The National Health Insurance (NHI) Bill has been published in the Government Gazette, paving the way for the Health Department to set up an NHI fund that will purchase healthcare services on behalf of the population. Business Day reports that it is the first piece of enabling legislation for realising the government’s ambitions for introducing universal healthcare.
NHI is at heart a set of health financing reforms that the government hopes will change South Africa’s deeply inequitable access to healthcare, with wealthier people paying for generally high-quality private healthcare services while less well-off people depend on a patchy public healthcare service.
The report says the government plans to introduce universal healthcare that is free at the point of delivery for everyone, based on the social solidarity principles those who can afford to do so will subsidise those who cannot. The Bill proposes establishing an NHI Fund, which will purchase services from accredited public and private sector providers that have been certified by the Office of Health Standards Compliance.
A key aspect of the Bill that is likely to elicit fierce debate is its provision for annual price determination, the report says. This task will fall to a health benefits pricing committee, answerable to the NHI Fund board and the health minister. Patients will have to register with the fund, and will have to follow its rules about referrals, which means they will not be allowed to go directly to a specialist or an academic hospital except in an emergency.
The Bill says “comprehensive health service benefits” must be purchased by the fund. These benefits will be determined by an advisory committee.
The report says the Bill is silent on how the fund will be financed, saying only that the health minister must determine the budget and allocation of revenue to the fund in consultation with the finance minister on an annual basis.
Interested parties have three months to comment.
The abolishment of co-payments is one of the proposals of the Medical Schemes Amendment Bill, announced by Health Mininster Aaron Motsoaledi, reports Fin24. He was speaking at a briefing on the Medical Schemes Amendment Bill and NHI Bill, where he explained that the Medical Schemes Bill was amended to align with the NHI white paper and NHI bill which seeks to achieve universal healthcare.
According to the Health Department’s definition, NHI is a health financing system that pools funds to provide access to quality health services for all South Africans based on their health needs and irrespective of their socio-economic status.
The report quotes Motsoaledi as saying that while the NHI is phased in, beneficiaries of medical schemes need “immediate relief from serious challenges” they’re experiencing in the current medical scheme regime. “The nature and magnitude of the challenges is that it will be undesirable for medical scheme beneficiaries to have to wait for long term changes.” The amendment will also ensure a “smooth, harmonius transition” that does not disrupt access to healthcare during the implementation of NHI.
Motsoaledi explained that only 10% of South Africans can afford private healthcare, according to the World Health Organisation and the Organisation for Economic and Social Development, and it is important to ease the financial burden on South Africans.
The report says based on the proposed amendments to the Medical Schemes Amendment Bill – which are open for the public to comment on for the next three months – co-payments will be abolished. This means that “every cent charged” to the patient must be settled in full by the medical scheme. The patient will not have the burden to pay. Motsoaledi said that this amendment was “well thought of” and is justified by the number of public complaints received by the Department of Health and the Council for Medical Schemes.
According to the department’s data medical schemes hold close to R60bn in reserves which are not being used. There is a statutory requirement that 25% of income be held in reserve to cater for emergencies, but R60bn is equivalent to 33% of reserves.
Motsoaledi said this is an unnecessary accumulation at the expense of patients. “These huge reserves were accumulated partly through high premiums but also by introducing the co-payments such that medical schemes avoid having to pay or even dip into the reserves if the situation demands,” he said. The council is also reviewing the statutory requirement, as it is better to release the money for patients than for it to be held in reserves.
The report says the amendments also propose the abolishment of brokers. “Almost two thirds of principal members of medical aid schemes pay monthly to a broker as part of their premium. Many of these members do not even know that they are paying this money which in 2018 is R90 per month,” Motsoaledi said. The total amount paid to brokers in 2017 was R2.2bn. “We want this money to be made available to pay for direct health expenses of members rather than serving brokers who are actually not needed in the healthcare system.” Motsoaledi claimed that the work done by brokers is actually done by the Council of Medical Schemes.
Among the other amendments which will affect consumer pockets include the introduction of an income cross-subsidisation model. “The rich must subsidise the poor, the young must subsidise the old and the healthy must subsidise the sick,” said Motsoaledi. Currently the opposite is happening.
Medical aid schemes will also pass back savings if a member uses a designated service provider, according to the rules of the scheme. Currently these savings are taken over by the scheme or the administrator as opposed to being passed on to members through a premium reduction.
The report says another amendment will deal with cancellations and waiting periods between joining a scheme and accessing benefits. “Under NHI there will be no penalty related to late joining or age. This is further to protect the interest of living spouses after the passing of the principal member or after retirement prior to payment of their benefits,” he explained.
The Bill also addresses governance of medical schemes and proposes a minimum educational requirement and expertise to a member of a board of trustees or a CEO of a medical aid scheme.
The report says the NHI Bill seeks to establish the NHI Fund, a single public purchaser and financier of health services for the country. It is a mandatory prepayment health services system, the Bill read. During his address Motsoaledi said that all South Africans would have to ascribe to it as they do to the Constitution. The fund will pool revenue to protect users against financial risk and ensure the sustainability of the funding of healthcare services.
It will also provide for “equity and efficiency in funding” by purchasing healthcare services, medicines, health goods and health related products from certified, accredited and contracted service, the Bill read.
The Motsoaledi as saying that the sources of funding for NHI are to be determined by the Department of Health and Treasury. “This is a question that I am asked all the time,” said Motsoaledi. He said it is the job of Treasury and Cabinet to look for the funding, and not the minister. “I did not come up with NHI, it is the ruling party that did so and passed the resolution at the conference in Polokwane in 2007,” he said. “It is the function of the government of the country to sit down and see where the money will come from.”
In the National Budget, Treasury had allocated R4.1bn to NHI for the medium term.