Uncertainty looms over NHI’s coverage of essential services

How will the National Health Insurance (NHI) provide adequate quality care for South Africans’ medical emergencies, maternity, chronic and severe health conditions, which are covered as standard for nine million people by medical aids under prescribed minimum benefits (PMB) regulations?

That is still not clear because there has been no detail on what NHI will cover.

NHI services will need ‘significant funding’

But NHI services will need “significant funding” if they are to match these private medical aid services, according to Craig Comrie, chair of the Health Funders Association (HFA).

“Accessing these services in the private sector remains invaluable to South Africans,” said Comrie.

He said no-one who belongs to a medical scheme can ever run out of these PMBs, which medical schemes are bound by law to cover.

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“Medical schemes belong to members and part of the deal when you join is you are covered for these essential services – irrespective of how much you have contributed monthly,” he said.

PMBs include a host of conditions, ranging from cancer, to strokes, to heart attacks, kidney disease and some mental illness.

Accessing private hospitals without cover would be out of reach

Comrie said more than half of medical scheme members have a monthly household income below R30 000, meaning that accessing private hospitals for major health events without health cover would otherwise be out of reach for many without incurring debt.

“An ageing medical scheme population brings an increased prevalence of chronic conditions and this, along with a declining ratio of doctors to care for people, means prices will rise,” he said.

“The long-awaited regulations, such as a mechanism like risk equalisation, can alleviate some of the price pressures.”

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The HFA is engaging with the Council for Medical Schemes on a review of PMBs, which must be done every two years to keep the PMBs relevant to medical needs and improve affordability.

Although medical schemes may try to keep member contribution increases to a minimum, Comrie said: “It is the quality of treatment and ease of access to health care that people value most.

Medical schemes priceless

“It’s the times when our families are in desperate need, such as being critically injured in an accident, where medical schemes become priceless.

“Hard-working South Africans should be able to access the best health care they can afford for their families and the current model legislated in the NHI Act threatens to remove this right.”

Comrie added the industry was committed to collaborating with government on “workable solutions that will make access to advanced medical treatments more equitable in the future”.

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He said “in contrast to the state’s road map as described in the NHI Act, people accessing health care want freedom to access treatment options where cost is not the only deciding factor”.

He said scheme members should be aware their benefits “are not immediately affected by the NHI Act, which will only be the case once NHI is fully implemented, which by may be decades away”.