Late last week the Minister of Health announced proposed changes to the Medical Schemes Act in the Medical Schemes Amendment Bill, and the tabling of the National Health Insurance Bill. Over the weekend there’s been a flood of media coverage of the announcements. If you’re looking for a condensed version of what has been written, we’ve got your back. See below:
- The Minister published a op-ed here.
- IOL unpacked the Bills here and here.
- Daily Sun and Citizen responded with editorial here and here.
- The Ombudsman has come out in support of NHI and the City Press views the Bills as a step in the right direction: here and here.
- Citizen reports that medical aids are cautiously supportive of the Schemes Amendment Bill but do want more time to study it: here.
- The FMF and Anthea Jeffrey are set against the Bills: here and here.
Some of the more interesting snippets from press coverage are excerpted below:
“Despite the efficiencies that come from a wholistic approach, the NHS is still very expensive. The service costs about 7.1% of UK GDP and taxes that pay for it take a big bite out of taxpayers’ pay cheques. The total budget in 2017 was about £125bn, equivalent to about R2.2-trillion, or 47% of SA’s GDP. The UK’s population is about 14% bigger than SA’s, but the NHS budget is six times our public and private healthcare spending combined. As a percentage of GDP, our health spending does look better. There are tricky political issues at the top and the bottom of the income scale. All employees will suddenly have a new amount deducted from their pay cheques. As the Davis tax committee has provocatively suggested, that may go down as well as e-tolls have, as people will suddenly be made to pay for something they currently believe they are getting free. There are also proposed amendments to how private medical aid schemes will work, largely removing the current tax advantages. The ambition seems to be to make private insurance a top-up for the well-off, covering more elective aspects of healthcare, rather than basic health insurance. It may be impossible to square these two things — the basic NHI scheme is unlikely to cover what privately insured South Africans will consider to be minimum standards. They will therefore add expensive top-ups without the tax advantages they currently enjoy. And if the basic NHI contributions are set with graduated rates based on income, the wealthier could find their costs of healthcare escalate dramatically. Between workers and the well-off there is ample scope for a political backlash.
But he has yet to deliver on the assurances that National Health Insurance was contingent on improving the quality of public hospitals and clinics. His more recent insistence that improving the state of healthcare is an ongoing project and that its failings should not be used as a stick to beat back National Health Insurance does not wash. The government as a whole has a dismal track record in managing large funds intended for compensating injuries sustained at work or on the roads. The Compensation Fund, overseen by the Department of Labour and responsible for remunerating people for work-related injuries, has long frustrated doctors and claimants with its extensive delays. And the Road Accident Fund is technically insolvent and has contingent liabilities of close to R190bn. National Health Insurance will be far more complex to administer, with a far larger pot of money for the unscrupulous to plunder.
The country’s health system is in a crisis, according to President Cyril Ramaphosa. He has confirmed fears expressed by experts, activists and unions that the system has collapsed and contradicted Health Minister Aaron Motsoaledi’s strong opposition to the sentiment. Ramaphosa was addressing the National Union of Mineworkers (NUM) congress in Boksburg on Friday when he said the National Health Insurance (NHI) Fund would bring stability to the stressed system. He said the universal healthcare coverage meant the financially fit must help subsidise those who are not, and that was the trend across the world. “Our job as the governing alliance, as the ANC, is to make sure all South Africans have access to the best healthcare. Right now our hospitals are burdened and our healthcare is in crisis, and we believe the only way to [correct] this is to pool all resources and everyone makes a contribution,” he said. “There are vested interests; those who want to hold on to the current system that is bringing a huge burden on the health system. They will oppose it, but this is one issue we are going to see implemented whether people like it or not.
Medical schemes, however, have complained that they are at the mercy of providers who over service and increase their tariffs when they know schemes are obliged to pay as in the case of prescribed minimum benefits. The tariffs doctors, hospitals and other providers charge was referred to the Competition Commission’s Health Market Inquiry, which is due to release its findings next week, but Motsoaledi said he feared it may be interdicted from doing so by affected stakeholders. Asked how schemes could be expected to cover whatever providers charge without co-payments, the minister said tariffs “will have to be uniform”. Charlton Murove, head of research at the Board of Healthcare Funders, says schemes need more details on how the scrapping of co-payments would be implemented. The Council for Medical Schemes is conducting a review of the prescribed minimum benefits that is likely to take another two years. But expanded benefits are likely to add to the costs borne by schemes. Motsoaledi suggests schemes set aside less in reserves to ameliorate the financial impact. They are now required to set aside 25% of contributions, but on average schemes have 33% of contributions or R60-billion in reserve. Morose said setting reserve requirements according to risk should make schemes more affordable, but in some cases schemes might need to raise reserves of more than 25% of contributions.
But to get the country moving in that direction, the minister has to start with current problems in his portfolio. That means sorting out governance issues that face every hospital and clinic under his ambit. The systems in place don’t talk to the demands of the healthcare system. Historically, we have produced some of the best training systems for both doctors and nurses in the world, but in the past few decades, support from medical schools for the healthcare profession has dwindled. Highly skilled and knowledgeable people have drifted to the private sector and overseas markets, and professionalism has taken a dive. Infrastructure has aged, with poor maintenance. Baragwanath Hospital, which went through a heavy refurbishment some years ago, already faces a significant maintenance backlog. It’s all a question of governance, a consequence of which has been an inability to attract or retain talent. Another obstacle to overcome is a bit of a personal challenge to the minister, especially if he is to remain in his ministry after next year’s election. He must get over his distrust of the private sector. Often described as the most anti-business minister in cabinet, it’s for him to overcome this trust deficit, if the state, given its desperate fiscal position, is to make a sustainable play at improving lives. This tension between private and public healthcare is unnecessary, as these are the resources of the country. There’s absolutely no reason for parties not to properly engage. In pursuing universal healthcare, there’s no doubting that some large private-sector players can offer some solutions to a struggling public healthcare sector. One that we will hopefully all be using. While Discovery and hospital groups such as Netcare realign their business models, Motsoaledi or whoever replaces him in years to come shouldn’t undertake a national health insurance plan that doesn’t include the skills they house. Room must be made for co-operation. There is expertise in the private sector that, as things stand now, isn’t fully utilised.