The Tribune

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

The Government’s proposed National Health Insurance (NHI) scheme is “doomed to fail” if it abandons plans to make participation mandatory for all Bahamians and legal residents, a well-known physician said yesterday.

Dr Duane Sands said the Christie administration’s increasing dilemma had been further exposed by suggestions it may drop plans to make NHI registration compulsory for all, and instead allow citizens/residents to choose whether to participate.

While this was an “acknowledgement” that the Government could not force persons with private health insurance to drop their existing coverage for an inferior scheme, Dr Sands told Tribune Business it created another problem for the NHI design.

He explained that universal health coverage (UHC) programmes, and associated financing schemes such as NHI, required the broadest possible participation to work.

This ensures that, in insurance industry language, ‘risk’ is spread as widely as possible among a diverse population, helping to keep such a scheme financially sustainable.

Dr Sands, though, said such a scenario will not be achieved under an NHI plan where participation is voluntary, as the 100,000 Bahamians and residents currently enjoying private coverage will likely elect to retain it.

Their ‘opting out’ of NHI would leave the scheme with all those who cannot afford private health insurance and, more significantly, represent the highest risks and greatest system users.

Dr Sands suggested that the end result would be a hugely over-burdened healthcare system, especially in the public sector, where costs far exceed what the Government has budgeted for NHI.

He was speaking out after Dr Delon Brennen, the NHI project manager, told a radio programme on Friday that the draft NHI Bill had been amended to remove the legal requirement that all legal Bahamas residents register for NHI.

Dr Brennen suggested the Government had decided that the Bill’s section 17(1), which mandates that “every person who is eligible for the plan must enrol”, was unenforceable against those electing not to sign up for NHI.

“I think it is an acknowledgement of the significant hurdle that they will face when they put people into what can only be described as a financial and moral conundrum,” Dr Sands said of such a move.

“Why should it be mandated by the state to sign up to something that is inferior to what I already have, unless you can demonstrate to me that I am getting something as good as, or better?

“I am duty bound as a citizen to ignore what is being imposed.”

The Government has yet to fully define what will be included in the medical services/benefits that will be covered by NHI, beyond suggesting that it has budgeted $100 million from the Consolidated Fund to cover primary care’s first year.

“I think they have no choice but to remove the ‘mandatory’, given that this programme is little more than a concept right now,” Dr Sands told Tribune Business.

He said the Christie administration appeared to be watching “the road to passage”, meaning that it was seeking to identify and rapidly eliminate all “roadblocks” that stand in the way of NHI implementation.

Dr Sands argued that by removing the legal requirement for all Bahamians and residents to participate in NHI, the scheme was “doomed to fail from an actuarial viewpoint”.

With between 30-50 per cent of the Bahamian population likely electing to retain their existing private health insurance coverage, a ‘voluntary’ enrolment would leave NHI financing the population segment “likely to be the biggest users, highest risks and least able to pay”.

“If you look at universal health programmes, if you do not have the broadest possible participation, the benefits of shared risk are diminished significantly,” Dr Sands told Tribune Business.

“You are dooming it to financially or fiscally fail. For an insurance programme to work, you have to spread the risk among a diverse population.

“We talk about equity and parity. The only way the Government can achieve that is across-the-board participation,” he added.

“Government needs to use a carrot; that this [NHI] is a good plan, a good investment, but they’ve not provided the Bahamian public with that plan and guarantee.”

Dr Sands was backed by another doctor, speaking on condition of anonymity, who told this newspaper: “You have to mandate that everybody have it to spread the risk.”

Agreeing that dropping ‘mandatory’ enrolment was a ‘Catch-22’ from the Government’s perspective, the same doctor also agreed that it would leave NHI with a ‘higher risk’ population that included persons with pre-existing conditions, the elderly and those on low incomes.

Dr Sands told Tribune Business that the private sector and the Bahamian workforce, the latter of which is just over 200,000 strong, would ultimately have “to carry” such persons via payroll tax payments to fund NHI.

“What you will find is that the utilisation of services is skewed, and you’ll probably find that the amount of money spent in the first year is significantly more than budgeted, anticipated and expected,” Dr Sands told Tribune Business.

“It is not so much a matter of the product, but more the education, the consultation, the roll-out and the discussion.”

He added that the Government would have found it much easier to introduce, and implement, NHI had it sought to get “buy in” from all healthcare industry stakeholders at the start.