The Tribune

By NEIL HARTNELL

Tribune Business Editor

nhartnell@tribunemedia.net

The revised National Health Insurance (NHI) Bill unveiled yesterday eliminates the mandatory legal requirement for all Bahamians and legal residents to sign up for the scheme, while also tightening patient data safeguards.

The draft legislation contains several fundamental changes from the previous version, but most notable is the Government’s decision to make NHI registration optional.

Section 17 (1) of the original Bill, released in early January 2016, stated: “Every person who is eligible for the Plan (NHI) must enrol in accordance with prescribed regulations...”

However, the version produced yesterday for public consultation, and which carries a January 29 date, says in Section 18 (1): “In order to access any benefit under this Act, a person who is eligible.... must enrol in the plan in accordance with prescribed regulations.”

This effectively means that Bahamians and legal residents can choose whether to register for NHI. But they will only be able to access healthcare benefits and services under the scheme if they do so.

The change is likely to be greeted with some relief by the 100,000 Bahamians who are already covered by private health insurance, especially as they did not know what they were signing up to in NHI - and whether they would receive the same benefits and quality of care as they currently enjoy.

Many would likely have relinquished their private coverage, or shrunk it considerably under NHI.

Private health insurers yesterday declined to comment on the implications of the NHI Bill’s ‘mandatory’ revision, explaining that they were still assessing the consequences.

However, they are likely to be happy that the draft Bill contains new clauses which make it abundantly clear that Bahamians do not have to relinquish their existing employer-sponsored private group coverage.

“Where a person is covered under private group health coverage maintained by an employer, as provided for in section 20 (5), the selection of the administrator [insurer] shall be made in accordance with prescribed regulations,” Section 18 (3) of the new draft states.

And section 20 (5) merely adds: “Nothing in this Act shall preclude a person from procuring or maintaining private health insurance coverage, whether independently or under his employer.”

The Bill’s new section 21, ‘co-ordination of benefits’ also states: “Where a beneficiary is covered by private health insurance for a benefit included [under NHI], the private health insurance carrier shall be the primary payer in accordance with prescribed regulations.”

However, in dropping the ‘mandatory’ nature of NHI, the Government may be creating new problems for itself when it comes to the financial sustainability and viability of the modified scheme’s design.

Dr Duane Sands, while backing the elimination of the ‘mandatory’ clause, earlier this week 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.

Dr Sands’ views were backed by another doctor, speaking on condition of anonymity, who told Tribune Business of the change: “They’re absolutely destroying themselves. You can’t do a health system without it being mandatory.”

Notably absent from yesterday’s draft legislation release, though, were the accompanying regulations and any details about NHI’s costs - how much it will cost in total, who will finance it, and how much they will have to pay.

The regulations typically give all Bahamian legislation their ‘enforcement teeth’, and contain the ‘devil in the detail’ in terms of how it will operate and be implemented in practice.

Their absence leaves significant unknowns regarding NHI, especially as the regulations will specify the “contribution rates” that Bahamians and their employers will pay to finance the scheme.

This is revealed in Section 23, which deals with ‘Contributions’. Its language has been changed slightly from the earlier draft, and in such a way that implies that Bahamians with private coverage may have to finance their fellow citizens who are on NHI.

The initial Bill’s “a beneficiary shall pay contributions to the plan” has been altered to “contributions shall be payable to the plan on behalf of beneficiaries”.

The new draft also allows contributions on behalf “of certain classes of people” (who are not specified) to be paid from the Government’s Consolidated Fund. Different groups of NHI beneficiaries and employers will also pay different contribution rates.

The latest Bill also incudes a new Section dealing with information sharing, which appears to be a response to concerns raised by Dr Sands and Sharmie Farrington-Austin, the Data Protection Commissioner, that the first draft might compromise the confidentiality of doctors’ patient records.

While the NHI Authority is able to co-operate and share information with other government agencies, the revised Bill contains a new Section 33 (2), which states: “The Authority shall not share any information that relates to the medical history or medical status in respect of an individual.”

This can only be overridden by the courts, the patient’s consent and where the identity will not be disclosed, with the Bill further stating: “Any information shared pursuant to this section must be shared securely, and in accordance with section 39 and any regulations as may be prescribed.”

Dr Sands had previously told Tribune Business that the first Bill contained “sweeping invasion of privacy powers” that threatened the confidentiality of doctors’ patient records.

He had warned that the proposed legislation enabled the NHI Authority to access physicians’ records without placing limits on what it can see, or how the data is used.

“There are some stipulations in that [Bill] as it relates to the powers of the Authority,” Dr Sands said, outlining his concerns.

“They give sweeping powers to do intrusive invasions of privacy concerning sensitive private data within a physician’s office.”