The more things change...

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January 20, 2016

In 2006, the National Health Insurance debate was raging, much like it is today, 10 years later. Following is the contribution of then Opposition Leader Hubert Ingraham to debate on the NHI Bill that was before Parliament. The bill was passed, but no regulations were ever brought. The themes of his address are still relevant today and worth revisiting. Many of the questions raised a decade ago, under the first Christie administration, remain unanswered.

Health is a fundamental right. Our ability to access and benefit from healthcare should not be determined by wealth or ability to pay. For more than 70 years, The Bahamas has sought to provide basic healthcare to all; from the fly-in doctor to Family Islands; to postings of registered nurses and doctor and the provision of health clinics in the remotest parts of our country, to the provision of advanced medical services and procedures at Princess Margaret Hospital.

The promulgation of rules in 1935 mandated the provision of healthcare to:

a)persons on the permanent paupers lists;
b)persons for whom a course of treatment has been prescribed; and
c)urgent cases seeking admission to hospital was the beginning of the commitment of our country to make healthcare available at our hospital and clinics to all.

The adoption of policies and/or practices at our hospitals and public clinics mandating publicly paid care and prescribed medications for:

(i) persons 65 years of age and older;
(ii) all students attending school; and
(iii) all civil servants, further evidenced The Bahamas' commitment to the provision of healthcare to all.

The passage by Parliament of an amendment to the Health Services Act in 1963 - 43 years ago - reconfirmed our commitment to the provision of health for all. This amendment inter alia specifically required that the Health Department provide medical and surgical attention and requisites to:

(a)such poor and indigent persons as may need and apply for them;
(b)the inmates and staff of the prisons and of the industrial schools;
(c)the members of the police force.
And, the Public Hospitals Authority Act in 1996 specifically provides for the Hospital Rules, first promulgated in 1935, to continue in force.

In 1983, the Employment Injuries Benefit under the National Insurance Act kicked in.
As a result, all employed persons in respect of whom contributions are paid by an employer became entitled to medical care relating to on the job injuries.

In 1996 - 10 years ago - we extended the list of persons eligible to receive medical care at public expense by mandating that no fee is collected by public healthcare facilities in respect of: "a patient who requires any ante-natal care, care connected with childbirth, post-natal care, or any other medical care associated with pregnancy if that patient is a public patient", i.e. a patient without a private practitioner and who is not in the private ward.

Clearly therefore, persons 65 years old and older; school aged children; civil servants; policemen; prison overseers and other staff at the prison; pregnant women; persons for whom treatment has been prescribed; emergency cases and poor and indigent persons are entitled by law, policy or practice to free medical care at public healthcare facilities, i.e. hospitals and clinics.
There is, in a set aside building on the Princess Margaret Hospital compound, a civil servants' clinic with its own doctor and nurses.

The bill before us purports to require the following persons or groups of persons to pay for care at government healthcare facilities:

(i) pensioners receiving pensions as small as $205 per month from NIB;
(ii) policemen;
(iii) prison overseers and other staff at the prison;
(iv) pregnant women and
(v) civil servants.

All of these persons are now entitled to free care at all government healthcare institutions. These people do not pay for healthcare and/or medications at Princess Margaret Hospital and government clinics now; after this bill is passed they will have to pay. These people have legal entitlements. These entitlements should not be taken away as the government proposes to do.

This bill will not produce a National Health Insurance scheme. It is only an umbrella. More, much more needs to be done before National Health Insurance comes. By that time, we'll have a new government.

In 1984, 22 years ago when I was a minister in government with responsibility for national insurance, I appointed a commission to make recommendations, after appropriate consultations, for the introduction of a national health insurance scheme for The Bahamas. The commission included the present minister of health and his immediate predecessor in office. I was fired from the Cabinet before the commission made its report, however.

In office, the FNM recognized that it was serious and costly such as cancer (surgery, chemo and radiation treatment), cardiac surgery, renal failure, (dialysis), hip and knee replacement surgery, neo-natal care, trauma resulting from serious accidents and violence that created the greatest challenges for Bahamians - those with inadequate private health insurance coverage but most particularly for those unable to afford any level of private health insurance and who are without means to pay the cost associated with treatment.

Except for hip and knee replacement and heart surgery, the public health sector has evolved policies resulting in payments being made for persons needing all of these treatments. Assistance for hip/knee replacement and heart surgery is ad hoc. A policy for payment for needy individuals needs to be promulgated forthwith and additional monies provided to pay the cost of same.

In acknowledgement of inadequate funding to adequately meet the cost of services for these serious illnesses we consulted medical practitioners, providers of private health insurance and with the ILO on the feasibility of a partnership with the private sector in the development of a National Health Insurance scheme to respond to these inadequately met needs.

I find it concerning that the Blue Ribbon Commission report recommended a health scheme similar to the one previously proposed under the PLP and which for good reasons was not acted upon. I note that mention only was made of the study done by the government in 2001. One would have thought it useful to the discussion if the report had set out the merits and demerits of both proposals if only as useful background for their findings. Of course, the prime minister says his government is not proposing a PLP health insurance scheme.

The governing party sold itself during the last election campaign, as the party of consultation. To hear them was to believe that no government elected prior to 2002 had ever adequately consulted the Bahamian people on matters of national importance. Now they stand condemned for not consulting sufficiently on the proposed National Health Insurance scheme. I envy them not.

You know we believed that we had consulted widely on the financial services sector legislations enacted with the unanimous support of members opposite in 2000. We also believed that we had consulted widely on the amendments to the constitution prior to their unanimous adoption in this place and placement before the people in a referendum. Some people thought otherwise; they were aided and abetted by members opposite to cast doubt in the minds of many more. Now they, the governing party, are getting a dose of their own medicine.

The minister of health recently said that consultation does not mean accepting all advice or recommendations proffered. He complained that those whose points of view had not been adopted by the governing party now claimed not to have been consulted. He insisted that consultation did not give those consulted the right to give instructions.

That is what I used to believe; I know better now. The governing party made its bed; they must now lie in it. Let them reap the whirlwind from the wind they sowed.

Promises
A National Health Insurance scheme was promised by the governing party in its 2002 election campaign. Three months after it came to office it appointed a 15-member commission to make recommendations for a scheme. It is ironic that the recommendation to make the present minister of health chairman of the commission was rejected. (He was politically out then; now he is in and leading the campaign for a scheme he was not deemed suitable to propose.)

Seventeen months following its appointment, the commission reported - in January, 2004. The report could have been made sooner. Nearly three years later we have a National Health Insurance Bill, not National Health Insurance, but rather a Bill and even more promises. Having neglected to deliver on its promise we are still being told that the need for the national health insurance scheme is "dire".

"Bahamians are dying because they are unable to access healthcare" the prime minister told us. We heard that before. People voted to change that before; the governing party did not deliver. If according to them, "people are dying" because there is no National Health Insurance, then people will continue to die because this bill isn't delivering National Health Insurance. People want the real thing, not promises.

After the passage of this bill we'll still have the same public hospitals; same number of beds; same private wards; same public wards; same operating theatres; same public clinics; same diagnostic capability and the same healthcare providers. People insured under the scheme when it comes on stream still won't be able to go to the states for medical treatment at will.

People who receive benefits from the National Insurance Board Employment Injury Benefit can tell us about the need for referrals by NIB appointed doctors. And professional and healthcare institutions that provided services in respect of the benefit can tell us how much you will pay and what benefit you will receive. This half-baked proposition has been labeled "National Health Insurance delivered".

People are dying, they scream. Why haven't they done something about it during their term? Don't tell me about studies; it takes money to pay for insured persons.

The reality is after this bill is passed people will still die. They will die from natural causes or from overwhelming traumas. Some will die from illnesses for which treatment is properly administered. Others may die because of medical negligence. But we need not scare people to have our way.

Official statistics on the number of deaths annually in The Bahamas over the past decade do not support the governing party's assertion about deaths in The Bahamas.

Questions
Will every contributor to National Health Insurance be entitled to a private doctor and a private room at Princess Margaret Hospital or the Rand? Or, will private wards be removed from publicly-owned hospitals? Our public healthcare is amongst the best in our region.

Elective surgery can in most instances be had more quickly in The Bahamas than in Canada or the United Kingdom where they have national health insurance schemes. Inoculation rates against childhood diseases are amongst the highest anywhere. Our sick and well baby unit at Princess Margaret Hospital is amongst the best.

We do have challenges. With nine or more specialists OBGYNs, our infant mortality rate has climbed from 12.1 when we left office in 2002 to around 17 today. (During our terms in office we halved the infant mortality rate from the 24.4 we met in 1992). And pregnant women are still not generally seen by our OBGYNs at our public clinics. New mini-hospitals planned for Abaco, Eleuthera, Exuma and Inagua have still not been built and made operational by the governing party and instead these FNM plans are now being announced as new PLP intentions.

Likewise, FNM plans left in place for expanded and improved facilities at Princess Margaret Hospital commencing with a new maternal and child health wing and new critical care facilities have not been advanced. This is also the case at the Rand in Grand Bahama for which plans for new emergency outpatient and pediatric care facilities were well advanced. And the introduction of diagnostic services at the Elizabeth Estates and Flamingo Gardens clinics here in New Providence have not been put in.

The provision of adequate numbers of healthcare professionals and support staff at satellite clinics whose opening hours are extended late into the night will assist greatly in meeting an inadequately met need for out-patient care.

Politics
The introduction of a national health insurance scheme is not about politics; that is however what it has become.
No one, on either side of the House can claim to love the Bahamian people more or less than the other. To pander to emotion and raise people's hopes is to deflect attention from the need for health insurance for all.

No one who represents a constituency in this place wants "cook-outs", "office collections" and "sponsor sheets" to continue to serve as a means of financing health care for the un-insured afflicted by a serious illness. We do not accept that disagreement with the governing party over its national insurance scheme should subject those objecting to mean-spirited attacks by members of the governing party.

Our healthcare professionals, without whose support all our efforts at improved healthcare must surely fail, should not find themselves maligned and insulted, as was recently the case when no less than three Cabinet ministers publicly rebuked doctors putting their views to the Bahamian people. Why this fear of informing the public? Why this preoccupation with controlling what the people hear? Similarly, we do not accept that representatives of labor or employers of labor should be slandered for not agreeing 'hook, line and sinker' to what the governing party has proposed.

National health insurance will impact the take-home pay of workers throughout our economy. It will surely impact job security. And it will impact future employment of many thousands now engaged in the health insurance sector - in short, people will lose jobs if this proposed plan is implemented. And the national health insurance will impact the cost of doing business in The Bahamas. It is natural therefore, that all affected individuals would be anxious; they are entitled to full disclosure from the government.

Healthcare needs are exceeding the public treasury's ability to pay. We have a national health scheme - publicly funded from tax dollars. The public of The Bahamas is paying some $200 million annually to provide healthcare in The Bahamas.
Bahamians do not need to and do not hold cook-outs to cover the costs of routine visits to a clinic or hospital.

We believe that the genuine, greatest and most immediate health needs in our society relate to health insurance coverage to assist with catastrophic illnesses - cancer, heart diseases, diseases affecting major organs, trauma from serious accidents, violence, congenital birth defects, etc. Thousands cannot afford private health insurance. Some persons who can afford to pay premiums are denied coverage by private insurance companies because of what is called pre-existing health conditions. Many of these persons suffer from debilitating diseases.

Healthcare for all persons requires more resources; financial, diagnostics, additional trained healthcare professionals and a system to collect from private insurers for services rendered to insured persons at our public healthcare institutions. And it needs to ensure the provision of medication for treatment of hypertension (high blood pressure) and diabetes for all. Universal mandatory catastrophic health insurance coverage for all could/would make affordable, insurance coverage for all in respect of these illnesses. That is why we have an interest in pursuing a partnership with the private sector for the introduction of a National Catastrophic Health Insurance Scheme.

A start
Perhaps the government will explain its reasons for not transferring the unemployment injuries - industrial injury, benefits and payments by employers from NIB to NHI. We do not see the value now in the creation of another commission to administer the proposed new health insurance scheme. This is not cost-effective in design; better to prepare the National Insurance Board to properly administer and fulfil its full mandate as foreseen 34 years ago.
The FNM is opposed to the nationalization of health care insurance.

For the information of the public at large I would point out:

1. The time and manner for rendering healthcare services to contributors to the NHI;
2. The conditions under which services will be rendered under the NHI;
3. The exclusion of any type or class of services to be provided under NHI must be spelt out in regulations, and;
4. Regulations to be made under this Bill after it becomes law.

All regulations and orders will need the prior approval of Parliament; hence they will be subject to debate in this place.

National Health Insurance ain't here yet; it's gonna be a while. So said, so not done! A workable national health insurance scheme will have to wait for those who say what they mean and mean what they say.

Today, a start is being made. The FNM will support the start. Upon our return to office we'll make changes as appropriate.

We commit to convening a meeting with all stakeholders - the privately insured, the uninsured, the private and the public medical sectors so as to achieve a consensus on the best and most effective means of providing health insurance for all.
The FNM supports healthcare insurance for all. As a consequence, the FNM will vote for the bill.

Click here to read more at The Nassau Guardian

News date : 01/20/2016    Category : Business, Health, Nassau Guardian Stories

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