By NEIL HARTNELL
Tribune Business Editor
The National Health Insurance Authority (NHIA) must “give it another go” after failing to win Cabinet approval for the scheme at the first try, a minister revealed yesterday.
Dr Duane Sands, pictured, minister of health, disclosed to Tribune Business that the government wants answers to multiple questions raised during the authority’s first presentation to Cabinet on the reformed healthcare financing plan.
While not providing specifics on the queries raised by Cabinet, Dr Sands indicated there needed to be further testing of the “assumptions” that the NHI Authority has made to support how it has chosen to structure the scheme’s financing, operational and administrative mechanisms.
He hinted that the questions posed included the proposed inclusion/non-inclusion of certain medical treatments in NHI’s Standard Health Benefits (SHB) package; whether the pricing/cost estimates for these benefits can be “substantiated”; and how the scheme will impact employers, employees and the wider Bahamian economy.
Dr Sands emphasised that NHI had not been rejected by Cabinet, and said the request for further clarification “casts no aspersions” at the scheme. He praised the authority - led by chairman, Dr Robin Roberts, and managing director, Graham Whitmarsh - for doing “an absolutely superb job” with the breadth and depth of the consultation process they engaged in.
The minister added that once the NHI Authority “crosses the ‘t’s’ and dots the ‘i’s’” it will ultimately come down to the government’s highest decision-making body to determine “whether we’re going to play or punt”.
“They’ve given a presentation to Cabinet,” Dr Sands told this newspaper of the NHI Authority. “We have not made a definitive decision as yet. There are additional questions to be answered, and more specifics about some of the things dealt with somewhat hurriedly. We need to know how they would work specifically.
“I suspect they’ll need to come back and present to Cabinet again. As we get closer to the finish line, and hopefully we’re getting closer, it becomes incredibly important to look at the process by which certain decisions are made.
“What will be the impact on the economy? If you look at the benefits in the Standard Health Benefit, why have you included this and not included that? What are the implications if we include this and not that? Then there are the implications about the cost charges for things included in the Standard Health Benefit,” Dr Sands added, giving an insight into the issues in play.
“How far had this thing gone in terms of verifying how far these charges can be sustained. That involves conversations with various stakeholders, and at some point in time you’d need agreement. I would certainly say the conversation is ongoing.”
Little had been heard on NHI since the Authority completed its last round of consultations in early 2019, which were designed to inform medical industry, private sector and other stakeholders on the changes made following feedback provided on the scheme’s first policy document late last year.
One of the major queries raised by both healthcare providers and employers is how the NHI Authority has been able to price the scheme, and cost the SHB’s annual premium at $1,000, when it has yet to agree a fee schedule with both doctors and medical facilities - the basic determinant of how much healthcare will cost.
The greatest fear raised by the Bahamas Chamber of Commerce and Employers Confederation (BCCEC) and others in the private sector is that if the NHI Authority gets its calculations wrong, and the $1,000 SHB premium severely undervalues the scheme’s price tag, businesses and their employees could be burdened with ever-increasing levies to finance its escalating costs.
Dr Sands’ remarks suggest some members of the Minnis Cabinet raised similar concerns, but he expressed confidence that the NHI Authority would be able to adequately address all queries that were raised.
“Hopefully now a number of the outstanding questions will be able to be answered for the satisfaction of Cabinet, and decisions made as to how to proceed,” Dr Sands told Tribune Business.
“Once the ‘i’s’ are dotted to the satisfaction of the NHI Authority, the plan will be to seek an audience with Cabinet and give it another go. I believe that they have tried to get the answers to the questions posed.
“As you move closer to a conclusion, a final proposal, it’s like dotting the ‘i’s’ and crossing the ‘t’s’, looking at the polling data to see how people feel about this, how they feel about that; what impact does a particular approach have for a particular industry; and what is the real level of support among employers, employees and unions.
“It’s going to be critically important to have done your homework, and have done it well. That’s where I think we are. There has certainly been substantive progress.”
Dr Sands added that “the implications of certain policy approaches” to different parts of the NHI scheme needed to be “tested” so that the conclusions were based on sound “assumptions”.
Proposed NHI financing mechanisms include VAT levied on health insurance premiums; a reallocation from the existing Public Hospitals Authority (PHA) budget; and a so-called “sin tax” on sugary drinks.
The minister said the fiscal and other implications of such proposals needed to be worked through from the Government’s side, and “a range of projected outcomes” obtained, so that the Government could ensure its decisions were made on sound empirical evidence.
“Ultimately no matter how well the NHI Authority does its work it’s going to come down to the considered opinion of the Cabinet of The Bahamas,” Dr Sands told Tribune Business. “There’s no aspersions cast at NHI.
“It’s simply a matter of however much we try and predict, we can only give worst case, best case and likely scenarios, and have to decide whether to play or punt.”
Still, Dr Sands said the NHI Authority’s efforts to consult as widely as possible could not be challenged. “I’m very pleased with the comprehensive approach they’ve taken,” he added.
“There’s no question they’ve done an absolutely superb job in reaching out to the community in a very real way, and engaging a huge number of stakeholders. They have been to multiple islands, large and small communities up and down the country, and so I don’t think there’s any possible chance of anyone saying with any degree of sincerity that there’s not been a consultation process.”
Tribune Business revealed last month that NHI’s true cost was closer to a range between $200m to $236m, with the much-touted $100m-$130m price tag only covering “the government’s exposure” to the scheme.
Healthcare for the 206,000 persons covered by the employer mandate will be financed through their annual $1,000 Standard Health Benefit (SHB) premium, NHI’s minimum level of care, which is to come from a combination of 1.5 percent of their annual gross salary and employer contributions.
This cost is separate, and on top of, the $130m that will be incurred by the Government (Bahamian taxpayer) in financing NHI coverage for the 160,000 persons not covered by the employer mandate.
The NHI Authority has said the $130m cost for persons outside the “employer mandate” will be financed via “a diverse mix of revenue sources”, one of which is NHI’s “existing budget allocation” that stands at $20m.
That leaves a further $110m to be located, but the NHI Authority said it would come from VAT paid on private health insurance premiums; a “reallocation” of resources from the Public Hospitals Authority’s (PHA) existing $216m budget to cover services NHI will now provide; the $8-$10m that a “sugary drinks tax” may raise; and the scheme’s own “risk equalisation” method.
However, neither the “sugary drinks tax” or the reallocation of VAT on health insurance premiums has been legislated or approved. And some 80-90 percent of the PHA’s budget goes on staff costs, with the Princess Margaret Hospital operator also consistently facing an annual $30-$40m funding shortfall.