Towards a National Health Insurance (Part 1)

By Elvin Bailey

This week, I will step a little outside of my comfort zone of Social Security matters and attempt to discuss the much touted National Health Insurance. Let me state from the outset that I am not an expert at this matter, I simply have an opinion. Let me also state that the Social Security and a National Health Insurance are not one and the same.  Sometimes – and this is mostly with persons who have lived where Social Security is called National Insurance, people tend to confuse us with regular insurance.

At Social Security, we know how much the 65% wage replacement for working persons who are sick beyond three days amounts to, and we can extrapolate and adjust for the entire working population. We, like the doctors, also know what makes people sick, and what makes people sick the most.

The Ministries of Health know what the national budget for health is – they do the allocations, the adjustments and the subsidization. The apothecaries know how much is spent on medication, both prescription and over-the-counter drugs. The Insurance companies know how many claims are made for Health, Vision and Dental services and at what cost. The Ministries of Finance, through their Customs and Excise Departments know the levels and value of pharmaceuticals imported into the country. And the Health Care Providers know how much they charge. Right there, six units have been named that play vital roles in the provision and management of Health Care, and that is perhaps where meaningful discussion must start. That is step one: bringing the stakeholders together.

Step two is to decide what exactly will be covered under the programme. In addressing this question, Dr. Patrick Martin, Chief Medical Officer, states that personal medical services are increasingly more difficult to pay for compared to population based (primary health care) interventions that emphasize prevention and health promotion.

Primary Health Care services are cheaper and have a more enduring impact. But he acknowledges the demand for high technology curative and restorative care is irresistible. In other words, people want health care as seen on television and not Primary Health Care! The problem is that all health care has a cost and some persons do not want to pay at all. This is a serious side effect of subsidized medicine!

Notwithstanding, there is a certainty that we must identify a basic package of services to be delivered, bearing in mind the burdens of obesity (pun intended), diabetes, stroke, cancer, substance misuse and abuse, maltreatment of women, children and the elderly, mental illness, injuries (trauma) and HIV/AIDS. 

Add to that issues such as increasing life expectancy and ageing population and a dependency ratio where more and more persons are reliant on less and less workers for their livelihood and the poverty levels, and we begin to see the financial complexity of the situation. It is in this aspect of the discussion that insurance providers may find their biggest niche.

The biggest challenge is this: somebody has to pay for health care, and to repeat, there are no free lunches! At its most elementary, a National Health Insurance is a pre-paid health plan. Dr Martin writes: where there are benefits, there are also obligations. 

So who pays and how much? Should such a plan be a voluntary one? It cannot be voluntary if it is to be universal. And it cannot exclude anybody on any grounds because when one of us is sick, it threatens all of us. If an undocumented immigrants sneezes, who catches the cold?

Some advocates have indicated that a 5% wage based deduction would be adequate to fund such a programme, but in consultations on Social Security reform, persons indicated intolerance for such high additional deductions, preferring instead to yield no more than 3% additional. Will this be enough or will continued subsidization be necessary? Should there be means testing whereby a sliding payment scale is implemented according to income? The dance definitely must pay for the lights!

Other key ingredients for a successful National Health Insurance include governance, a [re]distribution of the power base (medical practitioners must also come to the discussion table) and an enlightened population. I remain confident that as a people, we are sufficiently educated and exposed to demand the governance and fairness. My fear is that some will refuse to seek enlightenment because of denial and of being accustomed to freeness.

Ultimately, the leaders can only lead us to the proposal trough, they cannot make us drink. In the meantime each person must take personal responsibility for his/her health while preparing for retirement. It is always comforting to know that help is there if needed, but it is better, much better to be in good health. Social Security stands ready to do its part in providing quality health care to all in the Federation. You too, must do your part.

What then is my opinion? We need an NHI, sooner rather than later. Let us begin – today.

(The writer acknowledges the input of Dr. Patrick Martin, Chief Medical Officer, who provided research material & other support for this commentary).