Parliament’s ANC-dominated Health Committee is racing to complete its work on the contentious National Health Insurance (NHI) Bill, determined to get it through the National Assembly before the party’s elective conference in December. But, notes MedicalBrief, the Health Minister is yet to provide responses to repeated questions around a financial and sustainable model.
Approval by the National Assembly is a milestone in the Bill’s passage through Parliament, which will then submit it to the National Council of Provinces for concurrence.
The NHI has been on the ANC’s political agenda since 2007 and has featured prominently in its election promises ever since. If it’s approved by MPs, Health Minister Joe Phaahla will be able to show delegates at the conference in December that the current administration is making progress towards implementing the policy.
Parliament’s Portfolio Committee on Health has been considering the Bill since August 2019 and is nearing the end of its work, with two meetings left before it draws up its “A list” of amendments to the Bill, according to chair Kenneth Jacobs.
BusinessLIVE reports that countrywide public hearings were conducted on the Bill, with more than 33 000 written submissions being received and 107 presentations being heard.
Yesterday, the committee was scheduled to hear the Health Department’s final response to its clause-by-clause deliberations on the Bill, and on Friday, it will get input from the state law adviser’s office and Parliament’s legal advisers.
Jacobs told Business Day on Monday evening that the committee hopes to have the Bill adopted by the National Assembly by 6 December.
Once the Health Committee has completed its work on the A list, Parliament will draw up a revised version or “B version” of the NHI Bill, incorporating the approved amendments before submitting it to the National Assembly for a second reading debate and a vote.
It is expected that the Bill will differ little from the document tabled in 2019. Throughout its deliberations, the committee has been sharply divided on party lines, with opposition MPs raising detailed concerns about the Bill’s provisions, and ANC MPs expressing few reservations.
Munzoor Shaik Emam of the National Freedom Party said the question of how NHI would be funded should not be shrugged off. “If there are unanswered questions, is it not our responsibility as legislators to interrogate them?” he asked.
The ANC’s Nhlanhla Xaba dismissed opposition MPs’ complaints that their concerns had been ignored. “The ANC has seriously analysed the submissions made by stakeholders and made changes, where necessary, clause by clause,” he said.
Last week, after Parliament’s Health committee completed its discussion on the Bill and the amendments to the National Health Act that will need to be made for the NHI to be put in place, Phaahla was given the floor to respond to the public submissions and explain how the many glaring problems in the Bill would be addressed.
But the Health Minister either could not see the problems or decided not to try to fill in the blanks, writes Carol Paton for News24. "It seems that the missing pillars of the NHI – how it will be funded and whether it is institutionally feasible – were just as vague and woolly to Uncle Joe as they are to you and me.
"Phaahla acknowledged that concerns had been raised about the funding of NHI. Where will the money come from? This, he said, would really be no problem.
“The target is to spend no more than the current 8.5% of GDP and to reduce administrative overheads. The NHI is about redirecting current spending, and it will use tax tools to do so,” he said.
But actually, the 8.5% of GDP he referred to includes what is spent by the state (a little over half of the 8.5%) and what is spent by individuals on medical aid and out-of-pocket payments (just under half.) Phaahla’s belief is that once government imposes higher taxes, everyone will migrate to the NHI and give up their medical aid. Medical aid revenues would then flow directly into the big pot of money that government would manage.
For this to happen on a one-to-one substitution basis, the tax increases would have to be immense and people would need to respond in a way they don't usually do to large tax increases – by paying them. To illustrate, the entire tax take of the country is around 25% of GDP. To raise this by four percentage points would mean increases of a magnitude never seen before.
Phaahla’s response to the fate of medical aids in the future was also simplistic. The theory goes that as more services are provided by NHI, medical aids will be gradually prohibited from providing cover for them.
But how long this will take and how exactly the NHI will develop a phased schedule of benefits has never been spelt out. Medical aid administrators seem to be betting that the answer to how long this will take is probably forever and are continuing business as usual, regardless.
Phaahla has offered no concession on the long-term future of medical schemes, saying there will ultimately be no need for them as the NHI Fund will provide comprehensive benefits.
He also waved off apprehension and criticism about too much power being under the control of the Health Minister.
“Some stakeholders were concerned about too much power being vested in the Minister, and called for Parliament to have direct oversight,” he said. “I don’t believe the worry about accountability is warranted. It will be possible to amend some clauses to reduce direct involvement of the Health Minister in operational matters.”
Regarding fears about additional taxes to fund the NHI, these were “completely unfounded” because suppliers in the private sector would not have enough room to set prices, he said confidently.
Beeld reports that Phaahla fielded various questions from opposition MPs about qualitative studies and actuarial reports to establish the cost of the NHI. “Those who ask for that, are used to the current experience… Those who ask for qualitative studies and actuaries, expect that a hip replacement will cost a certain amount and then use that cost to calculate how many billions of rands would be needed…We will ensure suppliers at least earn an income, but they will not make super profits.”
The Minister said the current 8.5% of GDP spent on health expenses is expected to be sufficient if services are “properly rationed”.
Opposition
Earlier in the evening, the department’s director-general for NHI, Nicholas Crisp, finalised his two-day briefing on the Bill’s proposed amendments or repeals of other laws.
The ACDP, DA, FF+ and EFF reiterated their objection to the Bill, and opposed the proposed changes outlined by Crisp. DA MP Lindy Wilson called for other portfolio committees to be consulted on proposed amendments or repeals of legislation they oversee, such as the Road Accident Fund Act, which falls under transport.
DA MP Michele Clarke said the Treasury should be called to brief the Health Committee on the financing of NHI. “My colleagues on finance say the Bill’s costing has not been discussed at the Finance or Appropriations Committee. I believe the Treasury needs to address us (on the) finance model so we can understand what it is going to cost and its affordability,” she said.
For Phaahla, though, this would all be a simple and obvious process. And the implementation would go ahead, despite the country’s fiscal constraints, he said.
“Over time, as the fund covers more comprehensive benefits, there will be no need for medical schemes,” he added.
It was an alarming interaction. After three years of consultation with political parties, the medical profession, human rights organisations, medical schemes and hospital groups, the ANC has yet to budge on any initial positions in the Bill. There is still no financial feasibility study, no financial model, and no institutional feasibility study.
Pilot projects that were run in 2018/19 were independently assessed by consultancy Genesis, which found that many of the interventions had failed to work due to practical constraints, such as an absence of internet connectivity at clinics and the shortage of doctors to volunteer for the scheme. Genesis also made clear that what they had assessed was a string of interventions rather than a coherent system that could be called an NHI.
The plea from Clarke for a feasibility study and input from the Treasury on the financing have been swept aside. For her efforts, she has been accused by the ANC of "not caring about the people”.
Ready or not, the ANC is determined that the NHI Bill will be passed by the time it sits down at its national conference in December. While the implementation risk is clear for all to see, for ANC MPs who think short term, the risk of not having NHI done by the conference is considered bigger. As they steer us into an unknown future, Phaahla and his ANC colleagues must have realised the risk lurking in the background.
The most vociferous of its constituencies – public servants, organised workers and the urban middle class – will not take kindly to the restriction of medical aid benefits. To show that private medical aid was not all it was cracked up to be, Phaahla shared his own personal experience with the committee. He had recently visited a pharmacy only to be told that his medical aid saving funds were depleted, so he had “dig deep into his pocket”, he said.
It was a cringeworthy moment, and the EFF's fiery Naledi Chirwa did not mince her words about the hapless Minister's plight.
“With all due respect, that was a very low-level presentation by the Minister. I never thought I would see the day when a Minister came to justify the NHI because his own medical aid ran out of funds,” she responded.
Chirwa went on to offer the most cutting of all the criticisms levelled at the NHI proposal. Because people will go to their nearest point of provision for their healthcare services, it is those in cities and affluent areas who stand to benefit most from the NHI.
For those in rural areas and far-flung townships where there are no private hospitals and public healthcare is abysmal, healthcare prospects will be just as bleak as they are now.
The Minister, though, would not be put in such an invidious position of running out of funds again, she added. Chirwa, who tends to disregard the instructions of the chair when delivering her blows, was eventually kicked out of the meeting.
Business Day PressReader article – Rush to push through NHI Bill before ANC conference (Open access)
Beeld article – Minister ontken meer belasting gaan vir NGV nodig wees (Restricted access)
See more from MedicalBrief archives:
Government dodges issue of NHI funding model – DA
NHI inadequate for medicines provision, warns lobby group
Health ombud warns that worsening state health facilities won’t make NHI grade
NHI flaws: Lack of transparency, scant guidelines, says Angelique Coetzee