Professor Nicholas Crisp, deputy director-general for NHI in the Department of Health, has criticised an opinion piece written by Khulekani Mathe about the NHI Bill, and cautioned commentators to not "parrot" alarmist claims about the scheme.
Crisp, responding to a commentary in Business Times and reported in MedicalBrief last week, writes:
The article (“Private sector must participate in NHI”, Business Times 28 April) shows a profound misunderstanding of the National Health Insurance and suggests Mathe is parroting other commentators without reading the Bill.
The author must qualify what “proper public participation” is, since he is suggesting that 20 years of consultation and White Paper development and five years in Parliament are inadequate public participation. The implied arrogance is that if the views of one group are not adopted, all of the others are wrong.
Mathe refers to “public servants losing subsidies received through GEMS (Government Employees Medical Scheme)”. How does he arrive at that conclusion?
This is patent nonsense. Benefits are a matter of negotiation between employer and employee and have nothing to do with the NHI Fund nor any funder or provider of healthcare.
If the public sector co-ordinating bargaining council agrees to subsidise contributions to any scheme and whether it agrees to contribute to any future tax implications for NHI payments is entirely a bargaining matter. This applies to private sector employers too.
The reference to “tax credits” is also alarmist and spurious.
The credit for 2024 is a fixed monthly amount of R364 for a primary member, a further R364 for a first dependent and R246 for each additional dependent. It is difficult to explain to the broader public how giving a tax credit of this amount to a person who earns more than R2m annually might entice them to join a medical scheme.
This is the monthly cost of a family dinner out for many such people. And why would one need to continue to pay a tax credit for a medical scheme once the NHI Fund is paying what used to be paid by a medical scheme? Obviously, tax credits cannot be stopped for lower income earners until this happens.
But between now and then is it proposed that the taxpayer will subsidise people who even earn R50m-plus per annum to “encourage them to remain on a medical scheme”? The public are not so undiscerning that they won’t understand the narrative here.
Of course, “medical scheme contributions do not belong to the state”, but once the state provides funding for the purchase of a service for a taxpayer, it has a right and obligation to collect the required funds to pay for the service. The mechanism is through taxes, no matter which tax options one chooses.
The author complains of the “heavy tax burden” and raises the rhetorical alarmist figures quoted by others. Please may the department and the public be provided with the author’s calculations of the VAT and personal tax increases? They are baldly absurd.
Then there is a statement that “those now on medical aids will have access to less than one-third of the benefits that they now access through their medical aids”.
How is this statement justified and explained? We should be told by the author that the 71 medical schemes and their 311 options cost around R21bn to administer each year and, despite this spending, the sector is reported in the media as saying that fraud in 2022 amounted to R28bn.
This far exceeds the reported corruption in the public sector and is an indictment of the sector’s ability to control its money. More than 10 schemes pay their principal officers more than R5m per annum (and up to R8.7m), according to figures reported to the Council for Medical Schemes.
Then there is the cost of 833 trustees and about 5 000 brokers. This is unsustainable.
Despite all the funding claims, the country has seen basically zero growth in beneficiaries in the past five years and there is a constant down-migration from comprehensive to hospital-cover-only options. Presently 25% of beneficiaries have only hospital cover.
This funding structure is seriously sick and needs to be overhauled so that funds can be spent on patient care.
Mathe also refers to “fundamental constitutional breaches” but fails to mention even one. This is also old rhetoric, and every time constitutionality has been raised, the department has sought advice on those opinions. Until these claims are tested in court, we appeal to opponents to share their concerns with the public and not purely make alarmist statements.
The threat of “court challenges (that) will delay the country’s ability to advance universal health coverage (UHC)” is incredible! While any Act is in court the show goes on.
The NHI Act will not replace the current National Health Act nor any other statute. Even the clauses that are amended by the schedule to the Bill will only be amended when the President affixes a date to such amendment, and that depends on the progress through the transition.
What “advance of UHC” is the author referring to? We refer him to the 21 September 2023 UN General Assembly high-level meeting where world leaders approved a new political declaration on UHC. “The UHC target measures the ability of countries to ensure that everyone receives the healthcare they need, when and where they need it, without facing financial hardship.” Repeat: “Without facing financial hardship”.
Then the interesting statement that “no other country in the world places a legislative limitation on access to private healthcare cover”.
Private health insurance represents, on average, only a small share of total health funding across the Organisation for Economic Co-operation & Development (OECD) area. No fewer than 15 countries in the OECD have rafts of related laws and regulations.
Denmark limits private funding to a target of 6%. South Africa’s challenge is that 51% of health spending (2022) is in the private sector.
The concluding comments are that the NHI Bill must be amended to “allow for private sector participation in funding and provision of care”. Since throughout the Bill there is repeated reference to the fund purchasing from both public and private providers, this is merely a statement to hide the intention to sustain the highly dysfunctional and extremely expensive private funding system (medical schemes and insurance).
The department has been at pains to invite contributions to improving health for everyone, not just to sustain the current ailing systems of privilege.
We still hope President Cyril Ramaphosa signs the Bill so we can get on with the long journey of fixing the very duplicative, expensive and messy health systems with which we suffer.
Prepared to challenge
However, the Board of Healthcare Funders, the largest industry association for health funders, is ready to challenge the Bill when the “president finds a pen to sign it into law”, it says, reports The Citizen.
Managing director of the BHF Dr Katlego Mothudi said the NHI “will, in fact, worsen healthcare provision … as the limits placed on private healthcare funding will weaken the national health system”.
Integrated approach
Mothudi said the industry was currently characterised by an integrated approach towards public and private health citizens. “In this regard, the BHF supports UHC and recognises the NHI as one of the mechanisms towards its progressive realisation.”
The BHF and its members have embraced the principles of the UHC and the BHF has actively developed a framework to assist its members in aligning with these principles, he added. They do not, however, support the Bill in its current form due to the unconstitutionality of several of its provisions, its proposed restriction of medical schemes, and the concomitant loss of economic value that will inevitably follow.
He said the private health funding sector should “not be sacrificed in favour of NHI”.
“It is a valuable source of jobs, scarce skills, infrastructure, financial investment and quality healthcare. The value it adds to the economy and the support it provides to the public health sector cannot be underestimated.”
The Bill reduces the role of the private sector “and therefore the BHF wants those sections removed”.
“Weakening any aspect of the private health sector will weaken the national health system rather than strengthen it.”
A number of parties in the health sector were preparing to challenge NHI when it becomes law, and the BHF has invited various legal experts to present a way forward for the industry should the Bill be signed.
“We believe BHF members are well positioned to play a critical role in the NHI environment and we have urged them to fully adopt UHC principles,” he said.
TimesLIVE article – Patent nonsense and deep confusion about NHI (Restricted access)
See more from MedicalBrief archives:
Bold promises in SA as world experts urge momentum for UHC
Fix current system before NHI implementation
HFA opposes proposed medical scheme tax credits’ removal