Does The Proposed National Health Insurance Plan Raise False Expectations?

Based on the information that is being disseminated to the public by government on the proposed National Health Insurance (NHI) plan to provide comprehensive health care coverage at an affordable cost (to most Bahamians) one cannot help but conclude that NHI would be the greatest thing that ever happened in The Bahamas. However, once we scratch the glossy surface some questions arise, such as how comprehensive is "comprehensive health care"? How affordable will the NHI plan be? What will be the quality of health care provided by NHI?

     How Comprehensive is "Comprehensive Health Care"?
Although no media reports by government have yet placed limitations on the coverage provided under the NHI plan, limitations can be found in the Report of the Blue Ribbon Commission (BRC) on National Health Insurance. According to the BRC report, NHI will not include cosmetic care, long-term nursing and geriatric care, and certain organ transplants. The report also stated that further analysis of home health care needs to be made in order to determine if it can be included in the NHI plan.

While on the surface the exclusion of cosmetic care seems reasonable, there are times when cosmetic surgery is necessary to correct deformities or disfigurements. Although the report did not specify which "certain organ transplants" would not be covered, this exclusion would prove to be a major gap for those in need of those certain organs.

The BRC report goes on to state that mechanisms to limit unnecessary use of services and to contain costs and expenditures will have to be developed. The report suggests some of the ways to accomplish this would be to allow individuals to see a specialist at no charge only when referred by a primary care source, to provide high technology services only on referral per defined criteria, and that individuals will only be eligible to obtain medical services abroad with prior approval by the NHI system based on specific criteria. The costs associated with duration of services is also addressed in the report which states that guidelines which specify the standard for acute hospital care and regulate the duration of services will be established for all health care providers.

     How Affordable Will the NHI Plan Be?
The total cost of NHI and the method of funding has been predetermined and apparently accepted by government, even though the there are a number of critics who refute the total cost, that the details of the plan have not yet been worked out, and the needed improvements determined by the BRC report have not yet been accomplished.

In our News Bulletin last month it was reported that the BRC report recommended that the administration of NHI be done by the National Insurance Board (NIB), however the BRC raised the point that, "The NIB is currently operating with approximately 17% administrative overheads. A NHI system will not be feasible with that high an administrative burden. The cost of administering the NHI system should be less than 10% of the income of the system." Last month's News Bulletin went on to report that the administrative overhead of NIB now surpasses 20% showing that instead of improvement, the management of NIB has in fact become worse.

As for the cost of health services, the BRC report had this to say, "The current cost of providing health care services in the public sector must be reduced before a NHI system can be successfully implemented. The principal reasons for the high cost of services are a lack of systematic resource allocation and low productivity and efficiency. Improvements must be made in these areas to ensure the feasibility of a NHI system." As for the private sector, the BRC report stated, "There is insufficient information available on the private sector to decide whether or not costs need to be reduced in that sector."

Even if we ignore the question of whether or not the total projected cost is sufficient to provide adequate coverage, without improvement in the management of the NIB, improvement in the essential public health functions of the Ministry of Health, and improvement in the management of public health facilities and agencies, the BRC itself has stated that NHI will not be feasible and cannot be successfully implemented.

     What will be the quality of health care provided by NHI?
The primary health care provider under NHI will be government. Although private sector health care providers will be invited to join the NHI network, it is anticipated that a co-payment will be required from patients who seek health care treatment in the private sector. The best and brightest in the health care profession will naturally seek employment in the private sector in order to obtain higher remuneration.

In essence it appears that NHI is a Health Maintenance Organization (HMO) that will regulate which doctors you can see, the type of treatment that will be available, when treatment can be received, and even determine the length of time coverage will be provided. If you need to see a particular specialist who is not in the NHI network you will not be covered. If you need emergency medical care while you are outside of The Bahamas you will not be covered.

The promise of a comprehensive and affordable NHI is enticing; however the development of a truly functional NHI system requires that a number of improvements be made and several analysis and studies be performed. The current perception of NHI as presented is thought by many to be unrealistic, and when the false hopes of the public are dashed it will lead to disappointment, frustration, and diminish the credibility of those proposing the NHI plan.

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