also need to set out holistically how the different pillars of long-term care financing support work together so that people, just as Members in this House have, will have a holistic view of the different schemes, the different support structures that exist in this space.

We should also explain how different types of basic insurance schemes such as MediShield Life, the Dependants’ Protection Scheme, and CPF LIFE – they all serve a different aim and purpose, and perhaps a different constituency of people, but they are all complementary in this landscape.

Finally, Mr Deputy Speaker, let me conclude. As Singaporeans live longer, our healthcare system has to evolve to better serve the needs of Singaporeans.

We have put in place measures to help Singaporeans remain healthy for as long as possible, and on that I thank Dr Lee for so warmly embracing HPB's efforts. They will continue to do so. We do believe that going upstream to ensure that we keep the healthy well for as long as possible, should be the next bar.

At the same time, we will continue to invest in infrastructure and the services, as I outlined in the start of my speech, to support those who fall into disability. At the same time, we have built up our long-term care financing eco-system, with the introduction of various new schemes, based on the key principles of inclusiveness, affordability and sustainability.

The CareShield Life and Long-Term Care Bill contributes to that effort, strengthens the landscape in that space and enables the key pillars of this financing framework to be put together. As we continue to build on those efforts, I would like to urge the Members of this House to give your support to the CareShield Life and Long-Term Care Bill. Mr Deputy Speaker, on that, I beg to move.

Mr Deputy Speaker: Ms Anthea Ong. You are raising a clarification, right? This is for clarifications only.

6.14 pm

Ms Anthea Ong: I am not going to make a long speech; do not worry. Thank you for the reminder. I thank the Senior Minister of State Mr Edwin Tong for his response. I appreciate that that was very comprehensive.

Could I just ask a very simple question regarding the gender-differentiated premiums? He mentioned earlier that the concern is that if we do it as gender-neutral premiums, then we are going to be worried about men not wanting to come on the scheme. I am finding it a bit of a struggle to understand how do we know that that would be the case? Maybe we should do a dip test here, but I just find that hard to understand. Could you please clarify that?

Mr Edwin Tong Chun Fai: If you follow the numbers that were outlined earlier – and that is one set of numbers and there are others that support this proposition as well – then, you would know that women, generally – I do not want to say specifically – generally will live longer, longer life expectancy. They fall into disability and require support for a longer period of time.

So, if you look at the scheme design, if you fall into serious, severe disability. You will make the qualification and the payouts are then given. For a typical woman, that payout will last for a longer period of time, and so the assets of the common fund will be depleted more quickly as regard a woman than it is for a man. Over time, that will have a bearing on the premium that will be payable.

When that happens, if you pay the premium in equal proportions between a man and a woman, and the man depletes the resources in the pool at a lower or slower rate than the woman, then you can see that there will be a differentiation. And over time, that differentiation will result in the man effectively paying for part of what the woman enjoys in the context of this scheme, which is why we made the point earlier – I think in the previous debate, last year, Minister Gan also made the point – that we try as far as possible to keep the scheme design and the terms of the scheme actuarially consistent. We look at what insurance typically do. Calculate it on the same basis, but at the same time, outside of the scheme, we look at ways and means to assist. And it is not just for the gender-differentiated premium. We assist also those at the lower income.

It is not built into the scheme's terms because that is not part of the actuarial calculations. But at the same time, we use that which makes the integrity of the scheme actuarially correct, but at the same time using additional support mechanisms to support those and help those who may not be able to afford it. So, I hope that answers the Member's question. But she may want to look at the paper that I can share with her that looks at this and looks at what impact this has on the way in which premiums are calculated.

Assoc Prof Walter Theseira: Mr Deputy Speaker, I thank the Senior Minister of State for the really wonderful wrap-up speech. But while I agree with him that adverse selection is going to be a problem if you have gender-neutral premiums in the private market, I wonder what are his views on whether this would be an issue in the mandatory component of CareShield Life. Because with the mandatory component, the Ministry is, in fact, free to have gender-neutral premiums without incurring any sort of adverse selection there. I think the issue, really, is although I generally believe prices must be right, there is an element of equity here and obviously many learned Members believe that it is important for there to be some kind of cost-sharing between the genders here. So, equity also is a consideration besides just prices being right, here.

Deputy Speaker: May I request that both clarifications and answers be kept short? We still have two more Bills after this.

Mr Edwin Tong Chun Fai: Yes. The Member's point concerns the impact that a universal scheme might have. If the scheme was universal, there might well be different considerations, but this scheme, the way it is designed as the Member would know, is not universal. There is an option for the existing cohorts. And that is where the differentiation will result in there being an imbalance.

Ms Jessica Tan Soon Neo: I thank the Senior Minister of State for the round-up. I would just like to ask him clarifications fir the question I asked earlier, which is, if someone does not qualify because of the three ADLs, but with two ADLs or even one ADL, is somewhat unable to continue to work and earn an income and therefore has difficulties paying for the premium, is he or she still expected to continue to pay the premiums, in those kinds of situations?

The second area – and I seek the Deputy Speaker's indulgence on this – I did not want to speak about the gender aspect because I had read the report, but after hearing the Senior Minister of State's round-up speech, I have to ask some questions. Just as it is an actuarial view of the risk factors, it is also a lens that we all put on to look at which risk factor or which differentiated factor we look at. Last night when I read the report again on the burden of disease, I actually looked at it from a gender differentiation lens. And therefore, I came to the same conclusion that, actuarially, it is a fair system to have that differentiation. But having heard this and hearing the point about the fact that this is a partial universal system and all that, if we took from an actuarial standpoint another factor, that is the risk factors affecting the disease burden or the disability, and I go back —

Mr Deputy Speaker: Ms Tan, please do not make an advocacy for that point.

Ms Jessica Tan Soon Neo: Okay, sorry. On the point about the health factors that affect Singapore in 2017, it is really dietary risk, tobacco, high blood pressure and high blood sugar. A lot of these are due to lifestyle and also genetic factors. If we took that view and we put the same actuarial lens on it, then we would come to a different conclusion on the differentiation to be used for premium. I will leave it at that point.

I will ask the Senior Minister of State, with better experience, can we, at some point in time, with the experience of CashShield Life, as he has said it many times in his speech, can we re-look, with that data, the experience and the trends, to see if premiums could be adjusted, at that point in time with better knowledge and intelligence from the data?

Mr Edwin Tong Chun Fai: I think the short answer to the second question is certainly yes. With more claims history, with the progress of the Scheme and with more information and obviously more studies done, all those will be taken into account as adjustments are made; and maybe even the design architecture of future schemes considered.

But for now, I think the Member will remember that I have cited the paper which says that the period of time that a woman is living in disability is about three times – 2.6 and 7.8, I think it was. And I think that is the type of number that actuaries would use to look at the calculations.

On the first point, if one is not at the severely disabled stage, then yes, the premiums do continue until the three ADLs is hit. But if the policyholder is unable to support it, then, she has heard from the Minister and myself, the whole series of support mechanisms will kick in to ensure that this person will not suffer a dropout from the policy, only because he is unable to pay his premium. And particularly, as the Member Ms Tan has mentioned, if it arises from the one or two ADLs and he has lost his job, then I think a case can be made for support to be given to this policyholder.

Mr Deputy Speaker: Mr Pritam Singh. Clarifications; no more advocacy please.

Mr Pritam Singh (Aljunied): Thank you, Deputy Speaker. Just a quick question. Earlier on, there was a comparison about how high premiums could rise if we drop the qualifying criterion from three ADLs to two ADLs: that premiums will go up by one-third. Is there a similar calculation the Ministry has done if indeed there were gender-neutral premiums? How much more would men have to pay?

Mr Edwin Tong Chun Fai: We have not done this calculation simply because when we looked at it and when the Scheme was designed with actuaries, that was the component that was put in. This was the recommendation of the actuaries. When you look at the way in which the current ElderShield policies are designed as well, that is no different. I will make one other point, that when we look at the – the Member's earlier point was on the way in which we designed the Scheme?

Mr Pritam Singh: No, just this question.

Mr Edwin Tong Chun Fai: Just that? Okay.

Mr Deputy Speaker: Mr Yee Chia Hsing. Last clarification.

Mr Yee Chia Hsing: Thank you, Sir. I would like to ask about additional support for those families who are currently struggling with senior care, and who need to hire helpers or to put their seniors in nursing homes, for MediFund, the trigger at present is when the families cannot pay their hospital bills. The medical social worker will then be triggered. But for these families, since they put the seniors in nursing homes or since they need to hire a helper, what is the trigger point to let the agencies know that these families actually need additional help?

Mr Edwin Tong Chun Fai: That is a broad question and I would say that we have a broad number of options available. When the Member said "trigger point", I am not sure I follow. But obviously when a family is in need of assistance, there is a whole series of schemes that can be invoked – and I do not want to repeat them but I have outlined them and the Minister has outlined them. The Member mentioned a helper, the Home Caregiving Grant does serve that need as well. And the criteria there is, of course, as I have mentioned earlier, the threshold is lower than the current CareShield Life ADL criteria.

So, I hope that addresses at least a part of the Member's question. If there is a specific point that the Member wishes to follow-up on, I am happy to do so offline.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. – [Mr Gan Kim Yong].

Bill considered in Committee; reported without amendment; read a Third time and passed.