The Tribune

Dr Robin Roberts continues his examination of the complex and emotive issues surrounding the impending introduction of a National Health Insurance scheme. In the second part of a series this week he looks at which system might suit The Bahamas best against the background of political, economic and cultural realities.

A national health system or plan is where the government mandates comprehensive and essential health care services to which all residents/citizens have access and availability as needed, without the barrier of affordability, at the point of delivery of the service. This is normally funded from the consolidated fund or general tax revenues appropriated for health services, not collected specifically for health care.

A national health insurance system or plan theoretically defines a list of comprehensive and essential services which are covered by a mandatory insurance premium or plan which the government mandates to cover all residents and to which everyone must contribute; thus all are entitled to access care as needed without the barrier of affordability, at the point of delivery of the service.

Universal health coverage, universal health or universal coverage extends the financial affordability and guarantee of a national health or national health insurance plan. It aims at securing access for all to appropriate promotive, preventive, curative and rehabilitative services at an affordable cost that secures financial protection with no fear of financial hardship or impairment.

Nerdwallet, the US consumer-based financial analysts and advisors, illuminated clearly the limitations of health insurance coverage and financial risk. Nerdwallet’s research in 2013 determined that health care is the biggest cause of bankruptcy in America: “Almost two million people will file for bankruptcy protection (from health care bills). Outside of bankruptcy, 56 million adults, more than 20 per cent of the population between the ages of 19 to 64, will have major financial impediments because of health care costs. Fifteen million people have depleted their savings to cover medical bills and another 10 million will be unable to pay for necessities such as rent, food and utilities … more than 25 million people are skipping doses, taking fewer medications or delaying refilling prescriptions to save money.”

Health insurance, be it personal or national, does not eliminate financial hardships in seeking medical care. The required or desired government services may not be readily accessible or available, and the insurance co-payments, deductibles or premiums may be financially constraining. In many developing countries, while government services may be available at minimal costs (as in The Bahamas), people seek private care, through direct, out-of-pocket expenses, for easier access or perceived better quality care. For many who can afford to purchase private care, they incur significant financial hardships.

A universal insurance coverage plan mandates a national health or insurance programme to this higher calling of removing all financial impediments to access, availability and appropriate health care. It maximises risk pooling, cost sharing and greater financial efficiency and equity. Universal coverage undertakes the philosophy that health care is a public good, hence, a state responsibility. The individual’s monies can be invested in other economic endeavours, such as purchasing a home or higher education, rather than securing their personal health.

Universal health coverage then becomes a vital tool for state development. So, though well intentioned, national health systems and national health insurance per se do not translate automatically or guarantee financial security from financial hardship. For many national health care systems, universal coverage remains the Holy Grail.

How might a health care system look?

Let’s return to the issue of who pays and how, and who owns and regulates these national health funding strategies. What health care funding mechanism or model do we seek to emulate or create in The Bahamas? What models are out there and what lessons can we learn?

T R Reid’s The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care classified the health care systems of the 200 plus world nations, of which only about 40 have established health care systems. In his treatise, he catalogued the countries’ health care systems into four major groups based on their funding models. The variations reflect the debate, culture and resolve to “meeting the three basic goals of a health care system: keeping people healthy, treating the sick and protecting families against financial ruin from medical bills”.

At one end of the spectrum was the British model type - a health care system predominately government owned and run and funded by general taxation. It’s a much-regulated system in which the government determines physician fees and the services the system will provide. Variants would be in Spain, New Zealand and most Scandinavian countries. Cuba would be the purest form with complete government control and no private practice sector.

The German health system represented the opposite end where health care is essentially privately owned, administered and funded; government serves as the regulator. Funding is by sickness funds, essentially reflecting a not-for-profit insurance, guild or union-based groupings called sickness funds in which employees pay premiums, half paid from wages and the other half from the employer. Government covers premiums for its workers and the indigent. Countries with variance of this model include France, Belgium, the Netherlands, Japan and Switzerland.

The Canadian system is a national insurance, one payer system; every resident must have insurance coverage, for a defined set of essential medical services. It uses private-sector providers, but payment comes from a government-run insurance programme that every resident pays into. Each province has a small variation on collection, with each system reflecting components of both the British and German model.

The fourth type applies to countries where individuals are expected to pay out of pocket directly for care; this applies to most undeveloped countries with poorly available health care system and services. Reid emphasised “that most of the nations on the planet are too poor and too disorganised to provide any kind of mass medical care. The basic rule in such countries is that the rich get medical care; the poor stay sick or die. In rural regions of Africa, India, China and South America, hundreds of millions of people go their whole lives without ever seeing a doctor. They may have access, though, to a village healer using home-brewed remedies that may or not be effective against disease. In the poor world, patients can sometimes scrape together enough money to pay a doctor’s bill; otherwise, they pay in potatoes or goat’s milk or childcare or whatever else they may have to give. If they have nothing, they don’t get medical care.”

The consideration of these four types of health care models begs the question: where are we now in The Bahamas with regards to health care? Are we there yet and if so, when or where do we want to go?

In our Bahamian health care system, there is certainly a bright side. Our system has come a long way since the Princess Margaret Hospital (PMH) was constructed in 1952. When I graduated from medical school in 1980, there were an estimated 15 consultants in total at the PMH with seven specialty services; today there are some 100 consultant-level qualified physicians and 32 specialty services.

The PMH is the flagship of the government health care facilities featuring primary, secondary and tertiary care services. It is the trauma referral centre, with modern adult and neonatal intensive care unit services. All the modern diagnostic and therapeutic services are directly or indirectly available and accessible to all seeking care in the public health care sector. There are several vital services not available directly in the PMH, such as MRI scanning, open-heart surgery and radiation therapy.

The government subsidises most of the costs of radiation therapy for cancer care. In the case of MRI scanning and open-heart surgery, the government provides a partial subsidy when requested and means testing is applied by social services. This same policy exists for any services needed by Bahamians but not available in the public health care sector. There is provision too, though limited, for care sought internationally.

Currently, the PMH is being transformed from a service-based hospital to an academic one; this can only augur well for advancing medical care in The Bahamas. In 1997, the hospital was formally accredited for the teaching of medical students in the faculty of the University of the West Indies in their final two years of their medical undergraduate degree programme. As of June 2014, there have been over 300 graduates, of which 80 per cent were Bahamians. In 2003, postgraduate medical training programmes were introduced and to date, we have graduated 46 physician specialists.

In Freeport, the 70-bed Rand Memorial Hospital showcases an integrated health care system where the tertiary (hospital-based) health care system is integrated with the public health and community clinic (primary care systems) on Grand Bahama. Patients are referred to Nassau - critical cases and other services not provided in the Rand.

In public health, there are over 100 community clinics throughout the archipelago. These clinics are modern, well equipped, and staffed with primary care physicians, nurses and other health care providers. They are distributed such that a Bahamian resident anywhere in the country is within a five-mile radius of having access to the services of a physician or nurse. In the Family Islands, there is also a first responder service for local emergencies. The government contracts an air ambulance service, on a 24-hour basis, such that the Family Island patients can have emergency airlifts to the tertiary care facility in Nassau, whenever needed.

Prior to the onset of HIV disease and the resurgence of tuberculosis, communicable diseases such as measles, typhoid, rubella, polio, and tetanus are of historical interest only, as we have a population almost 100 per cent immunised. Today, malnutrition translates to obesity and over-eating as opposed to starvation where children and adults did not have enough to eat.

The government health care system is primarily funded through taxation, a spill-over from our British colonial heritage. Patients using the government services are charged nominal fees, essentially a co-payment. The total revenue generated from nominal fees collected, amounts to five per cent of government expenses for health care delivery. The government treasures its policy that no one can be denied care because of inability to pay; it is not surprising then that less than half of the nominal fees charged are actually paid.

Unfortunately, there is a dark side of our current health system. Over the past ten years, the government’s spending on health care has increased significantly. Since our initial national health plan in the 1990s, the government’s spending has doubled, $166.9m in 2001 to $314m in 2012. We have built and improved ambulatory clinics throughout the archipelago, increased our physician and nursing human resource pools, made multiple upgrades on the physical plants of our tertiary care institutions – even established a Public Hospitals Authority to improve efficiency and effectiveness.

Sad to say, our national health profiles with regards to our performance indicators have not been stellar. First, Bahamians are not living as long as they should, the infant mortality rate is too high; pregnant woman are not attending the free government clinics. Non-communicable diseases such as hypertension, diabetes, obesity, high cholesterol and cancers are occurring at alarming rates; heart attacks, strokes and kidney failure are our leading causes of death; the kidney machines are going 24/7 for those whose kidneys are damaged permanently.

It’s costing our health care system almost $70,000 per year per person to keep them alive. Violence and injuries, all preventable diseases, are overwhelming the health care system as elective surgeries and medical conditions are becoming unmet needs. For the communicable diseases, while gleaming in our notable decrease in HIV transmission during childbirth, some of our defined population groups are spiralling in numbers again. Tuberculosis is on the increase.

Full stop, for now. The list is exhaustive; no need to say more. The Bahamas is a nation of very sick people.

And so we conclude, we need more money to restore our health, make it better, maintain our health and more importantly prevent sickness from recurring and commit to a wellness care initiative.

To do this, our new health system must, at the onset, establish two targeted approaches: first, there must be a major focus to manage these chronic diseases better, while we simultaneously advance a major preventative health agenda.

The second is to implement all evidence-based measures to control and reduce the rising costs of health care. Every service delivered must embrace cost containment. This is the essence of chronic disease management and preventive health care: an ounce of prevention, continuity and integrative care for a pound of cure.

As taxpayers or purchasers of health insurance premiums, we want the best value for our health care dollars and we must evaluate and monitor for the best results. The emphasis in our NHI debate must be focused on the bigger picture: how to fund the system, and how best to spend the funds.

Which system best suits our Bahamian ethos?

In both prior proposed NHI schemes in The Bahamas, the government selected the social insurance model (a German-based variant). Every citizen undertakes the responsibility to pay the cost for use of the health care services, and pays their individual or family insurance premiums required for the sickness funds: the employer pays half and the employee pays the other half. The premiums are pooled and it provides the funds from which the service providers are reimbursed.

The government provides the premium for those who are unable to pay - the elderly, the physically and mentally disabled and the unemployed. Those whose incomes were below a certain level would have had a 50 per cent discount off their premiums, or pay none at all; the government would have paid for them. When those exempt categories were tallied, 52 per cent of the population was exempted from paying premiums.

To pay for this exempt group, an additional fund was to be raised through a health care levy (tax or charge - your choice of the label), on the traditional National Insurance Board payments in which again the employee would pay half and the employer the other half.

In the first proposed NHI, at least the minimum package of benefits could be sold by the private insurance carriers who would have the flexibility to add supplemental insurance for additional benefits not covered in the basic package. Bear in mind that the basic package applied only for services rendered at PMH and reimbursed at cost determined for PMH services. Private care would require supplemental insurance.

Not covered in the basic package of services were private physician services, private pharmacy services, private laboratory and imaging services except for CT scans and private dialysis services – these two were covered. These initial, non-covered services would be phased in at some later date.

In the NHI proposed in 2006, there was a 360-degree turnaround. All services were covered, from cradle to grave - it was a re-enactment of the British National Health Service introduced in 1948. There were a few non-essential services, such as cosmetic surgery. The big issue here was that government would be the only collector and payer in town; private insurance carriers could provide supplemental insurance coverage only and were not allowed to provide insurance coverage for the basic packages of services administered by the government. It was a true hostile takeover of the insurance industry.

The linchpin of the pros and cons of the social insurance system is centred on the unemployment rates; if most people are employed, this is an ideal system. However, with the high rate of unemployment in The Bahamas, implementation and sustainability of a social insurance based system pose serious concerns. So how do the other models of national health measure up for The Bahamas?

The Canadian one-payer system has the merits of a low administrative cost. The essential health services provided are comprehensive; there is choice, equal access, availability and equity - those who need get what they need and those who need more get more. There is great effort to apply these principles across the vast Canadian plains as well, minimising the geographical barriers to access as best as possible.

These measures would be ideal for the archipelagic nature of our Commonwealth. The Canadian Health Act prohibits private insurance carriers from providing the core essential services. The Canadians give high ratings to their health care system; they love it. But in Canada, they pay income tax and it’s significant.

This socialised medical concept has its critics, particularly from their neighbours to the south. There will always be opposition in the US to a government administrative process as the single payer, particularly one as huge and complex as health. Government agencies are perceived often as a bureaucratic albatross, lacking accountability, transparency and flexibility to accommodate change and innovation. Moreover, an essential service without a private option is an unthinkable scenario and the Canadian (and British) system manifests the worst of socialised medicine - the waiting times.

It’s the rationing of care. When everyone is equal and has equal opportunity and the supply is limited, everyone lines up. First come, first served. The end of the line could be six months, maybe even a year or more in some cases. This waiting issue has led to online access to see how long it would take to receive care. It’s what triggered the breakthrough for private medicine in Canada: the Supreme Court declared that it was unjust for a patient to have to wait over a year to receive a medical service, suffering in pain in the process without the option for an alternative service. There are lots of lessons for us to learn here coming from our American consumer-influenced community.

A paying out-of-pocket system is predominantly what we have now. Private insurance coverage is plagued with costly premiums, deductibles and co-payments which many cannot afford and therefore, have limited or no access to care. Many who can afford to purchase care directly out of pocket do so at a great financial sacrifice, depleting their accounts and reserves; a significant number declare bankruptcy.

We inherited a British health care model; they reformed theirs in 1948. Sixty seven years later, we are still seeking to reform ours.

The British system, the National Health Service, like the Canadian and those adopted by the Organisation of Economic Co-operation and Development (OECD), is funded primarily through income taxes. To implement this funding initiative is perceived as political suicide; the phrase “income tax” is taboo in The Bahamas. Our entire financial services industry, our second major industry, is based on no income taxes. Unlike the Canadians, however, the British do have a two-tier system; if you don’t want to queue, one has the option to pay for private care and move to the front of the line.

A note on the American system – God helps those who help themselves. Over 50 per cent of the population has help: those who have employment have private health care benefits, senior citizens enjoy the benefits of Medicare and the poor have government aid, Medicaid. It’s a country where individuals and companies pay income tax and it’s the tax rebates that cover health insurance premiums again. This still leaves an estimated 15 per cent of the population unable to afford health insurance coverage.

Health care in the US does not come cheap. At the highest per capita spending in the world, at twice that of the average of the OECD, even those with health insurance coverage can incur catastrophic health care costs from required out-of-pocket insurance expenses. Imagine those where the entire costs are out-of-pocket.

Dr Robin Roberts is a consultant urologist and Director and Senior Lecturer at the University of West Indies School of Clinical Medicine and Research in The Bahamas

TOMORROW: How do we generate revenue to cover the costs of providing high quality health care services for Bahamians?