YOUR SAY: Who should pay for healthcare?

By DR ROBIN ROBERTS

IT DEPENDS where you live, is the answer posed by the question in the headline.

If you lived in the USA, you would still be at the fork in the road. One hundred years later it remains the hottest debate in every congressional, senatorial, gubernatorial and presidential election campaign: individualism, a personal responsibility versus collectivism, the common good. If you lived in the other 34 of the 35 most developed countries in the world, it would be a slam-dunk. All of them have a national health insurance programme – a government guarantee that every person is covered for basic health care services.

The Bahamas government espoused the values of collectivism, that health care is a human right, a public good. Such a philosophy was a no–brainer for us, a country grounded in the Christian values that we are our brother’s keeper.

As in most countries the journey to NHI in the Bahamas has been a long process, a 40-year long tortuous path manoeuvring through the political gauntlet: Who to pay? For what? How much? When, where and how to pay? So amidst the fury and dust of the recent general elections campaign, in April 2014, the first phase of a NHI programme was implemented - Primary Care.

The phased approach was a realisation that health care is expensive: we take heed in that Bahamian proverbial phase – “don’t hang your basket higher beyond your reach”. In this onslaught of the noncommunicable diseases (NCDs) that afflict us in The Bahamas - where we are leaders in the region in obesity, diabetes, hypertension, cancers, violence and high cost of care - there is great wisdom in the Primary Care-first approach. An ounce of prevention is worth a pound of cure.

The journey to NHI continues. It is time to take the next step. There are times when we need more than a primary care physician; we need specialised services inclusive of hospitalisation too. This is where 70 percent of our healthcare dollar is spent. And it’s not cheap. We recognise that we have to face the challenge of paying for high cost care, expensive care.

We can’t kick the can down the road any longer. Too many Bahamians can’t afford it. Insurance premiums and out-of-pocket expenses; even the government nominal health facility charges exceed their income. It gets worse as we age and face the inevitable: we need and use more hospital-based and specialist care. Too many of our people do without because they can’t afford it. They suffer too; and God forbid, some die for lack of ability to pay for health care.

As we journey into the minefield of high cost care, the collective responsibility cannot be overemphasised. In a society, collective responsibility recognises that in health and disease, by its very nature, there are those who cannot pay because they have limited or no earning capacity: our children, the elderly, the unemployed, the indigent. Paying for health care translates to a health mutual. Those who are healthy pay for those who are sick and can’t pay. For health care is fraught with uncertainty. We don’t know when or if we’ll get sick, or what disease we’ll get. Accidents happen. The young will become old.

In this spirit of collectivism, that healthcare is a public good, paying for health care becomes a shared responsibility. It’s a commitment to being our brother’s keeper as in the parable of the Good Samaritan – we are all neighbours along the journey.

The National Health Insurance Authority embodied this shared responsibility in the foundation of the new NHI programme to pay for high cost care within the standard or essential package of health care benefits. It’s the worker and the employees contributing their shared proportionally through salary deductions with a portion to go to those who could least afford. It’s the government contributing its share through continuing their budget allocation from the treasury to fund the essential benefit package for those least able to pay, namely senior citizens, retirees, children, the indigent and the unemployed.

It’s the insurance companies contributing their share through a waiver of exclusions and penalties for pre-existing conditions; it’s a community, not experienced based-ratings. It’s the providers contributing by reducing their reimbursement rates to deliver care to those least able to pay. NHI becomes a catalyst for transforming the reimbursement models for physicians.

The Public Hospitals Authority and the Department of Public Health are the people’s ownership and their investment in human capital. The criticisms and complaints of the Ministry of Health, namely PMH, Rand Memorial and the public health clinics are valid, but the problems are not insurmountable and doomed to fail.

The evidence is without dispute: making public health services work is the best proven route to achieving universal and equitable health care in developing countries. Making it work requires determined political leadership, adequate investment, evidence-based policies, and popular support. When these conditions exist, public health systems can take advantages of the economies of scale, standardised systems for regulation and improving quality, and claim legitimacy and capacity to redistribute resources and reduce inequality

With everyone covered for the same package of essential benefits at the same price, puts affordability, accessibility and equity at centre stage of a shared responsibility. Enrolment identifies every user, allowing the public institutions to submit for payment of every service delivered. The hospitals can project revenues in concert with expenses. NHI then, becomes a catalyst for transforming the reimbursement models for the public institutions as well.

Affordable, realistic and sustainability is the message of our shared responsibility in our proposed, advanced NHI programme. Health becomes not only a benefit to the individual, but to society as a whole. Healthier societies are wealthier, because they take advantage of more of their human potential. In so doing, the whole becomes greater than the sum of its individual parts.

• Dr. Robin Roberts, MD, MBA, OBE, is chairman of the Board of the National Health Insurance Authority