The following presentation was part of the Bahamas Chamber of Commerce forum on National Health Insurance, March 21, 2007.
Ladies and Gentlemen good evening.
National Health Insurance is a burning issue for the Country and where one would expect that the development of a plan would be reason for unifying all stakeholders, it has in the main created a divide.
Tonight I speak to you on behalf of the National Coalition for Health Care Reform, comprising Employers, Unions, Medical Professionals and Business Organizations – a group committed to making a difference.
Allow me to quote from our press statement which formally introduced the Coalition to the Country "The Coalition shares the government's view that we must make substantial and meaningful upgrades to the delivery of health care in the Bahamas and all Bahamian residents should have full and fair access to the best available health services."
As the Coalition examined what was being projected to the Public, it became evident that the proposed NHI did not provide the best solution for achieving this objective. The Coalition's mandate from the outset was to scrutinize the proposed NHI Scheme, understand the current system, clearly identifying the gaps and to articulate a range of alternative options.
Our intent was to engage the Government in meaningful consultation so as to contribute to the construction of an efficient and cost effective solution for the country. In accordance with this commitment, we developed our eight Guiding Principles which we see as key to a successful implementation. They are as follows:
1. Upgrading the present health care infrastructure should be the first priority
2. All Bahamian Residents should have access to health care
3. True and Meaningful Consultation and Consensus
4. Detailed Breakdown of Benefits Under the System
5. The Importance of Public Choice in Health Care
6. An Ombudsman for Health 7. Viability and Sustainability
8. Phasing In Health Care Reform
I will now address more specifically our collective thinking on these principles.
1. A process must be devised to identify the gaps in the infrastructure and then use such data to develop a plan for the elimination of the identified gaps. The referred to infrastructure includes the physical, human and administrative, all of which are currently stretched beyond capacity and in many instances outdated. I would also like to point out that the Government's own Blue Ribbon Commission recommended that these issues be addressed BEFORE the implementation of NHI.
2. Access to health care for all Bahamian MUST go beyond just access, it must be mandated that quality health care should be available to all Bahamians regardless of where they interact with the system. Proper management and oversight is essential to ensure that quality and timely health care is available for all. Research has shown that access to timely health care has presented a major challenge for universal health care systems worldwide.
3. With respect to our third principle which calls for true and meaningful consultation and consensus, the exercise to date has been sadly lacking in this regard. It has become increasing clear that constructive observations and alternative approaches would not be enthusiastically entertained. The consultations turned out to be public relations exercises without any real opportunity for open and frank exchange of ideas and opinion. The Coalition feels it absolutely essential that an atmosphere is created in which all stakeholders can openly share information, work through key issues and reach consensus on the way forward. We see the medical community as being a key stakeholder in this process as they will be the ones called upon to implement and participate in the final product. The continued integrity of the system is also very reliant on their continued participation and performance. The French implementation of universal health care had the medical community at its core since they knew the system best. In the true spirit of consultation, we also feel that full disclosure of pertinent information and analysis is essential. A mechanism for proper transparency, consultation, negotiation and dispute resolution should be adopted as the process moves forward in the establishment of the benefits and regulations for the proposed National Health Insurance plan.
4. Speaking of benefits, this information seems to have become a moving target with no transparent documented systems as to what will be included and why. The resources required to provide cradle to the grave coverage of all the comprehensive benefits alluded to will never be readily available. It is extremely important that the proper expectation level is established with the public from the outset. It is not feasible that every member of the public will receive the desired medical attention, within their timeframe and at their particular comfort level. It is important that realistic expectations are set as there will be a heighten culture of entitlement once funds are being deducted from employees salaries. A detailed listing of benefits will also afford the Private Insurance Companies the opportunity to offer supplemental insurance for persons who desire a higher degree of coverage and comfort.
5. Personal choice should also be a key consideration for the implementation of the NHI plan. In the Cayman Islands, mandatory health insurance was legislated however employers and employees still have the ability to choose from whom they would like to purchase the mandatory insurance which also directly relates to their choice of health services provider. Another key element of choice will be the improvements in quality derived from a competitive environment. Current implementations of NHI systems in other jurisdictions are moving toward greater private participation and away from monopolistic centralized implementations. Additionally, private sector efficiencies are being realized to the benefit of the system, consumers and stakeholders.
6. Our sixth Guiding Principle calls for an oversight body to be established for the health care sector. This body will address concerns raised from the public and the providers as well as monitor for breaches and violations of the system. It is also imperative that financial and managerial audits be undertaken at predetermined intervals. In this way we can ensure that a high level of accountability and transparency is maintained in the administration of the proposed National Health Insurance plan so as to dispel concerns of fraud and misuse of the system.
7. Concerns regarding the sustainability of the proposed system continue to absorb our attention. The challenge of implementing a cost effective yet comprehensive system is a daunting if not an impossible one. Even at this early date, the government has indicated that the cost projections will have to be adjusted. In one instance the answer from the Ministry of Health cited that increasing salaries will result in increased revenue; in the next instance those companies that express concerns about the plan are only concerned about their bottom line. We assert that improved profits lead to increased salaries which lead to increased NHI revenues. A matter of simple economics! It is important that long term projections be presented with several scenarios while also giving consideration for economic growth or retrenchment. A thorough economic impact assessment is essential to the decision making process before implementation of a NHI plan.
8. Last but not least, with all the challenges outlined above you can understand why our eighth guiding principle calls for a phased implementation. This will allow for the public to become more aware, the infrastructure to be updated and the administrative systems to be implemented and tweaked. It is also our recommendations that the benefit offering be limited to high priority issues initially addressing the major health concerns of the Nation. This way, the public will also understand the cost implication of each stage of implementation and the effect upon the economy.
The Coalition has requested a number of reports and information from the Ministry of Health and to date not much of what has been requested has been received. The ILO Report on NHI done at the request of the Government acknowledges that the $235,000,000 annual cost of the plan once implemented could only hold true for not more than 3 years. The Report goes on to say that it is inevitable that the tax level for NHI will increase in the face of anticipated increases in health care services. So in effect, the initial 5.30% tax will be adjusted upward as cost escalates through the years.
On the issue of Legislation, the National Health Insurance Act 2006, the Coalition prior to its enactment made certain recommendations on various sections. Unfortunately, our recommendations were ignored. Our major interest was with respect to Section 14 which in essence prohibits every employer from making any changes to an existing private medical plan for employees without the written approval of the Minister.
In our opinion, this condition removes the right of choice expressed in our Guiding Principles and also places an unrealistic obligation on employers.
We do believe that there is an achievable solution to health care reform however it will require a truly transparent and consultative approach coupled with a careful examination of the history of other countries that have traveled down this road before us. We have a unique opportunity to take the best of these examples and develop a hybrid solution to meet the special demands of the Bahamas.
Members of the Coalition have been characterized as being callous and indifferent to the needs of the poor in the area of health care. On behalf of the Coalition I will not attempt to defend such outrageous statements. Instead, I can assure the Country that every person associated with the Coalition is dedicated to improving the quality of life for the citizens of our Country, particularly those who cannot adequately help themselves.
Learn more about what The National Coalition for Health Care Reform is all about by visiting their website. Click here to be directed to their web site.
