The controversial National Health Insurance (NHI) Bill in South Africa could fundamentally change healthcare delivery in the country if it becomes law, says Andre Jacobs, Marketing Manager at The People Company and Vice Chair of the FIA Health Exco.
Medical aid and gap cover could still play vital roles, but the extent of their involvement remains uncertain. Jacobs advises the public to fully comprehend their current medical aid and gap cover to prepare for the NHI's potential impact.
South Africans continue to face high costs of healthcare as many medical schemes recently announced contribution increases for next year that range from 5% to 16% on average, a heavy burden for many as only 15.8% of the population can currently afford medical aid memberships.
The question then arises, does the proposed National Health Insurance Bill have the potential to alleviate the year-on-year increasing financial burden of medical aid on South Africans or are there other ways this matter can be addressed?
"The bill faces several challenges, including possible legal disputes that could delay much-needed healthcare reforms," Jacobs states.
He points out that these issues range from constitutional concerns to questions about funding, affordability, and healthcare demand and supply.
Jacobs also highlights inconsistencies within the bill itself.
"For instance, Section 33 suggests that medical schemes might supplement NHI coverage, but the definitions elsewhere in the bill create confusion about what services medical schemes would be able to offer," he explains.
"In one section, the bill indicates medical schemes could cover additional services beyond primary care, like specialised dental or advanced cancer treatments.
“But another section suggests the NHI will be the sole provider of all health services, leaving no room for medical schemes to operate," Jacobs concludes, emphasising the need for clarity as the bill moves forward.
A matter of speculation
The reality is that it is yet to be determined what benefits the NHI Fund will provide. This means that the role of medical schemes, and therefore the role of gap cover, is a matter of speculation at present.
The structure of the current medical scheme and gap cover range may need to be adjusted to align with the NHI offering that is enacted.
This may lead to the design of products moving toward a defined benefit structure where a particular medical intervention, such as a broken leg, has a defined benefit that is paid out irrespective of the amount of cover provided by the NHI.
This amount could then be utilised to pay for a private procedure. It is also likely that high-cost treatments such as specialised dentistry or advanced cancer treatment or biological medicine will not be provided by the NHI Fund.
However, the regulations post-NHI will dictate what can be offered.
“If we use overseas experience by way of example, there will be a role for both National Health and private insurance products, where the private cover will provide additional benefits to complement the base offering of the NHI.
For example, we often see this as providing a fast track for certain elective procedures that a person may need to address due to personal circumstances,” says Tony Singleton, CEO of Turnberry Management Risk Solutions.
Make sure you are covered in any eventuality
“The goal of expanding universal healthcare should be supported, but rather than abolishing private healthcare, South Africa should leverage the private sector to expand the level of universal health cover.
“We can develop a dualistic healthcare system with the same universal coverage elements based on social solidarity principles, with a healthcare system that is accountable to the communities it serves.
“Transitioning to a more equitable healthcare system demands not only sound policy decisions but also a shared commitment to overcoming societal attitudes and cultural beliefs that might hinder progress,” said Jacobs.
Private healthcare options, like medical schemes, are important because they can help make health services better for everyone, says Singleton.
He stresses that a variety of choices in healthcare is essential so that people can find services that fit their different needs and lifestyles.
Singleton points out that gap insurance is crucial right now. It helps cover costs that your medical scheme might not pay, protecting you from unexpected medical bills.
Even with the potential introduction of the National Health product, he believes that gap insurance will remain valuable, especially for services from non-Designated Service Providers (DSPs).
Singleton advises, "Before you decide on any healthcare plan, make sure you really understand what your medical aid covers and its limits. Talking to a financial advisor can be helpful.
“They can look at your medical aid plan and your family's health and money situation to find the gap coverage that works best for you."