Singapore

Bus Service Reliability Framework

This is a Parliament Question I asked the Transport Minister on 20 January 2014 regarding the new “Bus Service Reliability Framework”, which includes incentives for public bus operators for exceeding service standards set by the Land Transport Authority (LTA).

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Mr Gerald Giam Yean Song asked the Minister for Transport with regard to the new Bus Service Reliability Framework (a) what evidence does the LTA rely on to determine that providing financial incentives rather than just penalties to public bus operators to arrive at bus stops on schedule will improve waiting times; and (b) whether the incentive amounts will be funded by taxpayers.

Mr Lui Tuck Yew (The Minister for Transport): Bus operators have to incur additional costs to monitor and improve en-route reliability and regularity of the trial bus services under the Bus Service Reliability Framework (BSRF). For example, the operators need to hire and train more bus controllers to manage bus services more closely, instruct bus drivers to slow down and mobilise standby buses. The operators may also need to modify and enhance their operations control systems. Hence, there must be some net financial incentive in the design of this Framework.

We have also looked closely at overseas examples, in particular, the London system which has worked well and been carefully refined over many years. For a start, we have modelled our incentive-penalty structure for this BSRF pilot quite closely after the London system, but we will certainly review and improve along the way to make it cost-effective to benefit commuters who have consistently mentioned reliability of buses as a priority area for improvement.

The BRSF will be funded by the Government, as it is a trial to assess whether it can improve the reliability of our bus services.

[Source: Singapore Parliament Reports]

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There was also a debate during Question Time that same day on the service delivery requirements under the Bus Service Reliability Framework. This is a supplementary question I asked the Minister and his reply:

Mr Gerald Giam Yean Song: Would it not be more straightforward to just set high enough standards and then penalise the PTOs for failing to meet those standards? Because this can certainly spur improvements at the backend as well, and the PTOs’ reward really is in more satisfied customers and bigger ridership.

Mr Lui Tuck Yew: We also have to try and arrive at a position and at a model that is fair to all parties concerned. With greater demand, there will be calls for greater injection of resources. So we are trying to find a balance between incentives and penalties in order to arrive at a better situation than what we have today.

[Source: Singapore Parliament Reports]

Supper Club interview with the Straits Times

I did a two-hour long interview with the Straits Times for its “Supper Club” series, which was published on 18 January 2014. I shared my thoughts on a range of issues, including healthcare financing, public transport, media regulation, education and the Workers’ Party’s approach to political engagement. I also shared about my work as a Non-constituency MP and about my family.

Click the two links below to read the interview and watch the video.

Part 1:

Gerald Giam: ‘Rethink health-care financing philosophy’

Non-Constituency MP Gerald Giam is the Workers’ Party’s point man on health care issues. In Part 1 of this Supper Club interview, he speaks about what he thinks should be changed in health-care financing and public transport.

Gerald Giam: ‘Rethink health-care financing philosophy’

Part 2:

Gerald Giam: ‘We’re a moderate party, not fence-sitters’

In Part 2 of this Supper Club interview, Non-Constituency MP Gerald Giam of the Workers’ Party talks about whether he sees a shift in the Government’s policy approach, the difference between being moderate and sitting on the fence, and his personal life.

Severe bed crunch in hospitals

During Question Time in Parliament on 20 January 2014, several MPs asked the Health Minister what was being done to alleviate the severe bed crunch in public hospitals, which has forced some hospitals to house their patients in tents or on corridors. I asked the Minister if public hospitals had considered converting their higher class (A and B1) wards to C class wards. I also asked whether public hospitals were still marketing their international patient services to foreigners residing abroad.

I asked the Minister if public hospitals had considered converting their higher class (A and B1) wards to C class wards. This was a suggestion I had made during the Committee of Supply debate in 2012. Back then, I had pointed out that 22% of beds in public hospitals were non-subsidised (i.e., A and B1 class). My assessment is that since A and B1 class wards use up more space per bed, if they can be converted (permanently) to C class wards, hospitals would be able to free up more bed space for patients and this will help alleviate the bed crunch.

The Minister responded that this could not be done because of the re-wiring and re-piping that would need to be done. I am not convinced. If hospitals are willing to permanently convert their A and B1 class wards to C-class wards to maximise space for more beds, the necessary renovation works can be done.

On a related issue, I asked whether public hospitals were still marketing their international patient services to foreigners. Note that this had nothing to do with public hospitals treating foreigners who are already living and working in Singapore. (Of course we cannot deny medical treatment to these foreigners.) I was asking if the hospitals are still pro-actively marketing their premium healthcare services to foreigners residing outside Singapore. The Minister’s response was that these patients “only” take up 2% of hospital beds. But with many hospitals hitting 100% capacity during certain peak periods, wouldn’t this 2% make a difference?

Below is the relevant section of the debate. The full transcript can be found here.

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Mr Gerald Giam Yean Song: I have two supplementary questions. First, have the hospitals considered converting the A and B1 class wards to C class wards, especially in this period of bed crunch so as to free up more space for the patients? And, secondly, are the public hospitals still marketing their international patient services to foreigners because these would naturally add to the bed crunch as well?

Mr Gan Kim Yong: Madam, first, let me explain that for the wards in the hospitals, the conversion has to take into account the infrastructure design. It also needs to take into account the manpower capacity as well. Some of the wards in B1 may not be able to be converted into C class wards by simply adding beds because we need to ensure that the pipes are there, the wiring is there, and the system is capable of accommodating more than the number of beds that are currently in B1. But in the hospitals, what they have done is they have taken a very practical approach for patients when the bed capacity is tight. When they need more hospital beds to cater to the demand of the patients, they would allow the patients to be uplodged. Even if they are C class patients, we allow them to be uplodged to B2 or B1 wards. So I think all the private wards are being used as a potential capacity to cater to the need of the patient when the bed demand is high.

On the second point of foreign patients, I think I have replied in one of the PQs earlier. Foreign visitors form a very small component of our hospital beds. Some of them come for day surgeries, some of them are in the emergency and treated as outpatients and they go off. From my recollection, I remember that foreign visitors in our hospitals take up less than 2% of our hospital beds and these are sometimes urgent cases and some of them are already here in the emergency department. From the hospital’s point of view, these foreign visitors do not pose a significant stress on our hospital beds. If you look at the historical trends, as I mentioned earlier, I think extension of the length of stay and rising of proportion of patients aged 65 and above are key drivers of hospital bed demand. Of course, hospital bed occupancy is also a very dynamic number. It varies from day to day as you can imagine. It also varies from hospital to hospital. It depends to a very large extent on the number of emergency admissions and the number of discharges the hospital is able to undertake on each day. So it depends on how many patients arrive at the A&E, how many patients we plan to discharge and, therefore, in certain days, when we plan for a certain number of discharges but there could be a significant number of emergency cases that arrive at the emergency departments, and we have to address them and we may have to hospitalise them. If that situation happens, you tend to see a high bed occupancy rate for that particular day of that particular hospital. Once you admit a patient into a hospital ward, it is not just for one day. Sometimes it takes two or three days. For an elderly, it may take a bit longer. So even for that particular day, the occupancy rate is high because of high admissions. It will take a few days for the occupancy rate to come down even if you have low admissions because the patients will take up the bed for a couple of days, or three-four days, depending on the situation. So it is not just a simple factor. That is why I explained in my answer that a combination of factors will contribute towards a high bed occupancy.

[Source: Singapore Parliament Reports]

Debate on motion to increase Singapore’s World Bank subscription

I support Singapore playing a bigger role in international organisations like the World Bank. However, I would like more clarity on why our subscription needs to be increased by such a large amount, and how Singaporeans will benefit from this change.

Delivered in Parliament on 21 January 2014

Mr Deputy Speaker,

The Deputy Prime Minister and Minister for Finance is seeking Parliament’s approval to increase Singapore’s membership subscription limit to the International Bank for Reconstruction and Development (or IBRD) from the current US$40 million to US$672 million.

The IBRD – commonly referred to as the World Bank – is an important international development institution that focuses on uplifting poor and vulnerable communities in the developing world. It aims to promote global collective action on issues like health, trade, agriculture and climate change; strengthen governance and anti-corruption efforts; and prepare for crises.

Singapore has been a member of the World Bank since 1966. We have in the past benefited from World Bank loans for infrastructure development projects. Between 1963 and 1975, Singapore received 14 loans from the World Bank for port expansion, sewage, power, telecoms, education and environmental management. These included US$15 million for the Port of Singapore Authority and another US$15 million for Pasir Panjang Power Station.

Now that we are a developed economy, I think it right for us to contribute back to the development of other countries by supporting the work of the World Bank. As a responsible member of the international community, we should play our part to help alleviate poverty in our world.

Our current subscription limit is US$40 million. This limit has not changed since 1966, when we were much smaller and poorer. Considering our economy has grown a lot since then, our current subscription appears relatively low. We have one of the lowest subscriptions among the 188 member countries in the World Bank.

Having said that, the quantum of the proposed increase in our subscription limit is not small. It is going up from US$40 million to US$672 million – an increase of almost 17 times. Can I ask the DPM how the Government arrived at this quantum?

I understand that voting power at the Bank is allocated based on the capital stock held by each member. Is the increase in our subscription intended to strengthen our voting power or increase our influence at the Bank?

If so, can the DPM explain what tangible benefits it translates to for Singaporeans? Does it make much of a difference if we raise our vote share from the current 0.05% to 0.25%, and is it worth the full US$672 million?

What will be the frequency of the payments of our subscriptions, and under what extreme circumstances that the DPM mentioned will Singapore have to make a full subscription? Will be be obliged to contribute the full subscription if the Bank calls for it?

Sir, I support Singapore playing a bigger role in international organisations like the World Bank. However, I would like more clarity on why our subscription needs to be increased by such a large amount, and how Singaporeans will benefit from this change. Thank you.

Adjournment motion: Easing the cost of healthcare for Singaporeans

While we are all at risk of falling ill, unaffordable medical costs are not inevitable. The Government must reform the way that healthcare is financed in Singapore, so as to ease the healthcare burden on all Singaporeans. This will give all our people peace of mind, knowing that they will be able to afford all necessary treatment if they fall ill.

I filed an adjournment motion on healthcare financing in Parliament on 12 November 2013. This was my speech.

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Madam Speaker,

Thank you for the opportunity to speak on this adjournment motion.

Many Singaporeans are worried about falling ill and not being able to afford their medical expenses. A survey conducted last year by Mindshare, a global media and marketing services firm, found that 72% of Singaporeans felt they “cannot afford to get sick due to high medical costs.”^{^[1]}

This echoes the sentiments of many Singaporeans I have spoken to, many of whom are elderly or have sick family members to care for. In particular, the high out-of-pocket payments at the point of treatment are a great source of worry for many.

It is not uncommon to hear accounts of older folks ignoring health problems and delaying visits to the doctor because they fear that medical expenses will be a financial burden to themselves and their families.

Medical inflation in Singapore was almost 9% in 2011 – much higher than general inflation.^{^[2]} Our people should not have to face these increasing medical costs alone. The structure of our healthcare financing system is a critical factor in determining whether healthcare is truly affordable for all Singaporeans.

In Singapore, less than one-third of all healthcare costs are paid by the Government.[3] More than 60% of costs are paid by patients out-of-pocket, which includes cash and Medisave. This is much higher than the average of 14% in high income countries, according to data from the World Health Organization.[4]

Is it any wonder then, that Singaporeans are feeling the strain of healthcare costs? High out-of-pocket spending can create barriers to healthcare access and use, because people who have difficulties paying medical bills may delay or forgo treatment even though they need it.

It is a fundamental responsibility of the Government to ensure that all our citizens have access to high quality healthcare based on their medical needs, and regardless of their income.

The healthcare burden cannot continue to be borne so heavily by individuals and their families. Singapore’s population is ageing and healthcare costs are expected to continue rising.

The Government must be prepared to shoulder a much larger proportion of healthcare costs than it currently does. We need to shift away from seeing healthcare as primarily an individual responsibility, and emphasise more government intervention, risk sharing and fairness in financing.

We need to change the way healthcare is financed, so that Singaporeans who fall ill can focus on seeking the most appropriate medical treatment, without worrying about whether they will be able to afford it.

*****

I would like to make a few proposals on healthcare financing to reduce the financial burden on Singaporeans when they fall ill, to improve the efficiency of the healthcare system and contain medical inflation.

MediShield premiums

First, on MediShield.

MediShield is an insurance scheme intended to help cover large hospital bills. However, it does not provide full coverage. Patients need to make hefty co-payments^{^[5]}, in addition to other claim limits like caps on hospital ward charges, and annual and lifetime claim limits.^{^[6]} As a result, MediShield claims covered only 2.1% of total healthcare expenditure in 2011.[7]

In August this year, the Government announced plans to provide expanded insurance coverage under a new “MediShield Life” scheme. These changes to cover all Singapore residents, without exclusions for old age or pre-existing conditions, are certainly welcome. They are consistent with what many Singaporeans and the Workers’ Party have been calling for.

However, I remain concerned about the rising premiums. The Government has already warned that premiums will go up.[8] While I accept that increased coverage will come at a cost, there are two questions we must consider: Should all of these cost increases be borne by policyholders? And will some groups of Singaporeans find the premiums unaffordable?

MediShield premiums rise with age. An 86-year old pays a premium rate that is more than 23 times that of a 20-year old.^{^[9]} The elderly shoulder a disproportionate premium burden. Policyholders over age 60 contribute about 36% of total premiums, even though they make up just over 12% of policyholders.^{^[10]}

Most of the elderly are retired with little or no income. It is unfortunate that many of those who are least able to afford the premiums are paying the most.

Many of our senior citizens have exhausted their Medisave accounts and have difficulty coming up with money to pay their premiums. Every year, an average of 650 elderly policyholders opt out of MediShield coverage completely.^{^[11]} This leaves them vulnerable and without insurance protection, putting them at risk of financial catastrophe if they fall ill.

The Government does not directly subsidise MediShield premiums, although it does give ad hoc Medisave top-ups to the elderly and a Medisave grant to newborns.

I would like to propose that the Government introduce a MediShield premium subsidy programme for all vulnerable groups of Singaporeans. These would include elderly persons with no income and limited savings; people with disabilities; patients who have exhausted their Medisave; low income families; and those who already qualify for Medifund, Public Assistance, ComCare and the Community Health Assist Scheme (CHAS).

The appropriate level of premium subsidies should be automatically extended to them, without a need for them to apply separately. This could help many more Singaporeans to cope with the rising premiums, while ensuring that the MediShield Fund remains solvent.

Annual cap on out-of-pocket payments

While MediShield is intended to help cover the costs of large medical bills, policyholders still have to make co-payments in the form of deductibles and up to 20% in co-insurance. Last year, over 2,400 MediShield policyholders made co-payments of over $10,000 each.^{^[12]}

These co-payments can be financially crippling on their own. Would MOH explore the introduction of an annual cap on out-of-pocket co-payments made by each patient. Any medical bills above the cap would be borne by the Government.

Such schemes are a feature in most developed countries, including Japan, South Korea and New Zealand.[13] It is also one of the key consumer protections in the Affordable Care Act in the US.

An annual cap on out-of-pocket payments will limit the financial risk that individual patients are exposed to, and help allay the anxiety of many Singaporeans about uncertain medical expenses.

Co-payments

From the Government’s perspective, co-payments are necessary to discourage over-consumption. The Government’s fear is that “free” healthcare will escalate costs, and become fiscally unsustainable.

However, people do not consume healthcare like they do other goods and services. Most people visit doctors rather grudgingly – usually when they fall sick and have obvious symptoms. Demand for healthcare is therefore not unlimited.

A health insurance experiment conducted by the RAND Corporation, involving over 7,000 patients in the US, found that indeed, higher co-payments reduced the consumption of healthcare. However, the experiment also found that co-payments caused patients, especially the poorer ones, to reduce the use of medically necessary care. The experiment found that poor patients with hypertension tended to avoid treatment, leading to significantly higher mortality rates.

High co-payments have also been shown to have an effect on patients adhering to their prescriptions. In another experiment by researchers from Harvard Medical School, nearly 6,000 patients who had just suffered a heart attack were prescribed drugs that reduced the chance of another attack. Half of them had their co-payments for these drugs waived, while the other half paid the usual fee. The result showed that more patients in the zero co-pay group took their medication regularly. They saw their health improve, with lower incidences of stroke and repeat heart attacks than the patients who had to co-pay. Interestingly, the elimination of co-payments did not increase total spending by patients and insurers, and even reduced spending in some areas.[14]

The lesson from these two experiments, is that if co-payments are too high, poorer patients may be deterred from seeking necessary treatment. Similarly, it is difficult enough to get patients to adhere to their prescriptions, and high co-payments could make it even harder. This could have knock on effects like higher rates of hospital re-admissions, which will cost both the patient and the system more in the long run.

Means-testing

The Government’s claim that no one will be denied healthcare because of inability to pay is cold comfort for some Singaporeans who regularly forego medical appointments or cut back on prescribed medication because of the high costs and the difficulty in obtaining financial assistance.

A few weeks ago, I met an elderly resident at his home in Bedok, who suffers from COPD[15], a chronic lung disease. He is unable to work and has no children to support him. When I asked him how he was coping with his medical expenses, he told me that he was using his Medisave but had almost exhausted it. I was disturbed to learn that he often skipped medical appointments and cut back on his medication just to save money. I told him that there was financial assistance available, and that he should not compromise on his health. But he told me that he had given up applying for assistance because of all the documents that he had to submit, and interviews he had to attend, for the purpose of means-testing.

Recently, a colleague sent me a photo of a large banner at the counter of a pharmacy at a government restructured hospital that read: “Please inform our staff if you do not want to take the full supply and/or if you need to know the total cost of your medication”.

These two situations illustrate how many Singaporeans find themselves making hard choices between getting the necessary treatment and saving money, and how the onerous process of means-testing may be deterring some needy patients from obtaining financial assistance, and therefore treatment.

I have spoken in this House before about how all means-testing should be done without the need for patients to physically submit income documents. The patients and their families should only need to give their consent for the provider to assess their income records with the relevant government agencies like CPF Board and IRAS.

This facility should be available at all institutions, whether private or public. The providers of all assistance schemes, including Medifund, hospital endowment funds and other charity schemes, should be able to access these records. This will better ensure that patients receive all the financial assistance that they qualify for.

Better still, can vulnerable groups of patients be pre-qualified so that they don’t even have to submit any applications before receiving financial assistance? Currently this is already being done for the CHAS cardholders receiving outpatient treatment. MOH should consider extending the same for inpatient financial assistance schemes.

*****

Containing healthcare costs

As I call for an expansion of the role of the Government in easing the healthcare burden on Singaporeans, I am also aware of the many challenges that our healthcare system faces in containing ever-increasing costs. We need to look into ways to contain healthcare costs while still improving patient outcomes.

Integrated healthcare

Many of the current measures to contain healthcare costs focus on curbing consumption by patients. However, most patients do not have sufficient knowledge to decide on the type of treatment they need. These decisions are usually entrusted to healthcare providers, which include doctors and hospitals.

Providers therefore drive the bulk of healthcare spending through their decisions to admit patients to hospital, order medical tests, prescribe drugs and charge fees.^{^[16]} Therefore, if we seek to control costs, we need to actively engage providers.

To achieve this, all providers – including GPs, hospitals and preventive care providers – must be made collectively responsible for providing a full spectrum of care for patients. These providers should cooperate and share patient information with each other, in order to make more accurate diagnoses and coordinate patient care.

They should focus on keeping patients healthy and ensuring they take their medication regularly. This will minimise hospital re-admissions, investigations and treatment, all of which are much more expensive. Providers should be paid based on their achievement of measured quality improvements, not simply the volume of patients they see or the level of fees their patients pay.

All this could lead to healthier patients and lower costs for both patients and the system.

Health technology

Technology should be used as a “force multiplier” in the face of limited manpower in our healthcare system. While Singapore is no laggard in healthcare technology, its potential is not being fully realised. Often, the problem lies not with the lack of technical expertise, but a lack of adoption.

One example of this is the National Electronic Health Records system (NEHR). The NEHR enables patient health records to be shared across the healthcare system. It can reduce medical errors, and improve productivity and coordination between providers. This will lead to better diagnoses and treatment, and reduced medical costs.

The NEHR has been rolled out to all public hospitals, polyclinics and long-term care providers. However, while over 5,000 clinical users have access to the system^{^[17]}, what percentage of these users are fully utilising the functionality of the system? Is usage lower than it should be, due to usability issues or some providers still preferring to use handwritten clinical notes? How is MOH ironing out these issues to increase usage of the system?

The usage of NEHR in the primary care sector is lagging even further behind. As at March this year, it had been rolled out to only about 50 out of the 2,000 private GP and dental clinics.^{^[18]}

The Government has already invested $172 million to develop Phase 1 of the NEHR, and is paying about $20 million each year in maintenance costs.^{^[19]} The subsequent phases are expected to cost more. While the Government deems it important to recover the cost of developing and maintaining the NEHR, the goal of cost-recovery must not impose a roadblock to the full adoption of the system by all healthcare providers in Singapore. It is important to ensure that all providers, including GPs and specialist outpatient clinics, enter the necessary clinical data into the system, so that the full benefits of having electronic health records can be realised.

*****

Madam, healthcare is an issue that is close to the heart of every Singaporean. While we are all at risk of falling ill, unaffordable medical costs are not inevitable. The Government must reform the way that healthcare is financed in Singapore, so as to ease the healthcare burden on all Singaporeans. This will give all our people peace of mind, knowing that they will be able to afford all necessary treatment if they fall ill.

*****

[1] Mindshare “3D” Survey 2012, quoted in Hooi, Joyce, “Singapore’s emigration conundrum”, Business Times, 6 October 2012.

[2] Towers Watson, “2012 Global Medical Trends Survey”.

[3] Singapore Parliament Reports (Hansard), 13 May 2013, “Healthcare spending and funding sources”.

[4] World Health Organization, “World Health Statistics 2013”, p.138 (“Health Expenditure”).

[5] The MediShield deductible is $1,500 for Class C wards and $2,000 for Class B2 and above wards. Co-insurance is between 10% and 20% of bills.

[6] Claim limits include a cap on normal hospital ward charges of $450 per day, a lifetime claim limit of $300,000 and a maximum coverage age of 90 years.

[7] Singapore Parliament Reports (Hansard), 13 May 2013, “Healthcare spending and funding sources”.

[8] AsiaOne, 26 September 2013, “’We have made significant progress’: PM Lee”.

[9] Ministry of Health, MediShield Premiums. A 20-year old pays a premium rate of $50 per year, while an 86-year old pays $1,190 per year.

[10] Singapore Parliament Reports (Hansard), 21 October 2013, “Age Profile of MediShield Policyholders”; and MediShield Premiums (Ministry of Health).

[11] From 2010 to 2012, an average of 650 MediShield policyholders aged 60 and above opted out of MediShield coverage each year. Source: Singapore Parliament Reports (Hansard), 13 May 2013.

[12] Singapore Parliament Reports (Hansard), 21 October 2013, “Payments made by MediShield policyholders for cumulative MediShield Basic co-insurance”.

[13] Paris, Valérie, et. al (2010), “Health Systems Institutional Characteristics: A Survey of 29 OECD Countries”, Table 10 (Exemptions from copayments), p.24.

[14] Niteesh K. Choudhry (2011), “Full Coverage for Preventive Medications after Myocardial Infarction”, New England Journal of Medicine, 1 December 2011. Mentioned in Mullianathan, Sendhil, “When a Co-Pay Gets in the Way of Health”, New York Times, 10 August 2013.

[15] Chronic obstructive pulmonary disease.

[16] Rand Corporation (2013). “Solving the Health Care Cost Challenge: Leveraging RAND Expertise”. Retrieved from: http://www.rand.org/health/feature/health-care-cost.html.

[17] Singapore Parliament Reports (Hansard), 12 March 2013.

[18] Ibid.

[19] Singapore Parliament Reports (Hansard), 13 May 2013.

Debate on the amendments to the Employment Act

I am glad to note the introduction of some new protections for workers and some PMEs in this Bill. I have mentioned a few concerns about salary deductions, penalties, exemptions from work hour limit protections, compensation for holiday work and the powers of inspecting officers.

This was my speech during the debate the amendments to the Employment Act in Parliament, on 12 November 2013.

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Madam Speaker,

I will focus on the amendments to the Employment Act in this Bill.

Section 30 – Deductions

I have several questions regarding the amendments to Section 30 pertaining to deductions for accommodation, amenities and services provided by employers to their workers.

First, how is the value of these deductible expenses determined? Has MOM conducted any inspections to determine if the prices charged by any employers are excessive?

Second, is the value of the accommodation based on the actual cost or the market value? If it is based on market value, these employers could potentially profit from providing accommodation to their workers, since private market rentals are very high. I note that Section 27(1)(c) allows for deductions for only the actual cost of meals, but Section 27(1)(d) does not specify “actual cost of accommodation”. Can the wording of the latter be changed so that employers are only allowed to deduct for the actual cost of accommodation?

Third, what can “amenities” and “other services” include? Unscrupulous employers could potentially throw in anything as a service or amenity, in order to deduct their workers’ salaries and reduce costs. I understand that some workers earning less than $800 per month still face deductions to their salaries. This could lead to financial hardship for them and their families, as their salaries may fall even further below subsistence levels. Would the Ministry consider prohibiting salary deductions for workers who earn below a subsistence threshold?

And fourth, I note that the protections under Section 30 are all still subject to mutual agreement between the worker and his employer. While one could argue that the worker is free not to sign the contract, in reality, most low wage workers are not in a strong bargaining position to refuse. This makes it more necessary for the law, and not just a contract, to protect the worker.

Section 34 – Penalties

Next, on penalties. This Bill specifies in Section 34 the penalties for failure to pay salary in accordance with the Act. A first-time offender will be liable to a fine of between $3,000 and $15,000 and/or six months’ jail, and a subsequent offence could double that.

Non-payment or late payment of salaries are a concern for many workers. Stiff punishment must be meted out to errant employers who fail to meet their obligations to their employees, in order to send a strong deterrent message.

However, the penalties do not guarantee that the worker will actually get paid what is owed him. While Section 134 stipulates that the court can order fines to be paid to the aggrieved worker, this is discretionary. Can the fines imposed be automatically paid to aggrieved workers, so that they receive all their salary arrears?

Section 40 – Exemptions from work hour limit protections

The amendments to Section 40 allow workers in “essential services” industries to work for more than 6 consecutive hours without a break or more than 12 hours a day, and without being paid for overtime work if it does not last for more than 3 weeks. Currently, this exemption is granted mostly for ad hoc work exigencies, like accidents, unforeseeable interruptions and urgent work, or defence and security duties.

This amendment could greatly increase the number of workers in Singapore who will not enjoy the work hour limit protections under Section 38(1). It will now include workers in broadcasting, newspaper and postal services, and even bulk distribution of fuel and lubricants, from among a list of 28 essential services listed in the Criminal Law (Temporary Provisions) Act.

What is the reason for including these new exemptions and in what way was the previous list of exemptions insufficient?

More importantly, how will the Ministry ensure that essential services workers are not made to work excessive hours without breaks, rest days or overtime pay, over an extended period of time?

Section 88 – Compensation for work during holidays

The insertion of a new subsection 4(A) in Section 88, increases flexibility for employers to compensate employees who work on holidays by granting them time-off in-lieu of overtime pay. It also specifies the number of hours of time-off in-lieu, depending on whether the employee worked a full day or half a day during the holiday.

Madam, holidays are very important for workers, as they provide them a day to spend with their families and recuperate from work. A disruption of a holiday due to work exigencies should be properly compensated by the employer.

This Bill allows the employer to grant only part of a day off to replace a full day of holiday work, “as may be agreed between the employee and his employer”.[1]

Why is it necessary to give this additional option to employers? It could give employers a way to avoid fully compensating their employees for holiday work, as the employee will find it hard to refuse a lower compensation.

Why not take away this option, so that it will be mandatory for employers to either compensate the employee with extra pay, or time-off in-lieu in proportion to the time spent working on the holiday?

Section 105 – Power to arrest

The Bill introduces a new Section 105, which gives inspecting officers the power to arrest without warrant persons suspected of committing offences under this Act. It includes powers to “use all means necessary to effect the arrest”. Section 105D provides for the inspecting officers to be armed.

Currently, Section 103 gives inspecting officers no such powers. They are allowed to examine, search and retain evidence, but not to arrest suspects.

I would like to ask the Minister why is there now a need to give inspecting officers powers to arrest and restrain people suspected of violating the Employment Act?

With these new powers, will inspecting officers be given the same level of training as police officers to ensure that they do not use excessive force when conducting the arrests or restraining suspects?

Salary thresholds

Lastly, the Bill raises the salary threshold for employees covered under the Employment Act to $2,500 for non-workmen but keeps it at $4,500 for workmen. According to MOM, this will allow the salary threshold of non-workmen to catch up gradually with workmen and, in the longer term, will allow the removal of the demarcation between these two groups of workers.

May I ask the Minister how long it will take to remove this demarcation, and what are the existing obstacles to its removal?

Summary

In summary, I am glad to note the introduction of some new protections for workers and some PMEs in this Bill. I have mentioned a few concerns about salary deductions, penalties, exemptions from work hour limit protections, compensation for holiday work and the powers of inspecting officers. I hope the Minister will address these concerns in his response.

[1] Section 4(A)(a).

Health screening

We know that health screening is useful for early detection of chronic diseases and other illnesses like cancer. This can enable early treatment which means a better chance of recovery. The Health Promotion Board has been sending out letters to all Singapore residents aged 40 and older to attend health screening, yet from the Minister’s reply to my parliamentary question on 21 October 2013, it appears that the participation rate is quite low, and even MOH agrees that there is room for improvement. Here is my PQ and the Minister’s answer.

What can we do to increase the participation rate?

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Mr Gerald Giam Yean Song asked the Minister for Health from 2011 to 2013 to-date (a) how many invitations have been sent annually to residents of 40 years old and older to go for health screening under HPB’s Integrated Screening Programme (ISP); (b) how many residents took up those invitations in each of those years; (c) what are the charges for such screenings; (d) what is the rationale for charging such screenings; (e) what are the KPIs the Ministry uses to measure the success of the ISP; and (f) how does the Ministry rate the success of the ISP.

Mr Gan Kim Yong (Minister for Health):

The nationwide Integrated Screening Programme (ISP) offers affordable and convenient screening for high blood pressure, high blood cholesterol and diabetes, as well as breast, cervical and colorectal cancers to Singapore residents for the recommended age-groups. Under the ISP, Singapore residents who reach 40 years of age receive invitation letters to go for the various ISP screening tests at GP clinics. Those who are screened receive rescreen invitations according to the recommended intervals in subsequent years for the various screening tests. To enhance accessibility, the Health Promotion Board (HPB) collaborates with partners such as People’s Association as well as companies, to bring subsidised health screening to residents in the community and workplaces.

The total number of residents aged 40 years and older who received 1st invitation letters and rescreen invitations were 490,000 in 2011 and 200,000 in 2012. In 2011, 36,000 people attended health screening under the ISP and 19,000 people in 2012. The total number of invitations and residents who attended health screening was higher in 2011 because 365,000 invitation letters were sent to women aged 50 and above who were due for their mammogram screening in conjunction with the launch of the Celebrate Wellness (CW) programme, a HPB partnership initiative with WINGS and Toteboard.

Costs for screening services under the ISP have been kept affordable. For example, the cost of the blood tests in the GP clinics to screen for diabetes and high blood cholesterol is $8, the cost of Pap smear to screen for cervical cancer is $15, and the cost of the Faecal Immunochemical Test (FIT) which screens for colorectal cancer is $30. This is in addition to the GP consultation fees. Lower-income Singaporeans receive all these tests for free and only need to pay GP consultation fees. For community based screening, the cost of blood tests to screen for chronic diseases is $2 to $5.

Under the ISP, GPs can refer women for mammography for breast cancer screening at Breast Screen Singapore (BSS) centres at 16 polyclinics, at a subsidised cost of $50 for citizens. Women aged 50 and above can use Medisave to pay for mammograms at all Medisave-approved screening centres, including the BSS centres.

Patients are charged for screening under the ISP as the health of an individual is a shared responsibility. We have also targeted government subsidies at those who need help most. To make screening even more affordable and accessible, the Community Health Assist Scheme (CHAS) has been enhanced to increase the coverage of subsidies for screening tests under the ISP. From 1 January 2014, the recommended tests will be fully subsidised by the government for CHAS patients at accredited GP clinics. They will also enjoy subsidies for GP consultation charges of up to $18.50 per visit, for their screening and subsequent follow-up consultations, up to two times a year.

The results have been encouraging. In the National Health Survey 2010, among Singaporeans aged 40 to 69 years, 71% had been screened for high blood pressure in the past year; and 61% and 64% had been screened for high blood cholesterol and diabetes respectively in the past three years, in accordance with the recommended frequency of screening. In terms of cancer screening, 48% of women aged 25-69 years had undergone the Pap smear test within the past three years; and 10.3% of Singapore residents aged 50-69 years had a Faecal Occult Blood Test (FOBT) within the past one year.

Nevertheless, there is room to further improve the screening participation rate. My Ministry will continue to look into how we can encourage more Singaporeans to undergo appropriate screening, and make screening even more convenient and affordable.

Age profile of MediShield policyholders

I asked the Minister for Health on 21 October 2013 for the number of MediShield policyholders in each age group. Here was his written reply to my parliamentary question.

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Mr Gerald Giam Yean Song asked the Minister for Health how many MediShield policyholders are currently in age ranges of (i) 0-20 years (ii) 21-30 years (iii) 31-40 years (iv) 41-50 years (v) 51-60 years (vi) 61-65 years (vii) 66-70 years (viii) 71-73 years (ix) 74-75 years (x) 76-80 years (xi) 81-83 years (xii) 84-85 years and (xiii) 86-90 years.

Mr Gan Kim Yong (Minister for Health):

As at June 2013, 3.6 million members, or 93% of the resident population, were covered under MediShield. The breakdown of MediShield policyholders by age group is presented below.

Age Group	MediShield Policyholders
0-20	881,800
21-30	505,100
31-40	598,500
41-50	598,200
51-60	537,800
61-65	189,200
66-70	106,300
71-73	51,500
74-75	29,700
76-80	46,800
81-83	16,500
84-85	6,300
86-90	2,600
Total	3,570,200

The maximum coverage age for MediShield was recently raised from 85 to 90 years in March 2013, in view of the increasing life expectancy of Singaporeans. As a next step, with the proposed move to MediShield Life, we will be studying enhancements to provide universal, lifetime coverage for all Singaporeans, including the most elderly.

MediShield’s capital adequacy ratio

At the 21 October 2013 Parliament sitting, I asked the Minister for Health about the reserves and Capital Adequacy Ratio (CAR) of MediShield, the government-run health insurance scheme. The MediShield Fund has $507 million in net assets (as at December 2012). The purpose of this question was to find out what proportion of this $507 million consisted of reserves and capital set aside to meet MAS regulations for insurers. I also wanted to find out what was the target CAR of MediShield. In his answer, the Minister said that MediShield’s CAR was 165% as at the end of 2012. This means that the scheme has enough capital set aside to fund up to 165% of its claims in 2012. While MAS requires a minimum threshold of 100-120%, MediShield is in fact aiming for a CAR 200%.

This was a follow up to my parliamentary question on 21 November 2011, when the Minister told me that “(b)esides funding current claims, a portion of MediShield premiums is set aside as reserves in line with the Monetary Authority of Singapore (MAS)’s Risk-based Capital framework. Beyond the reserves, MediShield is also required to set aside a certain sum of capital, to meet MAS’s risk requirements and keep the Fund solvent in case of adverse risks.”

In his answer on Monday, the Minister said that MediShield’s CAR was 165% as at the end of 2012. This means that the scheme has enough capital set aside to fund up to 165% of its claims in 2012. While MAS requires a minimum threshold of 100-120%, MediShield is in fact aiming for a CAR 200%.

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Mr Gerald Giam Yean Song asked the Minister for Health regarding the $507 million in net assets of the MediShield Fund at the end of 2012 (a) how much of this represents (i) reserves set aside to fund the expected scheme liabilities (ii) capital set aside to meet MAS’ risk-based capital framework requirements for insurers; (b) what is the quantum of (i) reserves and (ii) capital set aside for each of the years from 2005 to 2012; and (c) what is the minimum Capital Adequacy Ratio (CAR) that MediShield targets to maintain over and above the minimum CAR of 100% required by MAS.

Mr Gan Kim Yong (Minister for Health):

MediShield is a self-sustaining and not-for-profit insurance scheme. This requires setting aside sufficient reserves in the MediShield Fund to meet its liabilities, expected risks and target Capital Adequacy Ratio (CAR).

Between 2005 and 2012, on average, about 65% of the MediShield Fund comprised reserves to fund the expected scheme liabilities. Scheme liabilities include policyholders’ claims as well as premium rebates to help policyholders with old-age premium affordability.

The remaining portion of the Fund, which is what Mr Giam has referred to in his question as “net assets”, is capital from which the MAS-based risk requirements are financed. CAR is computed as the ratio of these “net assets” to the MAS-based risk requirements.

The member also asked about the CAR that the MediShield Fund targets to maintain. While the minimum CAR is 100%, MAS requires funds to meet a minimum threshold CAR of 120%, below which a “financial resources warning event” is triggered and the regulator may intervene. No prudent insurance fund operates by holding only the absolute minimum requirement, otherwise a small variation in claims would immediately cause a breach. Reserves and capital numbers change from year to year as claims payout changes and the Fund’s assets are marked-to-market. As at end 2012, the CAR of MediShield Fund is about 165%. The MediShield Fund has set a target CAR of 200% to ensure that the Fund is able to meet its liabilities to policyholders even in adverse scenarios. This target is in line with industry best practices.

MediShield liabilities and reserves are reviewed on an annual basis in line with actuarial principles.

Median cash-over-valuation (COV) for resale HDB flats

Mr Gerald Giam Yean Song asked the Minister for National Development if he can provide the figures for the median Cash-Over-Valuation for resale HDB flats by town and flat type in each quarter since 2nd Quarter 2007, with a breakdown of buyers by (i) Singapore citizen (SC) households (i.e. households with at least one SC owner) and (ii) Singapore permanent resident (SPR) households (i.e. households with SPR but no SC owners).

Parliament sitting date: 16 September 2013

Mr Gerald Giam Yean Song asked the Minister for National Development if he can provide the figures for the median Cash-Over-Valuation for resale HDB flats by town and flat type in each quarter since 2nd Quarter 2007, with a breakdown of buyers by (i) Singapore citizen (SC) households (i.e. households with at least one SC owner) and (ii) Singapore permanent resident (SPR) households (i.e. households with SPR but no SC owners).
Mr Khaw Boon Wan : Detailed Cash-Over-Valuation (COV) data, provided there are sufficient transactions during the quarter, with breakdown by town and flat type are published in the HDB InfoWEB and updated quarterly. HDB, however, does not monitor the detailed breakdown as requested by the Member.

We do have some breakdown of COV data by buyer group, as tabulated below:

Source: Singapore Parliament Reports (Hansard)