Helping Our Disabled Live Life with Dignity

Sir, the proposed amendments to the CareShield Life and Long Term Care Act seeks to introduce certain amendments, to redefine the circumstances under which the scheme applies to certain individuals, and to provide for the service of documents related to the Act. I will focus my remarks on the first element, dealing with the scope of coverage of CareShield Life. I will begin with elements close to the specificities of the present Bill, before moving to more general issues of coverage.

Coverage aspects directly addressed by the Bill

Clause 3 amends Section 6(1)(b) to automatically enroll new citizens of permanent residents (PRs) born before 1980, and who became citizens or PRs after October 2020, so long as the individual was not already severely disabled. This would, effectively, compel enrollment for those aged 45 and older into the scheme, if they happened to have recently altered their immigration status. In contrast, long-time citizens and residents remain grandfathered on the older, discontinued ElderShield scheme.

This effectively creates a disparity between older new citizens and residents, and existing ones, if the latter had not opted into CareShield Life. Does the Ministry have any concerns over whether this disparate treatment may become an issue in the future? If so, would it not be better to compel all to move over to the new scheme?

Relatedly, these amendments—along with those to Section 6(4)(b)—exclude those who are severely disabled from the scheme, unless approved by the Minister. I understand the economic rationale for such exclusions: we do not wish to create a case of adverse selection, where those enrolled in the scheme are all already disabled, thereby rendering the risk-sharing aspect moot. Still, it remains a moral responsibility for society to take care of those that are already disabled.

Now, I understand that the government does have in place a multi-pronged approach for supporting such individuals. This includes taxpayer-funded, means-tested subsidies and grants, other insurance schemes, access to self-funded healthcare savings, and a last-ditch safety net. Still, I would appreciate a comparison of how those without CareShield Life coverage would fare, relative to those who are otherwise reliant on piecing together these disparate sources of financial support.

Moreover, it is unclear how the Minister will exercise this discretion afforded to him. Are there specific conditions that would lead an individual to be approved or excluded?

Clauses 7 and 8 formalize the 6 activities of daily living, for which an individual must require either maximal or total assistance in 3, before they are considered severely disabled, and thereby qualify for CareShield Life.

I will start by noting the slight difference in the 6 categories defined by MOH, relative to other standards. In particular, our basic ADLs include a separate mobility function, which I believe is a significantly higher bar than simply transferring. It also strikes me as a greater hurdle than either hygiene and grooming, or continence, which are used by the World Health Organization’s International Classification of Functioning, Disability, and Health, or the Katz Index, respectively.

Perhaps more important is that these 6 ADLs remain an incomplete representation of an individual’s ability to function in a modern community. They mainly describe aspects of physiological self-care, but exclude important ancillary aspects of psychological or social behavior that are nevertheless necessary for independent living, otherwise known as instrumental ADLs (IADLs).

While I accept that it is not possible to cover every possible aspect of effective functioning, I believe it is nevertheless important to recognize that such instrumental ADLs can be materially impacted after critical illness, which is precisely the sort of circumstances where one would hope insurance protection kicks in. Moreover, dignified living in modern Singapore virtually requires that individuals be able to perform certain IADL tasks, such as preparing or purchasing meals, handling money, and using transportation. The lack of mention of these activities in the evaluation criteria for disability coverage under CareShield Life is even starker, when such metrics are already being accounted for by local medical support organizations, such as Dementia Singapore and College of Family Physicians. It is also a bipartisan concern, having been raised in the previous term of Parliament by members from both sides of the House.

Admittedly, including all IADLs in coverage will likely mean a larger risk pool, which could in turn materially raise premia. This is an empirical question, but even if we do not go the full extent of including all on the list—which typically includes up to 8 tasks—activities like communication, transportation, and medical management appear to be functions much more necessary for living in a modern city-state such as Singapore.

A related concern is whether the need for maximal or total assistance in 3 activities is more reflective or indicative of severe disability than, say, moderate assistance in 5 activities? Indeed, using an index approach, it is possible to construct outcomes where those who qualify for CareShield Life as severely disabled might even score higher on an index of daily functioning than someone else who scored lower. If we take the notion of disability assessment seriously, then, we should move away from a binary outcomes—of an inability to perform at least 3 ADLs—toward a more clinically-corroborated approach that relies on index scoring. Following indexes is employed in jurisdictions such as Australia, Japan, the United Kingdom, and the United States.

Operational concerns related to CareShield

Let me move on to more general issues about Careshield Life, which were flagged in the 2025 Review Council Report, but not yet directly addressed in the present Bill. These have, directly or indirectly, resulted from my interactions with residents that have faced difficulties associated with the current operation of the scheme.

The first concern is related to the optional enrollment process for those born 1979 and earlier. One issue is whether the 60-day “free-look” period is too brief for those who enroll to decide on whether they wish to remain on the scheme permanently. Relatedly, some appear not to fully understand when they are truly getting themselves into, in terms of what it means in terms of ongoing premium payments.

While I understand that underwriting principles require that participants be locked in, I wonder if the free-look period may be extended to a longer duration, such as 3 months. Similarly, would it be possible for enrollees to opt out within a year, perhaps with some penalty. After all, while optional exits would undeniably mess with actuarial calculations, opting out tends to be far less distortionary for the long-term financial stability of the fund, compared to unrestricted opt-ins.

Second, the government has assured the public that they “will ensure that no one will lose coverage due to an inability to pay their premiums”. This is important, not least because cost of living pressures, while abating somewhat over the past year, remain a major concern for many Singaporeans, and the last thing we would like to do is to saddle our workers with yet another cost increase, at a time when they are also concerned about job security.

Will the Ministry clarify what proportion of current participants currently receive premium support, and what would the process for accessing additional premium support be? In particular, would this support kick in in the event that they lose their job, so that they do not simultaneously risk losing insurance coverage?

Third, I would like to know whether, in practice, CareShield Life will be run by the Central Provident Fund (CPF) Board—under the direction of the Ministry of Health—or if it will be outsourced to a third-party private insurer, such as Income Insurance, to administer.

I ask this because, to my knowledge, other insurance programs run by the CPF Board—the Dependents’ Protection Scheme (DPS) and the Home Protection Scheme (HPS)—appear to be administered by companies such as Great Eastern and Income Insurance.

I have encountered instances where residents expressed their dismay about how they were caught unaware that there were lapses in their coverage of either the DPS or HPS, due to insufficient funds remaining in their CPF Ordinary Accounts (OA). Of course, it is possible that some may be surreptitiously trying to reinstate their insurance plan ex post facto, to make a claim after an untoward event.

But here is another plausible reason: because premiums had previously been automatically deducted from their CPF OAs, they did not meticulously track the need to routinely make payments. They were thus unaware when, due to inadequate OA balances, that their coverage had lapsed. Moreover, because they were expecting a contractual relationship with the government, not a private entity, they proceeded to overlook reminder mailings sent by these companies.

For this reason, I believe that it would be useful to ensure that, should CareShield Life ultimately be outsourced to a private insurer for administration, that correspondence pertaining to the scheme still come directly from CPF Board, or feature a CPF Board logo prominently in the letterhead. This will ensure that policyholders treat such correspondence seriously.

At the same time, CPF must assure the public that, despite being managed by a nongovernmental entity, claims will continue to be evaluated not just with an eye toward actuarial prudence but also compassion and common sense. This will ensure that the hard-won trust of Singaporeans in the institutions of government is not inadvertently squandered by private corporations chasing a bottom line.

Conclusion

Mr Speaker, the recent ruling by the district courts against Income Insurance over its “wholly unreasonable” conduct in denying insurance claims by 78-year old Ko Wah for accident-related damages is a reminder that our pronouncements of a “we first” society must, ultimately, be backed by concrete action that is consistent with that aspiration.

This is, hopefully, an isolated case. Still, we must understand that the promises of CareShield Life to help the most vulnerable in our society continue living with dignity after a devastating accident will only go as far as this is realized in practice. If support is too meager, too perfunctory, or too grudgingly provided, then that promise will ultimately ring hollow.

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