~Lacks basis for sound financial calculations ~
ST. JOHNS–A Christmas tree with no lights was how the White and Yellow Cross Care Foundation (WYCCF) described the draft National Health Insurance (NHI) law that is currently being worked on.
“Implementation of NHI in its current form and in today’s economy will result in major negative economic consequences and a negative impact on the locally available quantity and quality of healthcare,” the Foundation told The Daily Herald in an invited comment. “For a developing country with a healthcare system that needs upgrading and expansions, this will have major consequences.”
The Foundation says the current draft NHI ordinance lacks the basis of sound financial calculations based on real and complete data such as correct size of population and visitors, complete medical consumption data, defined package with cost covering tariffs and premium structure, etc.
The draft, the Foundation continued, is based on financial assumptions that appear not to be realistic. For example: the cost per insured per year with NHI is estimated to be significantly lower than the current cost per person in Curaçao. It is highly doubtful that this assumption is realistic, the Foundation said.
“In Curaçao these costs are NAf. 4,400 per person and for the St. Maarten NHI calculations NAf. 3,600, is used (including disability insurance AVBZ care) for the estimated cost per person. As a comparison, the (Caribbean Netherlands) (small scale economies) spend more than NAf. 10,000 on healthcare per insured.
“When healthcare costs are higher than expected (after NHI implementation) this will result in a rapid depletion of the fund and will have major economic consequences,” the Foundation told this newspaper. “Once the fund becomes unaffordable, tariffs will have to be lowered and/or premiums will increase, both having devastating consequences on healthcare and the economy.”
According to the WYCCF, in the past Government and Social Health Insurance SZV opted for freezing the tariffs. “This had a significant negative effect on the diversity of care providers, making it increasingly difficult to service the needs of the population locally. This has resulted in an increasing need to purchase care abroad, at a significant extra cost for the fund.”
WYCCF said also that the functioning of SZV is far from optimal. “Working relationships with the majority of care providers is poor. Yet SZV is, realistically, the only organisation that can execute the NHI tasks as now intended. The question is whether it is a good idea to significantly increase the responsibilities of SZV before it solves its internal organisational issues.”
During all NHI stakeholder sessions, experts from the region presented their experiences with implementing similar NHI structures. They all indicated any country considering NHI should at least have two conditions met before embarking on a NHI trajectory. The two conditions are a healthy economy and a stable Government, with trust from the general population. “WYCCF contends that both these conditions are not met in St. Maarten to start this healthcare reform that is called NHI.”
Asked whether its concerns have been conveyed to authorities, WYCCF said together with seven other stakeholder organisations, it had placed an advertisement in this newspaper to state their concerns. This was followed by a meeting with Health Minister Emil Lee and his cabinet and policy teams. During that meeting an alternative way forward that would achieve the goals set was presented and the idea was that this proposal would be considered first before the draft NHI law would be further developed. But WYCCF said the latest draft shows that the original plans are still moving forward, with only very slight adjustments that really do not change the outcome.
WYCCF said the latest draft made available contains more than 30 issues that have yet to be decided upon such as premium system, own risk, Governments contribution, exemptions/exclusions, amongst others. “The legislation needs to create the right to care, the content of that care, the funding of the care, compliance for the insured, the care provider and the premium payers, the obligation to cooperate with and provide information to SZV, etc.
SZV will be the entity in charge of purchasing care, disbursing it, levying premiums, auditing premium payers, establishing assessments and deciding on objections (judge in first instance), the same applies to the insured (objections to treatment and care offered) as well as care providers (disputes with respect to quality and quantity of care, etc.).”
“We have been made to understand that the Netherlands insists that NHI will be implemented. The NHI draft law is still a Christmas tree without lights and decorations, a skeleton law that leaves more than 30 important topics to be regulated later on by LBHAM. That is a concern as a LBHAM does not pass parliament. This means that very important parts of the NHI will not be anchored in one or more national ordinance(s) and future changes of the NHI with major impact on St. Maarten’s residents, healthcare and the economy can be made without a thorough democratic process and full information to the public,” WYCCF said.
An example of a topic that will be regulated via LBHAM is the contribution of Government towards the fund. “Such a vital part of the NHI structure should only be regulated by national ordinance. And the Government is already notorious for not paying its contributions and debts to the healthcare and pension funds. Recently its AVBZ contribution has been cancelled retroactively for the years 2016-2018. What assurance is there that Government will henceforth pay its debts on time or at all?” WYCCF asked.
Other examples are the design of the premium system, allowing the Health Minister almost unlimited power to establish a highly progressive premium system while at the same time increasing income-dependent own risk levels.
“In theory it would be possible to create the situation where a high-income earner would pay a huge premium while not being able to claim anything because of a huge own risk threshold. All this without mandatory consultation with Parliament. The real costs to employers and employees must be made known and debated based on (negative) economic impact and ability to pay by the premium payers,” the Foundation said.
WYCCF said it and other healthcare stakeholders agree with Lee that healthcare reform is needed. “However, the content of such reform is different in its counter proposal. Starting with synchronizing the current insurance schemes (ZV/FZOG/OZR) and creating one uniform package, with one administration and one tariff structure – by national ordinance(s), safeguarding already existing objectives and coverage will result in savings and can be seen as a first step towards NHI.
This will give the selected execution agency of the fund (which for now appears to be a single-payer system, executed by SZV) the chance to streamline its operations, collect and analyse sound medical data and prove to the entire population that they can (in future) be the best NHI provider the country needs.”
WYCCF said this includes seamless high quality service, good collaboration with all healthcare stakeholders including prompt payment for services delivered and sound care procurement locally and in the region (covering all required specialties).
The Foundation urges Government to “slow down,” noting that all countries that implemented any form of NHI took many years to get there. “Minister Lee has indicated that St. Maarten is also already busy with it for years, but in reality only under his leadership has the topic been recently addressed. Those early-on discussions in 2008/2009 were never much on content and are not part of a real NHI trajectory. So it is not correct to state that NHI has been for years in the making here in St. Maarten.”
She said NHI cannot be rushed in one to two years since data is lacking and transparency is needed where it concerns these data and numbers. Reports should also be shared, much more stakeholder input is needed (expert committee, with balanced representation of private/public sector and healthcare stakeholders) and new drafts should reflect stakeholder input adequately. “This will create much needed trust and collaboration to develop healthcare reform in partnerships of all that will be affected by such reform.”