Making CareShield Life and long-term disability care more inclusive

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

The CareShield Life and Long-Term Care Bill, which Parliament passed on Sept 2, establishes a mandatory public insurance scheme for long-term care. Its policy intent of being universal and inclusive is admirable.

I’m heartened that my concern raised in Parliament for mental health illness to be included in the definition of severe disability has been allayed. Disability assessments will include cognitive impairments and be based on what the patient actually does rather than what patients can do.

Yet significant groups of people are still undervalued or left out in the policy design. Several parliamentarians, including myself, have questioned why women will have to pay a higher premium for CareShield Life than men.

The Government has explained that this is based on the actuarial assessment that generally women live longer as well as fall into disability and require support for a longer period of time.

In other words, for a typical woman, the payouts will last for longer than those for a man, and hence the differentiated pricing to keep the design and terms of the scheme actuarially consistent.

The Government adds that premiums for the current ElderShield scheme are also gender-differentiated. But ElderShield is administered by private insurance companies and not a compulsory national scheme. Elsewhere, the European Union’s highest court in 2011 banned the practice by insurance companies of gender-differentiated premiums.

Surely, we must go beyond the actuarial rhetoric. Our social and health policies are not defined along gender lines, so why start now?

Men and women receive the same amount of healthcare subsidies and benefits despite the greater susceptibility of women to chronic illness and disabilities. This is because 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 Central Provident Fund balance for females aged 60 years and over was S$69,732, which was about 24 per cent lower than that of males.

Among women, only 53 per cent were able to reach the Basic Retirement Sum as compared to 66 per cent of men. In the 2018 Labour Force Survey, 80 per cent of family caregivers who are outside the labour force to provide caregiving to relatives/families (this does not include children) are women, all 75,000 of them. They suffer from loss in income, affecting their ability to save for their own retirement and healthcare needs.

We must not forget the unaccounted value of how much women have contributed since the independence of Singapore. Instead of recognising and compensating the vastly unequal amount of unpaid work they do, it appears that we are now proposing to further penalise them. I don’t believe this is the kind of social compact we aspire to build.

Article 12 of our Constitution also provides that “all persons are equal before the law and entitled to the equal protection of the law”. The Government has acknowledged in its latest Convention for Elimination of Discrimination against Women report that the principle of equality for women is entrenched under this Article.

Designing a mandatory and national long-term care insurance scheme with a framework that discriminates based on gender will set us back a long way in pursuing gender equality.

According to the Care Where We Are report by Lien Foundation, Singapore spends only 0.19 per cent of Gross Domestic Product on long-term care compared to the Organisation for Economic Cooperation and Development (OECD) average of 1.7 per cent of GDP.

We are certainly in a position where we can afford to spend slightly more to pave the way for a more equal society, especially if we are concerned that men may not come on board CareShield Life if we make the premiums gender-neutral.

It might also be helpful if we know exactly how much more men would have to pay in such a scenario.

If we use gender now, what is to stop us from using race and other genetic factors in the future to determine pricing with the advent of precision medicine as challenged by my fellow Nominated MP, Irene Quay? I agree with her because we are opening a Pandora’s Box in social equity.

Besides, of the five OECD countries that offer national long-term care insurance — Japan, Germany, Luxembourg, Netherlands and South Korea, none opted for premiums to be differentiated by gender. Somehow, they managed to put aside the actuarial science to design the premium pricing by income instead. 

Beyond gender, it is also pertinent to ask if we should also extend CareShield Life to children and young persons with disabilities who need long-term care? 

Studies have estimated that there are around 2,000 children with life-limiting conditions in Singapore, who would potentially be in need of long-term care should they continuously manage to stave off their life-threatening conditions. 

These children and their families require support for significant long-term care costs, including for hospitalisation, surgery rehabilitation, special aids, among other expenses.

We should consider allowing children and young persons to be enrolled into this national long-term care insurance, with premiums paid by their parents either through their Medisave accounts, or through government schemes like Baby Bonus. Medisave withdrawals for long-term care should allow all to do so regardless of age.

While actuarial fairness and sustainability of the schemes are important considerations, we must not forget that public long-term care insurance schemes are often designed on the bedrock of social solidarity.

I believe that solidarity with all Singaporeans — regardless of gender or age should be important guiding principles for a care system in a country which now ranks among the wealthiest in the world. Because surely the head can follow the heart, sometimes.

ABOUT THE AUTHOR:

Anthea Ong is a Nominated Member of Parliament, a social entrepreneur and author of 50 Shades of Love.