6 important questions about the NHI that remain unanswered

 ·22 Jun 2018

Health minister Aaron Motsoaledi on Thursday presented the National Health Insurance Bill and the Medical Schemes Amendment Bill to the media.

The bills will pave the way for more access to medical healthcare through National Health Insurance (NHI), and represent a massive shake-up to both the governmental and the private healthcare systems.

However, the impact of the bills is expected to be dramatic, said Neil Kirby, head of healthcare and life sciences law at Werksmans Attorneys, and will likely face a lot of challenges from all stakeholders.

While the two new bills give some idea of where the government is going with its universal healthcare plans, several questions remain unanswered, which are raising some serious concerns:

How will we pay?

The NHI Bill does not mention exactly who will be paying to finance the scheme, or how this will be done – but it is clear that it will be taxpayers.

The NHI Fund is compulsory for all South African citizens, and it has been left to the National Treasury to come up with a way to finance it. According to the bill, Treasury must allocate funds to the NHI from the national budget every year – with some estimates already pointing to the scheme costing R182 billion, annually.

It has been suggested that one funding mechanism could be from doing away with medical aid tax credits – while others have speculated that new taxes will be introduced. However, no plans have been officially put on the table.

Motsoaledi has made it clear, however, that it will be the rich subsidising the poor, the young subsidising the old, and the healthy subsidising the rich.

What will the services cover?

The purpose of the NHI is to become the sole purchaser and financier of a specific basket of healthcare services which will be made available to all South African citizens. However, what services this basket will actually cover is unknown at this point.

“The actual elements of the basket of services remain unclear as the services are to be set out in regulations following the introduction of the NHI Bill into law,” Kirby said.

The NHI documents describe the scheme as being ‘comprehensive’, but says little else. This ties in with the financing of the fund as, along with the actual number of people it services, the services being funded will be a key component in determining how much this will ultimately cost the taxpayer.

When will it be implemented?

The NHI Bill gives no timeline for implementation – so while we know the system is coming, we have no idea when. The general public has 30 days to comment on the bills, but Motsoaledi is preparing for a long battle, saying that he expects the NHI to face many court challenges.

This could drag the process out for years.

According to a response from DA, the party estimates that the NHI as it is currently written would take 12 to 15 years to implement.

What will happen to your current medical aid?

The introduction of the two bills shows that the medical aid sector, in its current form, will be facing some pretty drastic changes, but the full extent of these changes, and what will be left when the dust settles, is very much an unknown.

According to Kirby, the greatest likelihood is that medical aids will become a supplementary system to the NHI, but questions remain how this will work. Schemes may decide to cut down what they cover – or there may be convergence among different groups. Some schemes may be forced to shut down altogether.

“Medical schemes may end up performing a supplementary role in the provision of healthcare services to South Africans – primarily, as a top-up device or ancillary provider of services not offered by NHI,” he said.

What will happen to healthcare providers?

Healthcare providers will have to be registered, certified and accredited under the NHI. Currently there are no details on how this process will take place – leaving many questions about what will happen to various players, particularly small, private providers.

“The qualification process, within and of itself, means that certain providers may be excluded from providing NHI benefits and, in turn, from receiving payment for the provision of certain healthcare services,” Kirby said.

“The prudence of excluding healthcare providers, in an already strained system starving from a lack of available expertise, is highly questionable if not irrational.”

Will this even work?

The NHI has faced criticism from its inception, with many – opposition parties, medical aids and healthcare professionals – calling into question its viability.

The prevailing perception is that South Africa’s public health system is not at a level that would make something like universal healthcare possible – with recent reports and incidents backing up the claim.

“Publishing the NHI Bill is a controversial step in the current context of the healthcare services debate in South Africa,” Kirby said. “Particularly in the wake of the Life Esidemeni findings and statements concerning the ability of the public healthcare sector actually to provide access to healthcare services at all in certain settings.”

“While the proposed NHI may, at first blush, satisfy the requirements of government’s obligations to progressively realise access to healthcare services, further examination of the structure reveals a paper-based set of aspirations largely divorced from the realities of public sector infrastructural problems and endemic capacity constraints – notwithstanding the activities of the Office of Health Standards Compliance and the Health Ombudsperson to date.

“It’s a bit like building a house with no land on which to put it,” Kirby said.

Read: What the new National Healthcare Insurance Bill says about who will pay – and where medical aids still come in

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