Hansard, Monday, 2 September 2019

1 Mr Chong Kee Hiong asked the Minister for Manpower in the last five years, what are the statistics for persons with disabilities with regard to (i) their general employment rates, (ii) their employment rates by 10-year age groups and (iii) the main sectors employing them.

2 Mr Chong Kee Hiong asked the Minister for Manpower (a) whether he can provide an update on the progress of programmes to help companies employ and train persons with disabilities (PwDs), including the current number of companies and PwDs involved; and (b) whether there are long-term studies to monitor the effectiveness of these programmes in integrating PwDs.

Minister of State Zaqy Mohamad. Would you like to take the two questions together?

Yes, Mr Speaker. I will take Question Nos 1 and 2 together.

Yes, please.

Mr Speaker, the Ministry of Manpower (MOM) recently started collecting data on the employment outcomes of persons with disabilities (PwDs) through our annual Comprehensive Labour Force Survey, with data available from 2018 onwards.

Among PwDs in the working ages of 15 to 64, the resident employment rate was 28.6%. Another 4.2% of PwDs in this age range were without a job and actively looking for one, translating to a resident unemployment rate of 12.9%. The remaining two-thirds of PwDs aged 15 to 64 were outside of the labour force, with most of them citing poor health or disability as the main reason.

The Member also asked for a breakdown of employment rates by age bands. The resident employment rates for PwDs were 27.6% for those aged 15 and 39; 37.8% for those aged between 40 and 49; 26.1% for those aged between 50 and 64; and 5.9% for those aged 65 and above.

The sectors employing the most resident PwDs are Community, Social and Personal Services, Food Services, Administrative and Support Services and Manufacturing, which together account for more than half of PwD employment.

Besides Mr Chong Kee Hiong, Dr Intan Mokhtar had also filed a Parliamentary Question* for the next Sitting on the effectiveness of Government schemes in helping companies or employers to hire adults with disabilities. In particular, she cited the Special Employment Credit (SEC), Open Door Programme (ODP) and Workfare. I would like to take this opportunity to address Dr Intan Azura Mokhtar’s1 question as well.

To enable more PwDs of working age to be active in the labour force, the Government provides support in several ways. In 2012, MOM extended SEC to employers that hire Singaporeans with disabilities of all ages earning up to $4,000 a month. SEC provides an automatic wage offset of up to 16% of the employee’s monthly income for PwDs aged below 67, and up to 22% for PwDs aged 67 and over. Last year, more than 5,700 employers hiring over 8,600 Singaporeans with disabilities benefited from SEC. This number has increased from 2012, when SEC was paid to around 3,200 employers hiring about 5,000 Singaporeans with disabilities.

Employers and PwDs can tap on the employment support services and programmes under the Adapt and Grow initiative. This includes the ODP and Career Trial. ODP, which is administered by SG Enable with funding support from Workforce Singapore, provides job placement and job support services for PwDs and their employers, and grants for training and job redesign. The ODP Training Grant provides a subsidy of up to 90% of course fees to support the training of PwDs and their co-workers. The ODP Job Redesign Grant provides employers with funding of up to 90% of the job redesign costs, capped at $20,000 per employee with disability, to help integrate PwDs at the workplace.

Some employers and PwDs may have reservations about job fit and the suitability of the work environment. To address these concerns, Career Trial provides an opportunity for jobseekers and employers to try out each other and assess job fit through a trial. During the trial, which can be up to three months, jobseekers receive a training allowance from the Government.

From January 2016 to June this year, close to 780 companies have hired more than 2,000 PwDs with support from the Adapt and Grow initiative. At least 60% of these PwDs remained employed after six months.

Finally, the Workfare Income Supplement (WIS) and Workfare Training Support (WTS) were extended to lower-wage PwDs of all ages in 2012 and 2017 respectively. WIS tops up the salaries and CPF savings of lower-wage PwDs, with up to $3,600 in cash and CPF contributions annually. WTS provides support, such as course fee subsidies, monetary awards and training allowances, to encourage lower-wage PwDs to upgrade their skills. Last year, more than 6,400 Singaporeans with disabilities benefited from WIS, up from more than 3,500 in 2012. The number of Singaporeans with disabilities who benefited from WTS training also increased last year to about 860, up from about 640 in 2017.

There are also ongoing efforts to help PwDs integrate into the workforce. Earlier this year, MOM and SG Enable launched the Job Redesign Guide for Inclusive Employers. The Guide provides step-by-step information for companies on how they can redesign jobs to suit PwD workers, for instance, through changes to the workplace or working arrangements. SG Enable also runs disability management workshops and a biennial Inclusive Business Forum to equip employers with knowledge and skills on how to recruit PwDs and integrate them into the workforce.

Inclusive employment requires collaboration amongst the public, private and people sectors. In March this year, the Ministry of Social and Family Development (MSF) announced the formation of a new workgroup under the Third Enabling Masterplan to look at preparing PwDs for the future economy by enhancing access to lifelong learning opportunities and employment pathways. The workgroup is co-chaired by Minister of State for Social and Family Development Sam Tan and Mayor Denise Phua. The workgroup is engaging PwDs and their caregivers, social service agencies and other disability stakeholders to better understand the needs, challenges and aspirations of PwDs. The workgroup aims to release their recommendations early next year.

Dr Intan Mokhtar.

Mr Speaker, I thank the Minister of State for sharing the data regarding employment of persons with disabilities. I just have two supplementary questions. Firstly, would the Ministry consider extending even more incentives, such as enhanced corporate tax relief for employers, or even instituting some form of affirmative action to ensure that they employ PwDs or those with special needs.

Secondly, would the Ministry also consider setting up a one-stop portal to help PwDs and special needs gain employment? That is, the Ministry consolidates all the job vacancies from different employers so that PwDs know that there is a one-stop portal that they can go to, to look for employment or even training opportunities; likewise, for the employers to do so.

I thank the Member for her questions. I would just like to clarify on the first supplementary question: is the Member asking for more schemes or just putting in place affirmative action?

Both.

As I have mentioned, today, we have the SEC which already subsidises the salaries of PwDs. Other schemes, such as ODP, help with job redesign and so forth. From the perspective of implementing schemes, I think we are quite well resourced. More can still be done to encourage employers to think about having more PwDs and being more inclusive. That is an effort that we are working quite closely with MSF and even the Ministry of Education for the Special Education schools, to see how we can make pathways more available. That is an area that the new workgroup that I mentioned earlier would be looking into. It is a bit premature to be talking about what upcoming policies we would need to shape. But clearly, we can do better in terms of employment outcomes. It is one area we can look at.

On the second question with regard to a one-stop portal, that is something we can study. Today, we have something like a Jobs Bank that Workforce Singapore already has. SG Enable enables the employment of PwDs. That is one area we could potentially study. Let me speak to the workgroup to consider the Member's suggestions.

Mr Chong Kee Hiong.

I thank Minister of State Mr Zaqy Mohamad for that reply. It was reported that just five in 100 PwDs here have jobs. Could the Minister of State please shed some light on the difference in the numbers that he has just cited versus what was reported in the newspapers?

I thank the Member for his question. I have said that today's employment rate for those between the ages of 15 and 64 was 28.6%, which is different from the 5% that was cited by The Straits Times in 2017. This was erroneous because the incorrect data was derived by The Straits Times using different sources of publicly available data. Back then, PwD data from our comprehensive labour force survey was not ready. Therefore, understandably, they had patched together from different sources. For example, for the number of employed PwDs, The Straits Times had used the number reported by MSF in a Parliamentary Question reply which is a composite of PwDs in the private sector who are eligible for the SEC, as well as PwDs in the Public Service. So, they patched that together. This was an underestimate, as SEC does not cover PwDs earning $4,000 and above a month. At the same time, there were also others who were not registered with SG Enable. So, some numbers were missed out.

For the total number of PwDs in our population, The Straits Times applied the estimated prevalence rate from a National Council of Social Service (NCSS) survey of 2,000 persons. This is different from what we have for our comprehensive labour force survey which covers about 100,000-plus persons from 33,000 households. So, it is a lot more accurate view of what the population is.

And given the small sample survey, there is a higher margin of error in estimating the true prevalence rate. Such a small difference in the estimated and true prevalence rate would result in a significant numerical difference in the derived PwD population.

At the same time, The Straits Times used NCSS' estimated prevalence rate for PwDs aged 50 and over to compute the population size for PwDs aged 50 to 64. This is inaccurate as the estimate is affected by PwDs aged above 64. For those above 64, you will find a higher prevalence of disability, not just because of conditions which you were born with, but also because of old age and so you have deterioration of health, stroke and other conditions that also add up to disability.

Therefore, if you look at some of these composites that were put together, there is a difference in the numbers that came out. So, we have now used the comprehensive labour force survey which is more comprehensive. Last year was the first year for which we have available data.

Ms Anthea Ong.

I thank the Minister of State. I have two questions. The first is, we have tracked the number of differently abled people who are employed. Do we know how long these employed people are in their employment? My personal experience is that I almost get a request for employment every other day at Hush TeaBar from the deaf community. I am wondering, as much as they are employed, how long do they actually stay in employment. The second question is, do we have any plans to commit to a national target? I want to qualify that I am not asking for an employment quota for employers, but I am asking if we, as a country, is committing to a national target in terms of inclusive employment, particularly for PwDs.

Earlier, I mentioned that for those PwDs who came through our Adapt and Grow initiatives, at least 60% remained employed after six months. Certainly, from a settling in perspective, we also provide support through the Job Redesign Grant. It is not just to support the placement but also to support the education and cultural awareness education of fellow employees as well, to help them settle in.

At the same time, it is a lot of work. Having spoken to members and workers from SG Enable and other voluntary welfare organisations (VWOs) who are doing this, there is quite a lot of work to do as well to help a PwD settle into some of the workplaces. They may not be easily settled in. But I think we can do better.

Overall, in terms of a national target, it is something we have considered. But I do not think we are prepared to do it at this point, given that we have just got some good visibility on how the situation is. I think our commitment for now is that our employment rates can be improved and this is something for which we need to get more employers on board in order to improve the employment rate and placements for our PwDs. I hope that through greater awareness, through Members like Ms Anthea Ong and other VWOs around, we can certainly do better to bring employers on board, create awareness and help our PwDs to be more gainfully employed.

3 Ms Foo Mee Har asked the Minister for the Environment and Water Resources (a) what are the factors contributing to this year's midges outbreak at Pandan Reservoir; (b) how different is this outbreak compared to previous ones; (c) how experience from previous outbreaks has helped PUB to stay ahead of the curve in fighting the midges issue; and (d) why PUB has not been able to find a permanent solution to the occasional midges outbreaks.

4 Ms Foo Mee Har asked the Minister for the Environment and Water Resources (a) what are the interventions used by PUB to counter the current midges outbreak at Pandan Reservoir; (b) how effective have these measures been in controlling the midges population and mitigating its impact to the surrounding living environment; and (c) what additional new measures are being contemplated to help the community affected by the outbreak.

5 Mr Patrick Tay Teck Guan asked the Minister for the Environment and Water Resources (a) whether there are other water bodies in Singapore experiencing a midges outbreak like that at Pandan Reservoir; and (b) whether PUB is able to predict, prevent and overcome such outbreaks.

6 Dr Chia Shi-Lu asked the Minister for the Environment and Water Resources regarding the persistent problems created by swarms of midges from Pandan Reservoir (a) what measures are being implemented to reduce the population of these chironomids; and (b) with rising temperatures, whether the Ministry will be considering long-term measures to prevent similar occurrences at this and possibly other reservoirs in the future.

7 Ms Foo Mee Har asked the Minister for the Environment and Water Resources (a) what expertise and resources does PUB have to understand, monitor and prevent midges outbreaks at reservoirs; (b) what are the key indicators that PUB uses to predict and pre-empt an outbreak; and (c) how can residents living near reservoirs be better protected from the outbreaks.

Mr Speaker, can I take Question Nos 3 to 7 together?

Yes, please.

Thank you. Non-biting midges, also known as chironomids, are a type of flying insect that thrive in water bodies, such as ponds, rivers and reservoirs. Midges are part of natural aquatic ecosystems and they are food for fishes and birds.

Midges can multiply very rapidly, with each female adult midge laying up to 500 eggs in the water bodies. The eggs take a few days to hatch and become larvae, which live at the bottom of the reservoir. After about two weeks, they develop to become pupae, swim to the water surface and emerge as adults. The adult midges live for only one to two days, during which time they remain above water bodies to mate and lay eggs to continue their lifecycle.

Midges' emergence occurs from time to time in several reservoirs, including Pandan, Bedok, Punggol, Serangoon, Poyan, Tengeh and Marina reservoirs, as well as Punggol Waterway. Midge emergence has been known to occur at Pandan Reservoir since the late 1970s. Each emergence can be as brief as two weeks or as long as five months. There are several factors that determine the scale and duration of each emergence, including the specific midge species and the environmental conditions, such as rainfall, temperature and water chemistry at time of the emergence. We have just experienced a period of hot weather, with July being the second warmest July recorded since 1929. This unusual hot spell hastened the midges' growth process, resulting in the situation at Pandan Reservoir. With climate change, we will experience more extreme weather, which will have a corresponding response from nature.

Midges neither bite nor spread diseases. But they pose a nuisance to the public when they swarm in large numbers and, being weak flyers, get blown by wind into the surrounding residential estates. The Public Utilities Board (PUB) takes a comprehensive suite of measures to mitigate this nuisance factor as far as is feasible. PUB monitors for midge emergence at reservoirs with known emergence by conducting frequent checks for larvae in samples of reservoir sediments or adult midges trapped around the reservoir vicinity. At Pandan Reservoir, PUB observed an increase in midge larvae since mid-June 2019. PUB kicked in mitigation measures swiftly when the midge emergence began in mid-July 2019.

Similar to what I explained to this House previously in 2016, PUB's mitigation measures for midges include increasing the frequency and dosage of the application of biological liquid larvicide within the reservoir to kill midge larvae and increasing the frequency of fogging and misting around the reservoir dyke and surrounding vegetation to kill adult midges. These methods have proven to kill midges at the relevant stages of their lifecycle. PUB has also installed bright spotlights at the Pandan Reservoir pumping station and turn them on at night to attract the adult midges as they emerge from the reservoir. By keeping the midges within the reservoir area, PUB can then carry out targeted and effective measures, such as fogging at these spots.

Unlike the midge emergence at Pandan Reservoir in 2016, the current dominant midge species is considered a rare one that has not been studied in great detail. This species exhibits different behaviours from other species. For example, they hide in drains and culverts in the day and swarm above the drains in the evening.

PUB has adapted by adding to the usual suite of measures. They have greased the drain walls to trap the midges when they land to rest and have targeted these areas for fogging. PUB has explored the use of free-moving oily paper within drains to increase the capture rates of adult midges, which have worked very well, according to feedback from residents. PUB has also extended the existing 0.5 kilometres (km) of netting on the reservoir dyke by an additional one km. This netting acts as a barrier to trap adult midges and reduces the number of adult midges that would otherwise be blown to the residential estate.

PUB has worked closely with West Coast Town Council to engage affected residents through multiple channels, such as dialogues, daily walkabouts and distribution of flyers, and has advised affected residents on the actions they can take within their premises, such as, switching off their lights when not in use, as midges are attracted to light, as well as installing insect screens at their windows or drawing their curtains, if necessary.

But at the end of the day, we have to recognise that man cannot control nature. Midges cannot be eradicated as they are part of the natural aquatic ecosystem and will emerge to breed, especially when aided by favourable environmental conditions. Climate change, as mentioned, will further complicate our efforts.

Our reservoirs supply drinking water to the population and we have to be careful to ensure that – and this is important – PUB's mitigation measures, both short- and long-term, do not end up compromising water quality. However, PUB remains committed to working with the Town Councils and advisors to minimise public inconvenience caused. While PUB will continue to find more effective mitigation measures, we also seek residents' understanding and tolerance, should they find these insects in their homes.

Ms Foo Mee Har.

I thank the Minister for his response. Before I raise my supplementary questions to the Minister, I would like to thank the PUB and Town Council teams for the very, very hard work in tackling the mass midge outbreak. Speaker, since July this year, residents living near Pandan Reservoir have suffered greatly from the mass emergence of midges. Their homes have been invaded by the midges. Corridors, lifts and bus stops have been swamped. Cars, buses, bicycles and motorbikes have been affected. The midges stick to our clothes, really stick to your clothes, your hair, fly around your eyes, get into your nose, get into your food and they are everywhere.

This year's outbreak is the most severe we have witnessed yet and also persisted for the longest time, impacting the daily lives of our residents. Some have likened it to being in a horror movie. Seriously, if you have visited, it is really scary. I thank residents who took time to join the dialogue sessions we organised with PUB on the midge issues. There were some really great ideas that were shared and I would like to raise some for the Minister's consideration in my supplementary questions.

Speaker, I have four supplementary questions.

First, whilst I appreciate that fogging has been proven to be an effective way to kill adult midges, there are concerns among our residents about the health risk from exposure to chemicals from sustained fogging, particularly as the outbreak has lasted for an extended period. I would like to ask the Minister if PUB can find a more effective fogging method to target midges at the reservoir as they emerge and keep them away from residential areas.

Second, as the Minister shared, the midges issue cannot be solved or eradicated permanently. I would like to ask the Minister how the residents can be supported with insect screens for their flats as the installation of such features is costly, as well as other methods that PUB would consider to protect Housing and Development Board (HDB) flats and bus stops from the nuisance of midges.

Third, the most effective way to deal with midges is to eliminate them at source. I know PUB uses biological larvicide, bacillus thuringiensis israelensis (BTI), and using tonnes of it this time, at the reservoir, by injecting the larvicide into the reservoir's sediment. But despite all that, the problem appears to persist. I get constant questions that I would like to ask the Minister: how does PUB determine the effectiveness of BTI in controlling the larva population at the reservoir? How can the injected BTI be expected to zero in on the midge larva, given the vast area of the reservoir sediment?

Fourth, besides installing nets at the reservoir to serve as barriers to midges flying towards the housing estate, I would like to ask if more trees and shrubs can be added to also serve as barriers and places for the midges to congregate, so that they do not go into people's homes.

I thank the Member for the questions. I think this is a great opportunity for us to go back to our biology lessons. Like I mentioned before, this problem is really man versus nature, the kind of war man has never been known to win. Indeed, we can only suppress, we can only do our best, but we have to live with nature. In fact, we are the ones who are intruding into their living spaces.

Specific answers to the question on fogging. The pesticide we use is called Permethrin. This particular pesticide that we use in fogging has undergone the World Health Organization's (WHO's) pesticide evaluation scheme and has been certified safe and suitable for use. In addition to using a safe pesticide, we also dilute it, dilute it a lot, so that in addition to just thinking about killing these pests, we also do not want to harm the workers who are using them. So, they are used in a way, at a frequency that is known and recommended by WHO to be safe for humans, safe for the operators, as well as for the people that we are trying to help.

Secondly, on the insect screens, I think this issue of what you do to help yourself in your home has been well understood. Once you own your property, you own your home, you have to do what you can to protect yourself. Sometimes, we have residents who came to get help, for example, on their leaking pipes or issues which are more pertinent to their own home living conditions. Technically speaking, they should be taking care of these issues. But I think there is no harm, we can see what we can do to help, certainly from the advisors themselves. We can come together and look at what we can do, because this situation does not come all the time, not every year. So, to put in something which would become a permanent fixture, this may also affect the kind of image that the reservoir or the places around the reservoir should be. So, we have to be very careful about the kind of solutions we want to implement with or for them.

On BTI, the larvicide that we use to put into the water, it is a safe biological larvicide. It is actually a naturally occurring bacteria, soil bacteria, which produces spores, which are toxic specifically to the digestive system of midge larvae. As we put in the larvicide, we also monitor the quality of the water. We cannot put so much to kill, just because there are more midges in the river. In the end, the quality of the water gets compromised. So, there is a tradeoff between killing enough, or killing too much and we end up killing ourselves. We cannot do that either. There is a limit to which these measures can mitigate the issues that residents are facing.

Finally, on trees and shrubs, we can work with NParks to see, first, whether these are actually effective ways to prevent the midges coming in. It is a more beautiful way, definitely, than putting screens. But is it an effective way to prevent the midges from coming into people's homes? We do not want, in the end, to create new problems like people having different kinds of pests because of the kind of trees that we plant near their homes or around the reservoirs.

Er Dr Lee Bee Wah.

Sir, I noticed that Lower Seletar Reservoir was not mentioned by the Minister among the water bodies that have the problem of midges. My residents have been bringing up this issue on midges and mayflies. So, I would like to ask the Minister, will PUB carry out preventive measures for Lower Seletar Reservoir before it becomes, like my Parliamentary colleague mentioned, a "horror movie scene"? So, I hope something can be done for the Lower Seletar Reservoir area.

We do monitor for every reservoir and we take the appropriate measures. We do not want a sledgehammer for a small problem or small hammer for a big problem. So, appropriate measures.

Dr Chia Shi-Lu.

I thank the Minister for the clarification. Just one clarification. Part of the problem is climate change and something we cannot alter. I was wondering whether we have looked at ways of changing the micro-climate around the reservoirs. Because this only happens in certain reservoirs and I agree that it is because of the water. But there have been some studies that looked at the vegetation and the micro-climate around the banks of the reservoirs. Can we look at that?

I think we will study all these. Thank you.

Ms Foo Mee Har.

I thank the Minister for his response to my supplementary question. I understand that this is part of nature. But for the community that is impacted by that, it is really bad. So, I would like to propose for the Minister's consideration and collaboration with maybe HDB and other agencies, given that this phenomenon cannot be eradicated. In fact, PUB says that this may happen more regularly given the climate change. We should really seriously consider helping residents with protection against the nuisance created by midges, whether helping, especially vulnerable families, with screens or HDB nets or definitely in public areas like bus stops, so that it is bearable for people to be in those places to take public transport. So, I urge the Minister to seriously consider this.

We will study how we can help residents. We must also take this into consideration for the kinds of things we have to spend for when we try to tackle bigger issues in the years to come when climate change is upon us. We have not really understood properly how it will affect Singapore. What the Prime Minister has mentioned are only those things that we know can happen and should start working on from now. Issues around pests are, in fact, more dangerous and I will mention it in my next Parliamentary Question reply around mosquitoes. They present a more imminent danger than perhaps what midges will present to us, and not to just particular areas around the reservoirs but, in fact, to the whole of Singapore.

So, in consideration of all those issues, yes, we will study them. We will see what we can do for localities. But we also should know that our resources are limited. We have to put focus on important areas and not over-promise on other areas, but rather to over-deliver.

8 Mr Ong Teng Koon asked the Minister for the Environment and Water Resources (a) whether he can provide an update on the number of dengue cases observed nationally and in Woodgrove constituency in the second quarter of this year; (b) what are the reasons for the high number of cases; and (c) what are the latest efforts to contain the spread of dengue.

9 Ms Joan Pereira asked the Minister for the Environment and Water Resources whether the Ministry will consider expediting the trial of Project Wolbachia in the top dengue clusters, given the high success rate of this project in eradicating the Aedes mosquito populations.

10 Ms Joan Pereira asked the Minister for the Environment and Water Resources whether NEA can consider allocating more resources to step up efforts in eradicating mosquito breeding habitats through surveillance and inspections.

11 Mr Dennis Tan Lip Fong asked the Minister for the Environment and Water Resources what are the reasons for the continuing increase in the number of dengue cases this year despite the increase in mitigation measures, such as fogging and inspections, that have been taken in reported dengue clusters.

12 Mr Ang Hin Kee asked the Minister for the Environment and Water Resources (a) whether the measures taken to reduce the instances of dengue fever have been yielding results; and (b) whether there are other reasons for the high number of cases so far.

Mr Speaker, can I take Question Nos 8 to 12 together?

Yes, please.

Thank you. Based on the National Environment Agency's (NEA's) surveillance, the surge in dengue cases this year is attributable to three key factors: an increase in mosquito population; the relatively warmer weather; and lower herd immunity in our population.

NEA's gravitrap surveillance system has shown an increase in the Aedes aegypti mosquito population by almost three times since the last major dengue outbreak in 2013. This persistently high Aedes aegypti mosquito population increases the risk of transmission of the dengue virus. In addition, the mean temperature for the first half of this year was 0.7 degrees higher than the same period last year. Warmer temperatures result in higher transmission of dengue due to the accelerated development of the Aedes mosquito and shorter incubation period of the dengue virus. Due to our past successes in dengue prevention, the proportion of adults who have had dengue before has progressively decreased from 59% in 2004, to 51% in 2009, and 41% in 2017. This results, however, in lower herd immunity among our population, and a large proportion of Singapore's resident population remains susceptible to dengue.

NEA, together with agencies in the Inter-Agency Dengue Task Force and Town Councils, have stepped up housekeeping measures and inspections of common areas to eliminate potential breeding areas. In the first six months of the year, NEA has conducted more than 442,000 inspections island-wide and uncovered about 8,200 mosquito breeding habitats. Sixty percent of the breeding habitats detected were found in residential premises. If we look at the dengue clusters, the proportion of breeding habitats detected in residential premises is even higher at 70%. This points to an urgent need for home and premises owners to step up their efforts to eradicate mosquito breeding habitats. NEA will enforce against premises owners found with mosquito breeding and has taken about 1,200 enforcement actions against households between January and June.

Since the launch of the National Dengue Prevention Campaign in April, 89 divisions across Singapore have organised more than 1,000 dengue prevention events and activities. Mayors, grassroots advisers, community leaders and dengue prevention volunteers have been visiting homes to share dengue prevention tips, including information on how to identify potential mosquito breeding habitats. To heighten the public's awareness and vigilance against mosquito breeding and dengue, dengue cluster alert banners, posters and notices have also been strategically placed around the estate in dengue cluster areas. Poster walkers have been deployed and dengue prevention advertorials have been displayed at high footfall areas within clusters. NEA has also reached out to the public through TV and radio commercials, as well as digital and social media platforms, such as Facebook and Instagram.

We are seeing positive outcomes from these collective efforts. As of 24 August, we have closed 863 of the 1,021 clusters formed in 2019. This weekly number of dengue cases has also come down from a high of 664 cases in the second week of July to the current 478 cases in the third week of August. Some of the largest clusters in Woodlands, Upper Thomson, Chai Chee and Pasir Ris have closed. I would like to take this opportunity to thank all our stakeholders, including the grassroots advisers, grassroots leaders, dengue prevention volunteers, Town Councils and residents, for your efforts.

NEA will continue to work with our partners to enhance the efforts in dengue control. From the second half of 2019, NEA will progressively deploy an additional 14,000 Gravitraps to new Housing and Development Board (HDB) blocks and landed estates. This will augment NEA's current network of 50,000 Gravitraps and enhance our surveillance capabilities. The Gravitrap surveillance system allows NEA to prioritise its resources and deploy officers to focus on areas with high mosquito population.

In addition, since 25 August, NEA has partnered the People's Association (PA) to step up dengue outreach. Five thousand volunteers from PA grassroots organisations and Community Emergency and Response Teams (CERTs) will work hand in hand with dengue prevention volunteers to conduct house visits and distribute dengue prevention leaflets.

Another new initiative by NEA is the sharing of information on areas with relatively higher Aedes aegypti adult mosquito population on its webpage to facilitate targeted action by key stakeholders, community partners and residents. The information aims to increase awareness of dengue risk in areas with high mosquito population which might not yet be dengue clusters, so that stakeholders can pre-emptively take measures to reduce potential mosquito breeding habitats and avoid the formation of new dengue clusters.

While the results from Project Wolbachia field studies have shown promise, the Wolbachia technology has only been tested in small study sites in Singapore and remains under research and development. It is important for NEA to evaluate the technology rigorously before deploying it on a larger scale. NEA's approach to Project Wolbachia is aligned with the World Health Organization's and the International Atomic Energy Agency's guidelines on developing sterile insect technologies using a phased approach.

Each phase of Project Wolbachia has a clearly defined objective to progress the study and evaluate the technology systematically. The project is now in Phase 3, which aims to determine if the Aedes aegypti population suppression achieved thus far can be sustained in larger areas. The release area covers 84 blocks in Yishun and 60 blocks in Tampines and is 3.7 times larger than the release area when Wolbachia first started. It also focuses on the development of automation for male Wolbachia-Aedes mosquito production and release to ensure scalability of the technology. As field studies require prior systematic design, preparation and historical data for comparison, they are not suited for reacting to current dengue clusters, which are very dynamic.

Wolbachia technology is also not a silver bullet. It will not replace the community's efforts to ensure good housekeeping, which is still needed to keep our homes and estates free from mosquitoes and dengue. Comprehensive mosquito surveillance, source eradication of mosquito breeding habitats, and spraying of insecticide where necessary to control the adult mosquito population, continue to be Singapore's key strategies for dengue prevention and control.

Mr Speaker, we are still in the peak dengue season, which stretches from June to October. The region around us is similarly seeing an upsurge in dengue cases this year. We need to remain vigilant and continue to work as a community to suppress the Aedes mosquito population and keep dengue cases in check. I urge everyone to join in the collective effort to stop the dengue transmission cycle by regularly doing the five-step Mozzie Wipeout and to remind your family members, friends and neighbours to remove stagnant water from within and around their homes.

Mr Ong Teng Koon.

Mr Speaker, there was a death due to dengue in my ward this year. Many of my residents are understandably very concerned and many of my residents have asked why fogging is being carried out infrequently as opposed to the past. I would like to ask the Minister if he can clarify whether fogging is still an effective method to combat the Aedes mosquito and if the Ministry will continue to use it as a tool.

As I mentioned just now, in areas where there are higher incidences of dengue fever, 70% of the breeding is found in homes. So, even if we carried out more fogging, residents will usually close their windows anyway. Therefore, the best way to prevent dengue from proliferating is to destroy their habitats and most of them are within homes. But do we do fogging? Yes, we can and we must, to kill the adult mosquitoes outside. There is no silver bullet in whichever method we choose and we cannot just use one method to stop this problem.

Ms Sylvia Lim.

Speaker, supplementary question for the Minister. Earlier, he talked about lower herd immunity and attributed it to the fact that the dengue prevention efforts of the past years have shown some effectiveness. I would like to ask the Minister whether there has been observed to be a change in the serotypes, the strain of dengue that is now predominant in Singapore, and whether that contributes to the higher incidence of cases?

There is no known significant switch in serotype of dengue strains found in Singapore. So, as I have mentioned, the three factors, among which is the low herd immunity, is one major factor which is causing the spike in the number of dengue cases in Singapore, rather than serotype switch.

Mr Ang Hin Kee.

I have two follow-up questions. First, is there any discernible difference in terms of breeding sites and residents contracting dengue in private estates and HDB estates? Secondly, a lot of residents and Singaporeans travel overseas. Are there incidents of them contracting dengue overseas because they let their guards down or they are not aware that the regions that they visit are also experiencing a dengue outbreak?

There are clear differences between breeding places in private estates and public housing. For public housing, some of them are found in common areas and the Town Councils must and should take all precautions possible to prevent breeding and mosquitoes. Some of these places are really hard to access. Whereas for private housing, most of the breeding places, in addition to being found within homes, are also found in their gardens, usually in pots which are not probably treated or pots which collect water.

For cases of dengue contracted overseas, as I had mentioned, our region is now suffering from a spike in the number of dengue cases. Therefore, as we travel, please take the necessary precautions, put on insect repellent on yourselves and, especially on your children, so that they do not get bitten by mosquitoes and inadvertently contract dengue.

Mr Dennis Tan.

I would like to ask the Minister, does NEA face any difficulties in accessing individual homes, whether in private estates or HDB estates? What measures are being taken to deal with this issue?

Generally speaking, it has not been difficult to access homes. When our NEA inspectors knock on doors, they would open the doors. But sometimes, there is nobody at home, or sometimes, it could be an elderly at home. So, we try very hard to work with the neighbours to find out how we can get access. Particularly for areas which are dengue clusters, we do not wait long. We will try to gain entry, and NEA has the powers to do so.

Ms Denise Phua.

I want to commend the very diligent NEA ground staff and, of course, the volunteers who walk the blocks and flats with them to educate and to warn residents about dengue prevention. As the Minister mentioned, most of the mosquito-breeding habitats are inhouse. We found that, on the ground, many of the NEA staff and the volunteers are very helpless when residents refuse to let them gain entry, sometimes out of non-cooperation, but a lot is also out of fear of the fine, the stick, thinking that when they open the doors, if they would be punished.

I was wondering if NEA could consider to, first, issue a severe warning, get entrance to the flat, check the premises and then, install the fine only from the second time that they visit. There is a lot of worry, fear and anxiety about someone coming to your house, inspecting your premises and then, punishing you straightaway, when you are not yet educated or aware.

I am quite sure if you go through some Hansard reports, this question had been asked before: can we first give a warning, then issue the fine later, be kind? I think if dengue does not cause death, we probably could do that. But dengue is known to cause death, and these could be our loved ones. I think everyone has to be responsible and accountable to take care of their homes, to make sure they do not breed mosquitoes. When NEA officers and dengue volunteers go in to check their homes, they are trying to help and also point out where possible breeding habitats could be found, and then, if found, they fine them. That sends a strong signal to everybody to take this seriously. We never know which breeding habitat will produce the mosquito that may kill somebody we love.

13 Mr Patrick Tay Teck Guan asked the Minister for Trade and Industry in light of the current economic conditions and our focus on hiring, developing and strengthening the Singaporean Core, whether there is a need for the Tech@SG programme which facilitates technology firms in the hiring of foreign talent.

Mr Speaker, Sir, deep tech industries and companies are the lynchpin for the future economy. Digital technologies have transformed the way we work and live. Today, technology companies are among the fastest growing in the world and occupy an increasing share of the Fortune 500 list. Singapore must develop our tech ecosystem and ride this growth to create more opportunities for Singaporeans.

Talent is critical in this effort. Tech companies require experts with specialised skills. Increasingly, companies are basing their investment decisions on the availability of talent instead of traditional factors, such as the cost and availability of land. Unfortunately, there is a global shortage of tech talent, and competition is intense. France overhauled its French Tech Visa six months ago to make it easier for tech talent to work in France. Closer to home, Thailand introduced a SMART visa programme this year to attract highly skilled tech professionals.

If Singapore sits back and does nothing, we will almost certainly be left behind. We have only a small window to build a critical mass of high-end professionals, startups and companies. There will only be a few such nodes globally. How we do today will decide whether we make it as a tech hub, or not. We must move fast and move now.

It is not only companies which are facing a shortage of tech talent. Our Government is also using technology to transform our public services and serve businesses and citizens better. The Government is, therefore, tapping on the same limited pool of local tech professionals as our companies. We need to urgently expand this pool.

We are accelerating our efforts to develop our tech talent while ensuring that Singaporeans remain at the core of our efforts. The first prong of our talent strategy, ever since we achieved Independence, has been to develop our local workforce. Our people are our most important resource and we spare no effort in nurturing them. In our efforts to widen our tech talent pool, we have been rapidly scaling up our local pipeline of tech professionals. Today, more than 74,000 training places have been taken up or committed under the TechSkills Accelerator and this will amount to about one-third of our information and communications technology (ICT) professionals across the country.

Our institutes of higher learning offer around 200 full-time tech-related courses today. In Academic Year 2018, there was an enrolment of more than 63,000 locals in these tech-related courses, which received about $1.1 billion in Government funding. We are also investing significantly in building new capabilities, such as cybersecurity and artificial intelligence (AI). Together, these efforts will increase our baseline of tech skills and capabilities.

As we develop our base, we must also stretch the top of our Singaporean crop. We have connected Singapore to the world to secure frontier opportunities for Singaporeans through programmes, such as the Global Innovation Alliance (GIA). GIA is a global network connecting Singapore to leading innovation ecosystems and key markets around the world. Singaporeans and businesses will be able to gain overseas experience and connect and collaborate with their overseas counterparts through GIA.

But even these efforts are insufficient because the demand for tech talent is far outstripping the local supply. This is not just a Singapore issue; it is a global challenge. The Straits Times recently reported that recruiting firm Michael Page said that the demand for technology jobs in Singapore rose by 20% in the last 12 months but there is a shortage of supply. Companies have also given our agencies feedback that we lack experienced software engineers and product managers. They are looking for people who can take charge of the development and rollout of digital products at a global scale, instead of only working on specific components of the product. These are often people that can marry both technical leadership and commercial acumen, manage larger tech teams in the hundreds and thousands, and are highly valued because they are in short supply.

Mr Speaker, Sir, this is the reality which we will have to face or we risk diminishing our competitive edge. We need to complement our local pipeline with skilled workers from all around the world to meet the surging demand from companies that are already in Singapore and companies that we want to bring to Singapore. The presence of workers from other countries and nationalities also provides opportunities for Singaporeans to work in globally competitive teams and advance the frontiers of innovation together. In a world where multi-sectoral, cross-discipline and cross-cultural teams are increasingly common, Singaporeans must learn how to work with people from all around the world. This will increase their competitiveness as individual employees and make them more attractive to employers.

Alibaba, Grab, SAP and Taiger are examples of some companies which have plans to expand significantly in Singapore. Many of these companies have shared that the ability to complement their local workforce with global talent is essential for them to quickly scale their operations in accordance with their plans.

This is why we launched Tech@SG to help fast-growth tech companies, both local and foreign, to grow in Singapore. This programme is intended for companies with the commitment and ability to build teams and products in Singapore. They will have to be incorporated in Singapore, have a digital or technology offering or have a business model built around proprietary technologies, research or hardware. Companies would also need to have secured more than US$10 million in Venture Capital (VC) funding cumulatively and have received funding from a Programme-recognised VC in the past 36 months. This will ensure the companies would have sufficient resources and readiness to internationalise and compete.

Tech@SG will enable such companies to put together globally competitive teams to develop their products and internationalise quickly. In addition, Tech@SG will raise the quality of tech talent in Singapore and create more opportunities for our tech experts to team up with the best from around the world.

We must be prepared for these fast-growth companies to recruit the skills they most require. In the short term, these skills may come from global professionals. But we must take a strategic view on this to reap the long-term rewards for Singaporeans. We did so for the semi-conductor industry in the 1960s. At that time, many multinational companies (MNCs) in the industry came here and set up their core team which comprised mainly foreigners. Over time, as these companies anchored themselves in Singapore, they began to rapidly grow their local pool of employees. In a span of just three years, the first three semiconductor companies in Singapore – National Semiconductor, Fairchild and Texas Instruments – created more than 7,000 jobs. They have also grown an entire generation of specialists and professionals in this area that enabled the semi-conductor industry of Singapore today.

Today, we have a similar opportunity to create a vibrant and dynamic tech sector, generating new and exciting job opportunities for yet another generation of Singaporeans. But time is running out.

I would like to highlight some examples where we can already see the benefits to Singaporeans. Visenze, an AI and image recognition company founded by four Singaporeans, now hires more than 60 tech professionals to form multinational teams that develop and improve their AI technology. Abel Lim, a recent graduate from the National University of Singapore's School of Computing, learns about applying machine learning to real-life problems from colleagues in his team who come from around the world. Together, their team makes improvements to Visenze’s algorithms.

Another example would be Mastercard. Mastercard is an MNC currently spearheading the creation of new digital technologies in payment solutions and smart mobility in Singapore, powered by AI. These innovative activities require new capabilities that would need to be built up in the Singapore team. To that end, the company introduced the Mastercard Graduate Programme that offers Singaporean employees a structured programme of rotations, international work experience and mentorship opportunities. These equip them with new skills and allow them to work alongside senior experts from around the world. Seliyan Silvarajoo is one such Singaporean who has undergone this programme. He started out as an intern at Mastercard and is now a senior digital product specialist. Seliyan counts his experience learning from and working with a global and diverse team as critical to preparing him for his role in developing new and exciting products.

Besides companies like Mastercard and Visenze, we have a good stable of companies like the digital giants Google and Facebook that create good opportunities for Singaporeans. We need to be able to create an environment for Singaporeans to learn from the best and to thrive. We need to grow our tech ecosystem and create exciting opportunities for all Singaporeans. This is what Tech@SG is about.

Mr Speaker, Sir, I would like to assure the House that we are deeply cognisant of the fact that this topic can be easily stirred up because of the emotions involved and because it concerns the jobs and the kind of society we want to build in Singapore.

At the same time, this is a Government that has always sought to be honest with Singaporeans and has never shied away from explaining our challenges and sharing what needs to be done in order for us to grow and adjust to changing realities. We will never stop putting Singaporeans at the heart of everything we do and will continue to develop every Singaporean to their fullest potential so that they can fulfil their aspirations and seize opportunities in Singapore and beyond.

However, we must not go down the path of other countries which have started to put up barriers and take an inward-looking, protectionist approach, not just to trade, but including talent. Doing so, we will only hurt Singapore whose success over the last 54 years has been built on our openness and courage to do what is necessary for our country. To this end, we will continue to do our best for each and every Singaporean while continuously building on our efforts to take Singapore into the next lap, with the world as our hinterland for trade and talent.

Mr Patrick Tay.

I thank the Minister for his response and the rationale of Tech@SG. I have three supplementary questions for the Minister.

Firstly, whether such companies in the Tech@SG programme will still be subjected to the Fair Consideration Framework as well as the triple-weak scrutiny which the Tripartite Alliance for Fair and Progressive Employment Practices that the Ministry of Manpower (MOM) is rolling out.

The second question: whether the agencies concerned in rolling out Tech@SG considered leveraging MOM's Capability Transfer Programme to roll out some of these knowledge transfer, skills transfer and capability transfer to Singaporeans?

Thirdly, amidst this sense of uncertainty and quite dismal outlook in terms of the employment and job market, our focus is on helping, supporting and assisting fellow Singaporeans. I just wonder whether there are controls in place or will there be controls that will be instituted on Tech@SG to make sure that our local professionals, managers and executives are not compromised or prejudiced against?

Mr Speaker, Sir, let me respond to the three questions.

The answer to the first question is a definite yes. We are working closely with MOM. The Fair Consideration Framework applies to everyone and every firm in Singapore.

The second question: did we consider the Capability Transfer Programme? Yes, that is one of the various instruments that we use to level up our own professional knowledge. We will continue to do that and, where there are opportunities, we will even step up our gear to do that. But having said that, as I have explained, even though we are churning out as many people as we can, as fast as we can, it is still not sufficient to meet the growing demand. We must make sure that we do not miss the boat by losing the professionals, the startups and the companies for us to form a critical mass quickly.

On the third point, it is precisely because of the uncertainties with the economic outlook that we have stepped up our gear to make sure that we build the next generation of companies in this sector. At this point in time, I would say that this forms part of our overall surgical measures to help our companies transform and expand their market presence. At this point in time, the average of the economy may be about 0% to 1% growth, but that does not mean that every sector is between 0% and 1% growth. We know that the current numbers are dragged down by the global electronics downturn, the wholesale and retail trade, and some of the precision engineering sectors.

On the other hand, our economy is growing well in the financial services, ICT and many of the high-tech industries. This is why we must make sure that while we try to lift the bottom, we must never cap the top. We must make sure that we can do all we can to help those companies that are growing the fastest at this point in time, suffering from the global shortage of tech talent, including many of our ICTs and AI companies, to make sure that the Tech@SG programme will give them the best chance possible to succeed and will not make them lose out to other companies from other countries who are competing for the global talent at this point in time.

Mr Patrick Tay.

I would like to ask the Minister for a clarification. Now, we are doing Tech@SG for the tech sector. Will the Ministry of Trade and Industry consider or is it in the works to considering other sectors as well? Because it is not just the ICT sector that needs foreign expertise or even data analytics, data science expertise. It could be the financial sector or many other professional services, and all these contribute quite significantly this year and, moving forward, to the economic growth of Singapore.

The answer is yes. We are open to considering how we can work with the other sectors which are short of this talent at the global level. But I want to clarify. We are not talking about S Pass holders, we are not even talking about the average Employment Pass holders. We are talking about people who can manage programmers by the hundreds and thousands. These are the people who know and have the expertise to manage global teams of the hundreds and thousands of people, and these are in critical shortage.

Just to put in context how tough this competition is, China, the most populous country in the world, even China has a 千人计划 to attract the best from around the world to go back to China and help. If China, France and Thailand are all doing this, we can understand how critically short we are at the global level. So, while everybody is trying to churn out as many as they possibly can within the time, everyone is also fighting for the available talent at this point in time.

Mr Pritam Singh.

Just one supplementary question for the Minister. A few years ago, there was an initiative to increase the number of Singaporeans or work towards increasing the number of Singaporeans in leadership positions in the financial sector. Is there a similar parallel initiative that the Government has in mind for Tech@SG? I think the Minister raised some numbers about the number of students in our institutes of higher learning. But more upstream, in terms of taking on roles, since this is a long runway that we are looking at, does the Government have any plans in that regard?

I thank Mr Pritam Singh for raising the financial sector. In fact, that is a very good example of how we do business. When we grew our financial sector, there will obviously be areas where we initially lack the expertise. We brought in people and experts who are globally attuned and have the exposure. Over time, we progressively make sure that that expertise is localised and we have achieved much in the financial sector, under the leadership of the Monetary Authority of Singapore. We will continue to do this because we will never stay static and we will never say that we have done enough to get our locals into the top leadership positions.

This is exactly the same spirit that we intend to do for all the new sectors. That is why, just now, in answering Mr Patrick Tay's question, I talked about the Fair Consideration Framework, what Mr Patrick Tay called the "triple-weak". We want to make sure that every company, as they grow, are conscious of their responsibility to localise the talent and also to build up the capabilities within Singapore. That is how, progressively, we are not shy to learn from the best in the world. But as we learn from the best in the world, we want to make sure that our people have the best opportunities to learn from them, acquire those skills and maybe even go beyond. This must continue to be the Singapore way. This was how we built up the semi-conductor industry in the 1960s and 1970s and that will not change.

14 Ms Denise Phua Lay Peng asked the Minister for Education with regard to the new PSLE scoring system (a) what is the rationale of assigning the lowest three levels of the eight Achievement Levels in Mother Tongue Language (MTL) for Special Educational Needs (SEN) students who are granted exemptions; (b) what is the impact on PSLE results, course eligibility and school choices between the current and new scoring system for MTL exemption; (c) whether the Ministry will consider delaying the implementation of the MTL exemption scoring changes for the current cohorts who will be affected; and (d) whether the Ministry will consider an alternate PSLE aggregate scoring system for SEN students who are granted MTL exemption.

15 Ms Denise Phua Lay Peng asked the Minister for Education (a) whether the Ministry will address the concerns of families and educators that Special Educational Needs (SEN) students deemed not suitable to take Mother Tongue Language (MTL) as an examinable subject, are being further disadvantaged at an early age; and (b) whether more inclusive mainstream secondary schools can be developed by modifying the Secondary 1 Direct School Admission system to allow more admissions of SEN students affected by the MTL exemption scoring changes.

16 Mr Murali Pillai asked the Minister for Education (a) whether students granted exemption from studying mother tongue languages on medical grounds may be exempted from the new PSLE scoring system taking effect from 2021; (b) what is the number of currently enrolled primary school students who have been exempted from studying mother tongue languages and will now be subject to the new PSLE scoring system from 2021; and (c) what is the rationale for applying the new PSLE scoring system to these students who received exemptions from studying mother tongue languages under the prevailing system.

17 Ms Rahayu Mahzam asked the Minister for Education with regard to the application of the PSLE scoring system to those students exempt from studying Mother Tongue Languages (a) what are the guiding principles to determine which Achievement Level (AL) the student will score; and (b) whether there is an assessment of how the new scoring system will impact students with learning disabilities or special needs.

18 Ms Denise Phua Lay Peng asked the Minister for Education (a) what is the rationale and principle behind according a student an exemption from Mother Tongue Language (MTL) in national exams; and (b) whether this principle aligns with the new PSLE scoring system for MTL exemption.

Mr Speaker, may I take Question Nos 14 to 18 together?

Yes, please.

Today, more than 95% of our students take the Mother Tongue Language (MTL) examination at the Primary School Leaving Examination (PSLE) at either the Standard or Foundation level. This reflects the centrality of MTL learning in our education system. Learning the MTLs allows us to connect with our communities and draws on our rich ethnic heritage and culture to build our unique Singapore identity.

At the same time, we recognise that for a small group of students, such as those with special educational needs (SEN) or who have been away from Singapore for prolonged periods, it may be challenging for them to study one of our MTLs. Hence, upon application, we may grant them exemption from MTL. However, there are many students with SEN or who have been away and who still take MTL, notwithstanding the difficulties they encounter.

In any given year, on average, about 4.5% of our students are exempted from MTL. This group of students will take three examinations at the PSLE – English, Mathematics and Science. Hence, they will receive only three subject scores on their results slip. The question then is how to use these scores for posting to the next course of study, given that the vast majority of their peers have a score summed up from all four subjects.

That is why for purposes of posting, we assign an MTL score for these students by referencing the MTL scores of other students with similar English, Maths and Science scores, including those offering Foundation MTL. This basic approach will not change when we move from the T-score system to the new Achievement Level (AL) scoring system in 2021.

Ms Denise Phua asked about the underlying principles of this practice. The new AL scoring system is based on the level of attainment by the student himself and moves us away from the approach of the T-score system where a student has to outperform his peers to register a high score. However, when it comes to secondary school posting, the student still needs to use his PSLE score to compete with other students in order to be admitted into a school of his choice.

Our treatment of students exempted from MTL is aligned with these principles. For purposes of deriving AL scores, he was exempted from MTL, so no assessment of his standards took place and he has no score. But for the purposes of secondary school posting, he needs to be compared with other applicants and so we will assign him an MTL score by referencing his peers.

We can and must strike a balance between competition amongst students and self-mastery, but realistically, we cannot remove competition totally, and it is also not a reflection of the real life that we are preparing students for.

What is specific to the AL system is that the assigned MTL score will range from AL6 to AL8. We have done this considering the vast majority of students who offer an official MTL either at the Standard or Foundation levels.

This includes a significant number with SEN or those who have returned to Singapore after prolonged periods overseas. Currently, about 90% of our Returning Singaporean students study an official MTL, with our schools providing support for their language learning. Seventy percent of students with SEN in mainstream schools also take MTL at PSLE. Many of them take Foundation MTL. As the score range for those taking Foundation MTL is AL6 to AL8, it would be difficult to justify to those offering it why another student who did not sit for the examination could be assigned a higher score.

Ms Denise Phua asked about the implications of the new scoring system on course eligibility and school choices. Any student who scores 22 or below will qualify for an Express course. Under the current T-score system and the new AL scoring system, the outcomes are similar.

Our simulations using the most recent PSLE results show that a similar proportion of students with SEN and are exempted from MTL, would qualify for the Express course under both scoring systems. In any case, by 2024, Express and Normal streams will be phased out. In terms of school choices, if we held choice patterns constant, about 60% of them would secure their first choice secondary school, under both scoring systems.

For those concerned about the chances of success to be admitted into specific secondary schools, we have, over the past few years, significantly expanded places in the Direct School Admission (DSA) pathway to better recognise talents and achievements across different domains beyond general academic abilities. Most schools can now admit 20% of their Secondary 1 intake via DSA, up from 10% in 2017, and many schools have yet to reach this proportion.

Schools are also admitting more students with different strengths and backgrounds, including those with SEN. For example, we see students with SEN who are talented in Mathematics, Science, sports and performing arts, and admitted via DSA into the schools of their choices. The Ministry of Education (MOE) and schools will support existing MTL-exempt students affected by the new scoring system in their transition by providing advice on their school choices, and to also explore DSA as an option.

We also recognise that our students with SEN put in tremendous effort to cope with their learning. MOE has increased the resources to help students in Special Education (SPED) schools, and students with SEN in mainstream schools will also benefit from learning support programmes as well as allied educators for learning and behavioural support. MOE is committed to continue working with schools in providing the support needed to prepare our students for the PSLE changes.

Members also asked if we could delay the implementation of the scoring changes for current cohorts or consider an alternative PSLE scoring system for students with SEN. Given that we are changing the national examination scoring system, it would not be feasible for a small group to remain under the T-score system or to use an aggregate score of three scores, as their scores would not be comparable with the aggregate scores of other students for purposes of secondary school posting.

Ultimately, in grading, scores have to reflect standards, instead of effort or circumstances. Those are relevant factors, but we should exercise that judgement during admission mechanisms like the DSA, instead of compromising the consistency and integrity of the assessment and grading system.

Mr Speaker, performance at the PSLE is just one checkpoint in a child's education journey and it is not the final judgement of a child's ability or potential. The changes to the PSLE scoring, expansion of DSA and journey to Full Subject-Based Banding (SBB) aim to shift our education system away from an over-emphasis on academic results and encourage our students to focus on their own learning. Fundamentally, we want an education system with multiple pathways and opportunities, so that every child can maximise his or her potential and be placed in good stead for the future.

Ms Denise Phua.

I thank the Second Minister for the comprehensive response. I totally understand the importance of MTL and that requests and approvals for exemption of Mother Tongue studies must not be taken lightly.

But for students who are medically certified with SEN and, especially those in special schools taking the PSLE, those who are visually impaired, those who are deaf or autistic SPED students, the PSLE score is the main currency by which they are admitted, they have a chance to go to a mainstream secondary school and education. Cut-off points are still what many secondary mainstream schools use to admit these students unless one is exceptional enough to qualify for DSA. Hence, there are genuine concerns by the families and parents of these students. So, I have two supplementary questions to ask.

One, to ask the Minister that if the reason for exemption is valid, is medical, then will MOE consider an exemption as an exemption with no conditions attached? To the layman, the definition of exemption is that it is not conditional and, therefore, there is no excitement of the lower score if you are exempted. There are some who actually fear that the students are further disadvantaged by putting them back into a pool after recognising all the good work that MOE has done for SEN, that we are now putting these students back into the pool to compete with the rest of the others. So, that is one. Can an exemption be an exemption with no conditions attached?

The second is to do with informed choices. So, for those who are currently already in the Primary 1 to Primary 4 cohorts, so-called in-flight, the families had not made informed decisions at the time when they appealed for Mother Tongue exemption or language studies exemption, whether under the old or the new system now. So, would MOE please consider delaying the implementation for this group and grandfathering the current Primary 1s to Primary 4s, start the new system preferably full and not conditional exemption from the 2020 Primary 1 cohort onwards? I know these are deep issues and that MOE has done a lot of thinking about this. But I ask you not to say "no" to me first, but to take the time to consider these several options and let us work together to see what is the best balanced decision for this group.

I thank the Member for her questions. In fact, I think the Member has reflected the concerns of parents who are genuinely worried about their children, especially those with SEN. Perhaps, what I can do is put it in perspective and give the reassurance to those parents that even under the new system, their children will be treated fairly. Let me just outline and explain it.

I will take the second question first because Ms Denise Phua asked whether those who are already in-flight might have chosen otherwise if they had known about this, and whether the current system can remain in place for them so that only the new cohorts coming in for primary school will be under the new system.

The thing is this: the new PSLE AL scoring system will come into effect for the PSLE cohort in 2021. So, the students with SEN who are exempted and who are taking PSLE in 2021, they, too, as part of that cohort, will need to be posted to a secondary school. When you post, the posting has to be done in comparison with other students. So, all the students in that cohort will be posted under an AL system and you cannot remain under a T-score system. It is not possible to do comparison or to delay it. And that is the reason why you have to do it together. But recognising that you have to do it together, then this is the thought process that MOE went through and we hope that the parents will see that this does not actually disadvantage their children.

The first thing to remember is that, actually, more than 95% of our students take MTL. It is 4.5% who are exempted, out of which about 3% includes those who have SEN. Then, out of the ones who have SEN in the mainstream schools, as I mentioned earlier, 70% actually do take MTL at PSLE. So, the ones who are exempted are actually a very small percentage. And for the SEN students who take MTL at PSLE, about 40% of them offer Standard MTL and 30% offer Foundation MTL. So, there is actually already a very large group of students with SEN who do MTL and they compare together with the others.

Then, for those who are exempted, I think Ms Denise Phua asked: can an exemption be an exemption? The exemption is an exemption because if we followed the existing rule, what it would mean is that the student who, for medical reasons or otherwise, if you held very strictly to the rule, it would mean that that student has to take MTL. And we have given the exemption in recognition of the fact that such students may, because of SEN or for medical reasons, have great difficulty in coping with MTL and, therefore, have been exempted. So, an exemption is given and they do not have to do MTL.

But the difficulty comes, as I explained, with posting, because with posting, it is necessary to see how that child compares with other children. And, if you apply it very strictly, then given that you did not take MTL, the correct score should actually be zero, meaning that you have the worst possible score, and we did not want to do that. So, to be fair, we have to assign a score, and we do that by taking reference from their peers, including those who take Foundation MTL.

So, actually, the range of scores for those who take Foundation MTL, by and large, falls within AL6 to AL8. And AL6 is actually not a low score. It translates to up to 64 marks. So, do not be mistaken: AL6 is not a low score and it is still possible for these children to be able to get a place in the Express stream. Receiving an AL6 for the fourth subject does not automatically disqualify a student from accessing a particular course or his first choice secondary school. For example, a student obtaining two AL5s and two AL6s will get a PSLE score of 22 and will still be eligible for the Express/Normal (Academic) option band.

So, when we did the simulations, they indicate that, by and large, whether under the current system or whether under the new system, a similar proportion of all MTL-exempt students will be able to qualify for Express or the Express/Normal (Academic) option band and that is about 40% of these students. So, by and large, it would not be very different. Even now, you do have to assign them a score because there are MTL-exempt students today. I think at the end of the day, the key thing for the parents to ask is: some parents may be concerned about their children who do very well. They may get one for English; one for Mathematics; one for Science and then you get six for your MTL. You are well within the Express range. So, for those who are at the margins, when it comes to the choice of a particular school, there is always the DSA option. And I would ask, at the end of the day, for the parents to work with the teachers to consider what is the best thing for the child because we do want the best pathway, the best option for the child and, especially children with SEN. That, MOE will certainly not compromise on because we want to make sure that whichever path they take, they have good opportunities in order to be able to achieve their aspirations.

Order. End of Question Time. Introduction of Government Bills.

[Pursuant to Standing Order No 22(3), provided that Members had not asked for questions standing in their names to be postponed to a later Sitting day or withdrawn, written answers to questions not reached by the end of Question Time are reproduced in the Appendix.]

[(proc text) "to amend the Maintenance of Religious Harmony Act (Chapter 167A of the 2001 Revised Edition), and to make consequential and related amendments to certain other Acts to deal with religious intolerance", (proc text)]

[(proc text) presented by the Senior Parliamentary Secretary to the Minister for Home Affairs (Ms Sun Xueling) on behalf of the Minister for Home Affairs; read the First time; to be read a Second time on the next available Sitting of Parliament, and to be printed. (proc text)]

[(proc text) "to amend the Income Tax Act (Chapter 134 of the 2014 Revised Edition) and to make related amendments to the Stamp Duties Act (Chapter 312 of the 2006 Revised Edition)", (proc text)]

[(proc text) recommendation of President signified; presented by the Second Minister for Finance (Mr Lawrence Wong); read the First time; to be read a Second time on the next available Sitting of Parliament, and to be printed. (proc text)]

[(proc text) Order for Second Reading read. (proc text)]

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 caregiving for our seniors. These include the Home Caregiving Grant, respite care services, and caregiver 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 caregivers 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 Central Provident Fund (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 the Ministry of Health's (MOH's) disability schemes, AIC will be the natural touchpoint for seniors. They are best placed to advise disabled seniors and their caregivers 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 (PRs) 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 PRs 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 PRs after the Scheme commences. These are the new Singapore Citizens and PRs. This way, all new Singapore Citizens and PRs will participate in this national scheme and benefit from better support for their future long-term care needs, just like all Singapore Citizens and PRs today. The only exception is if they are born in 1979 or earlier, the older Singapore Citizens and PR, and are severely disabled. Like Singapore Citizens and PRs 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 the Monetary Authority of Singapore (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 caregivers. 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 caregivers 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 caregivers 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 for 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 willful 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 premium 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 premium 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 willful 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 willful 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 the Inland Revenue Authority of Singapore 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 premiums 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 assessment 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 PRs 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 and $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.

[(proc text) Question proposed. (proc text)]

Dr Chia Shi-Lu.

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 if 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 activities of daily living (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 information technology (IT) system have thrown the issue of data integrity and security into sharp focus.

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 payouts 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 the Ministry intends 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.

Dr Lily Neo.

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 the 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 Community Health Assist Scheme (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 payout is welcome as severely disabled individuals require lifelong assistance with their daily living.

Two, the setting up of the Long-Term Care Support Fund 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 payouts 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 payouts 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 arise. For better piece of mind and coverage, individuals can take up extra insurance for higher payouts with private insurers. May I ask the Minister whether the Government can administer these "riders" for those who want better payouts, rather than depending 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 on their children’s or siblings’ MediSave once their own MediSave has 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 the 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 Caregiving Grant of $200 per month in lieu of Foreign Domestic Worker (FDW) 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 the 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 know 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 the 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, Interim Disability Assistance Programme for the Elderly (IDAPE) 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 for 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 for home care. May I ask the Minister how he plans to expand and better equip on the availability of home care?

May I request the Minister to prioritise home care for seniors, especially those living alone in Housing and Development Board (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 the Minister expand home care quickly with the tenets of prevention of further deterioration of physical frailty and mental disorder, such as depression? The Ageing Gracefully at Home programme at Chin Swee, supported by AIC, is a good home care programme. This home care provides the seniors living alone in 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 emphasises 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 the 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.

Mr Png Eng Huat.

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 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 the 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 Singaporean, 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 of 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 am 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 cohorts of Singaporeans who would be enrolled into the compulsory scheme upon attaining the age of 30.

Take the case of 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 in 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 healthily.

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 these savings into the premium calculations? And what would be the projected profit and loss for the CareShield Life scheme under the sole administration of 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.

Prof Fatimah Lateef.

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 among the public, private and people sectors. In Singapore, co-sharing is among 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 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. 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 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 people, those with disability and members who have a disabled person 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 forward 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 caregivers at home who need a break from the caregiving 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 caregiving 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 ADLs. Therefore, perhaps there is also a need to review and align this with the Ministry of Social and Family Development 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 ADLs that we can actually include under our consideration for certain schemes, whether it is one, two, three or four. I would like to urge the Ministry to consider, even for people who have less than three, perhaps two ADLs that they cannot fulfil, we can give them a case-by-case consideration because, in considering ADLs, 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 World Health Organization (WHO) stated that long-term quality care is related to two factors; first, the type of care provided and, second, the lack of integration among 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.

Miss Cheryl Chan.

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, the CareShield Life 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 a 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 that 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 raises concerns about the cost of care in the long run, but also who in the family would become the primary caregiver 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 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 caregiving.

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 caregiving 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 an 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 an LPA from the onset of joining the scheme? This would mean a less likely 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 PRs 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 be 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 a 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 by 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 the 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 prevent an individual from being fully assessed by the same doctor for all conditions on ADLs?

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 and 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.

Mr Leon Perera.

Mr Speaker, Sir, I declare my interest as the Chief Executive Officer 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 that the ElderShield scheme will be administered by the Government from 2021 on a not-for-profit basis. The insurers will transfer to the Government the liabilities and corresponding assets backing these liabilities 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. The 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 outweighs the 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 by? 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 is a feature that provides for the three insurers that administer ElderShield to 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 grants 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?

Lastly, because the changes to this Bill concretise the optimum effects of our ageing society, we should work towards the creation of a vibrant ecosystem 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 ecosystem 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 ecosystem 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 assisted 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 United States (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 ecosystem should be provided by companies, not-for-profit voluntary welfare organisations 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 amounted 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 caregivers, 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 as the concept dates back to the 1980s. During the Committee of Supply 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 one another. 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 all existing ALFs in the world represent 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 startups 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.

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?

Assoc Prof Walter Theseira.

Mr Speaker, Sir, in 1994, Prof William Kissick defined the set of three tradeoffs that any healthcare 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 tradeoffs.

We have, by international standards, solved the health system problem better than most. In 2000, WHO ranked Singapore sixth in the world in overall health system performance. Because this ranking was so controversial – the US 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 gross domestic product (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 prefunding 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 of 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 prefund CareShield Life and what the implications are for our broader healthcare 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 tradeoff 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 prefunding. If the policy problem was only prefunding 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 needs.

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 excessive 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 US 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 prefunding 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 Yee Chia Hsing.

Mr Speaker, Sir, sickness and death come 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 AIC as a one-stop agency to assist families on matters relating to our seniors. The work of 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 would especially like to highlight is the provision of a monthly cash grant of $120 to families which need to hire an FDW to take care of a family member who requires permanent assistance with three or more ADLs.

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 an FDW 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 PRs 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 an FDW 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 surpluses 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.

Ms Anthea Ong.

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 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 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 financial year (FY) 2017, 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 the Institute of Mental Health'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.

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, caregiver burden.

Currently, multiple schemes ranging from IDAPE, Pioneer Generation Disability Assistance scheme, FDW 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, for example, 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 caregiver, their journey in seeking care and support in his last days was 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 ongoing research conducted by the Association of Women for Action and Research (AWARE) of family caregivers 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 caregivers, 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 caregiver 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, enhance 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 (BRS) of $83,000 in their Retirement Accounts. Among women, only 53% were able to reach the BRS, 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 caregiving to relatives and families. This does not include children. In other words, 80% of family caregivers 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 (EU'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 (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 premium 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 require 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 youths to be enrolled into this national long-term care insurance, with premiums paid by their parents either through their MediSave accounts, or through Government handouts like the 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 youths 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 youths, 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 require application through a social worker or directly to the relevant Government agency or alternatively require 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 caregivers, 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 were 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 Family Service Centre, Residents' Committee, AIC, Social Service Office, HDB, Immigration and Checkpoints Authority, 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 caregiver. 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.

Can you wrap up in the next few seconds?

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 —

Anymore?

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 is 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 Chen Show Mao.

(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 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 one another 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 ADLs 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.

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]

[(proc text) Debate resumed. (proc text)]

Ms Jessica Tan.

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 ongoing care needs as well as their children. His family does also receive financial assistance. However, financing his ongoing care needs as well as supporting their family's expenses have 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 who sought 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 $1,000 a month for their parent's nursing home care. For middle-income families that do not qualify for 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 groups 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 ADLs set out for CareShield Life. Feedback, as we have heard from many other Members in this Chamber, is that the criterion 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 the 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 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 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 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.

Ms Joan Pereira.

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. The Ministry of Finance 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 the Long-Term Care Support Fund 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.

Er Dr Lee Bee Wah.

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 the Health Promotion Board for bringing in all kinds 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, such as 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 PRs 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 on board? 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 Mandarin, 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.

Ms Irene Quay.

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 30, 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 SAS are in most cases Fellows of the Society of Actuaries in the US, the Canadian Institute of Actuaries, Institute and Faculty of Actuaries (UK) or Institute of Actuaries of Australia.

Like other professional bodies, 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 Practising Certificate awarded after attending relevant courses run by the SAS locally.

Hence, with regard to section 37 of the Bill regarding the CareShield Life Council, I propose that when the Minister appoints the Council, can the Minister consider including a Fellow of 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 are 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 is 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 SAS, who is governed by the standards and code of conduct of SAS, will be most appropriate for this role. Notwithstanding the clarifications and proposal above, I stand to support the Bill.

Mr Christopher de Souza.

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 the 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 policyholder 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 are 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 CPF 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 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 a 140% increase in demand for long-term care services or long-term care caregiver 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 being one of the highest in the world. But often, with long lives, though not necessarily so, come with it some loss of the kind of life as we knew it. Needing to rely on others to carry out ADLs 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 to 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 of those who are severely disabled, and for the reasons I have stated, I support it.

Ms Tin Pei Ling.

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 amounts of resources 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 multifaceted 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 ecosystem 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 subgroups. 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 lifespan 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 cohorts?

Moreover, women tend to "lose out" to men in earnings and savings, in part due to them exiting 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 do 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.