NMP Anthea Ong raises concerns over the CareShield Life Bill: mental health, non-severe disabilities, people with disabilities under 30, and gender discrimination

The CareShield Life Bill was passed in Parliament on Monday (2 September) after its second reading. The Bill makes it compulsory for Singaporean born in 1980 or after to pay CareShield Life insurance starting 2020. However, for those born in 1979 or earlier, the premium is optional. Future cohorts will join when they turn 30. CareShield Life is an insurance that covers Singaporeans if they are affected by ‘severe disability’ and is meant to eventually replace ElderShield which remains optional for Singaporeans. The premiums for this insurance start at S$206 a year for men and S$253 a year for women at the age of 30. This means that Singaporeans will end up making 38 payments until they reach 67. But if they are afflicted with ‘severe disability’, the policyholder will be given a payout of at least S$600 a month, for as long as care if needed. While providing arguments about the Bill in Parliament, Nominated Member of Parliament (NMP) Anthea Ong highlighted a few concerns regarding the Bill like adding mental health in the 'severe disability' category, include non-severely disabled individuals in the group, supporting under 30 Singaporeans who may have disabilities as well as discrimination against women.

Include mental health in the disability category

Under the Bill, a Singaporean is categorised as ‘severely disabled’ only when he or she is unable to perform three or more physical activities of daily living (ADLs)  like washing, dressing, feeding, toileting, walking and transferring. However, Ms Ong noted that ‘severe disability’ is defined in too narrowly in the Bill as it failed to include those with mental health conditions. In fact, she said that this is troubling given that the Ministry of Health announced in 2017 that 12.4% of locals aged 18-74 suffer from minor psychiatric conditions like anxiety or depression, and is estimated to rise to 14% this year. “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,” said Ms Ong, urging the government to have a more inclusive approach when it comes to defining disabilities. “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,” Ms Ong said. She added, “A critical start could be in how we explicitly consider mental health conditions when defining and assessing disabilities. For instance, we can include assessment of equally critical but non-physical ADLs like cognitive ADLs in functional assessments, or as doctors have advocated for regarding disability assessments, assess and score what patient actually does rather than what patients can do. This important differentiation between capacity and performance is crucial because it is what we do which actually determines care needs, and hence caregiver burden.”

Lack of coverage for non-severely disabled individuals

Ms Ong also noted that there are a lot of schemes in the country that that require one to have ‘severe disability’ to be eligible for it. However, there are many people out there who don’t make the cut because they can only, for instance, perform two ADLs and have other mental conditions that affect their cognitive ADLs. Although they should be qualified to receive the schemes designed for them, these individuals don’t get it as they’re labelled as “moderately disabled rather than severely disable”, Ms Ong said. In order to prevent more creation of schemes that concentrate on severe disability as the eligibility, she suggested to first “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”. Secondly, she suggested that “the level of financial support provided (with the current schemes) is tiered against the extent of care need – which in this case could be approximated by the extent of disability”. As a response to the lack of inclusion of mental health and non-severely disabled individuals in the disability category, Senior Minister of State Edwin Tong said that the Ministry understands and accepts Ms Ong’s suggestion, and is “working with experts to improve the disability assessment framework, to explicitly recognise the impact of cognitive impairment on physical disability, this is in line with requests from a number of Members for CareShield Life to also assist those with mental conditions or cognitive impairment”. As an example, Mr Tong said that a policyholder might be physically able to perform different ADLs, but require significant help and prompting on how a certain task needs to be done. As such, he said that the current framework will label this policyholder as “not disabled” as the assessors may not be sure how to assess this policyholder as he can physically complete the all the ADLs. “Under the new framework and revised training curriculum, assessors will be guided with more information, teaching and learning, and will be more explicitly guided on the aspects they should take 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 carry out the ADL. This will result in cognitively impaired policyholders being able to more consistently qualify for CareShield Life claims,” Mr Tong revealed. In terms of Ms Ong suggestion of basing the payout on the extent of disability, Mr Tong said that the Ministry have previously considered it. “I think Ms Ong would also note that lowering the claims criteria to 2 ADLs would immediately increase CareShield Life premiums for a 30-year-old policyholder by about one-third. That’s anything in the range of 25% to 33%, Mr Tong said. He added, “The premium increase for CareShield Life would likely be significantly and exponentially higher if the claims criteria is lowered to 1 ADL, given the higher incidence and length of disability. Not only will there be more persons with 1 or 2 ADLs and the period of support, which is for life, will also be longer. Both will have an impact on the amount of premiums that would have to be collected.”

Gender inequality

In her debate, Ms Ong stated that she understands that CareShield Life premiums are “gender-differentiated due to actuarial assessments”, but it shouldn’t be the case as other healthcare subsidies and benefits in Singapore are given equally to both men and women. She added that women may live longer than men, but they have to carry on with their life with less financial resources. “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,” she said. Therefore, she calls for the premiums pricing to be made gender-neutral given that CareShield Life is a “national scheme that aims to meet the needs of all in Singapore”. In response to this, Mr Tong said that since women live longer, they are “more likely to experience severe disability and live longer in severe disability”. “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 for a fully universal scheme, where there is no option,” he said. He explained, “As CareShield Life is optional for existing cohorts, gender-neutral premiums could encourage male policyholders to stay on ElderShield and buy gender-differentiated Supplements from the private insurers, which may now appear cheaper. Conversely, female policyholders would now find CareShield Life a much better deal than the existing gender-differentiated ElderShield.” Therefore, the Mr Tong said that this increases the risk of gender skewing in the risk pool as more women will opt for CareShield Life scheme compared to men. “The gender-neutral premiums would become increasingly unsustainable and premiums would have to increase, and possibly approaching the level women would have had to pay anyway under a gender-differentiated scheme, but without covering a significant proportion of men,” Mr Tong pointed out.

Age discrimination

Ms Ong also questioned the need to discriminate individuals below the age of 30 as illnesses and disabilities can hit citizens regardless of the age, including children diagnosed with life-limiting diseases. Therefore, she said, “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.” If that is not all, she also asks for amendments to be made on the CPF Act to “allow Medisave withdrawals for long-term care should allow all to do so regardless of age.” Since children and youth might not have a CPF savings that can fund their treatments, Ms Ong suggested to “extend flexibility in allowing parents to tap on their Medisave accounts to support the long-term care needs for their children.” As a reply to this, Mr Tong said that there are other schemes available in the country to help younger severely disabled Singaporeans. He added that MediShield Life will assist in supporting their bills for “inpatient and selected outpatient treatments”. In addition, younger Singaporeans can also gain benefit from schemes like Assistive Technology Fund, Home Caregiving Grant, MediFund and Comcare. Hospitals like KK Women’s and Children’s Hospital (KKH) and National University Hospital (NUH) also provide “programmes such as subsidised therapy services to help parents with children who need that specialised care”.