Close of debate
National Health Insurance Bill
House of Assembly

7th December, 2006
 
Mr. Speaker;
I rise to bring before the people of The Bahamas the key points needed at this time for us as a nation to understand the landmark proposed National Health Insurance Scheme, what it seeks to do and how it will impact us in a positive way; in this time now and for generations yet to come.

Mr. Speaker;
Ours is a country whose foundation is grounded and rooted in the principles of Christianity.

It is inherent that we, who are charged by the will of the people to give this country direction, ensure that the values of Christianity are reflected.

In instituting and implementing laws and policies, we must always seek to do that which is right.

One of these principles is to be found in Galatians 6:2: “…bear one another’s burdens, and so fulfill the law of Christ.”

This week has been a very important week in the life of the country, as we have debated the most important legislation of this decade.

In this debate, we have had support, criticism, passion, excitement, a sense of expectation and even tears.

Emotions have run high as this issue of the need for health care has touched the hearts, minds and souls of parliamentarians.

Now, Mr. Speaker; all of us know that no one is perfect and so sometimes we make mistakes.

I have always touted the importance of giving people a second chance in recognition that people are not perfect.  The same is true for laws and policies.

That is one of the major functions of this Parliament…not only do we introduce new laws, but we amend old ones to adjust them to the changing realities so that the laws can facilitate the ordered and progressive development of society.

But, Mr. Speaker; as we were reminded by the Hon. Member for Blue Hills we must, as and when we can, do that which is right.

And, Mr. Speaker; I feel confident that I can say, with little fear of contradiction that the vast majority of Bahamian people agree that now is indeed the right time for this.

Now is the time to introduce a well meaning and progressive piece of legislation such as the National Health Insurance Bill.  Why?...  Because it is the right thing to do.

This consensus of which I speak was made patently clear even in the contribution by the Hon. Member for North Abaco, leader of the official opposition.

He firmly threw his full support behind this Bill.  He committed all members opposite to demonstrate their endorsement of this Bill by voting in favour of a Bill for an Act to Establish a National Health Insurance Scheme.

Now, Mr. Speaker; all along we suspected that the FNM members of the chamber would vote for the Bill.

In the twenty-first century Bahamas, a country with the level of economic development that we have…a country with the level of technical expertise in the area of health; we cannot turn a blind eye and a deaf ear to those in need of something as basic and fundamental to the human existence as adequate health care.

All patriotic and caring Bahamians must at least acknowledge the facts:

We must all acknowledge that:
• Health care is a fundamental human right; and
• Access to health care should not be determined by an individual’s wealth or their ability to pay.

This is what this Bill aims to do; and it is in this spirit that we would like for Bahamians from all walks of life, to embrace the National Health Insurance Scheme.
We must see this Bill for what it really is and what it seeks to do.  This Bill is to ensure that we move forward, upward and, yes, onward as a country, and to ensure that we do so together.
 
Mr. Speaker;
For us to move forward together on the issues relating to the introduction of the NHI, it is important that the information that is circulating in the public arena is based on fact and not on erroneous information.

In many cases, this misinformation seems to have been introduced to scare and frighten the Bahamian public.

But, Mr. Speaker; we shall not allow Bahamians to be misled and bullied into objecting to something that is being advanced on their behalf and in everyone’s best interest.

I shall take some time to address some of the more pronounced statements of misinformation.

1.  National Health Insurance Schemes Don’t Work
Many countries, the world over, have a universal health care programme, similar to the proposed National Health Insurance Plan.

The list of countries include developed and developing nations, large industrialised states as well as small states, free market as well as state-controlled economies.

Just to give you an idea, Mr. Speaker of the kind of variety that exists, the following is but the beginning of a listing of countries with fully functioning national health insurance schemes:  Argentina, Aruba, Australia, Austria, Belgium, Bermuda, Brazil, Canada, Cayman Islands, Costa Rica, Denmark, Finland, France, Germany, Greece, Ireland, Israel, Japan, Luxembourg, The Netherlands, New Zealand, Norway, Philippines, South Korea, Spain, Sweden, Taiwan, Tanzania, Vietnam.

Germany, for example, has maintained its system since 1883!

Of course, none of these systems are without their challenges, but NONE, NOT a single one, has sought to abandon their plan because of these challenges.

This speaks to the fact that the benefits greatly outweigh any potential downside.

Overall; a system of health care that ensures that all in society are provided with an acceptable level of health care is a necessity in any progressive society.

In fact, I would like to bring up the case of Canada.

Now, the opponents to NHI here in The Bahamas have taken to disparaging the Canadian health care system.

And, Canada itself has admitted that its system is not perfect.
The Canadians have even formed the Commission on the Future of Health Care in Canada to look at what future steps should be taken in reforming their system.

But let me quote directly from their report, which stated, “Alternative funding approaches currently under discussion in some circles have a number of problems and would shift the burden of funding from governments to individuals.

Moreover, there is no evidence their adoption would produce a more efficient, affordable or effective system.”

Indeed, the Report went on to state that “Single payer health systems have proven to be significantly more cost-effective than alternative approaches, and that despite the sometimes over-heated rhetoric, Canada's health outcomes remain among the world's best”.

This is reflected in an average life expectancy for Canadians of 79.9 years and an infant mortality of 5.3 deaths per 1000 live births.

The Canadian Commission, which reflected the wide-ranging socio-demographic structure of that country, adamantly stated that the basic principles which form the foundation of their health system are still widely believed in by Canadians – and that the principles of the Canada Health Act “should be reaffirmed.”

Let me reiterate that… Canadians, after months of analysis and reflection, determined that the basic tenants of their system – a publicly funded and administered, universal access-to-care system, be maintained and that only changes to the periphery areas of the system were required.

Just as recently as 2004, the Canadian Broadcasting Corporation asked for Canadians to vote on who they considered the “Greatest Canadian of All Time”.
The clear response was the man responsible for the implementation of the Canada Health Act and known as the Father of Medicare.

This is landmark legislation and the Bahamian people will thank us for it for many, many years to come.

Let me share some more international information; this from a 2001 Health Affairs study of national satisfaction with health care.

This was further corroborated by data from the Harvard School of Public Health.

The study indicated that of 17 countries surveyed, all of those receiving marks of 70% satisfaction or greater had a national health insurance system or national health service in place - Austria, France, Belgium, Denmark, Finland, the Netherlands and Luxembourg.

In contrast, the United States, with its market approach to health care, which is similar to the system now in use in The Bahamas, had only a 40% satisfaction approval rating.

2. The Introduction of NHI will lead to economic devastation
Another statement of misinformation has been that the introduction of NHI will somehow lead to economic ruin for The Bahamas. Other countries with NHI have been described as falling into bankruptcy once their NHI plans were put into place.

Mr. Speaker;
I must point out the sheer fallacy of this claim. Of the world’s top twenty (20) economically developed countries, in terms of per capita nominal GDP as listed by the International Monetary Fund, or IMF, nineteen of them, yes sir, 19 of 20 of them have some form of universal nationalized health plan.

Now, for most people, the concept that investing in a nation's health leads to improvements in its wealth is logical.

It is obvious that the healthier a working population is, and the longer it remains healthy, its level of effectiveness will improve.

Indeed - there is a documented correlation between improvements in life expectancy and economic growth with studies suggesting that a 10% increase in life expectancy can lead to a 0.4% rise, annually, in economic growth.

However, beyond having a more productive workforce, other economic improvement factors can be expected from the introduction of a NHI plan. For example, NHI will remove economic stifling factors such as "job-lock".

This is a phenomenon that currently exists in our country because employees do not leave their jobs due to fear regarding the loss of health benefits.

In the US, between 15-20% of workers indicated they would not leave their jobs due to a potential drop in access to health care services, and this number rises to 40% for those with chronic conditions such as diabetes or hypertension.

This “job-lock” leads to the misallocation of workers among productive opportunities, higher training costs for workers who have stayed too long in their jobs, and the loss of innovation, employment, and competition associated with start-up ventures.
While some small businesses might encounter some level of difficulty in the initial stages of introduction of the plan, smaller employers stand to benefit in the medium to longer term by becoming more attractive to workers with higher skill levels than those currently in the available pool of workers.

Additionally, most small-businesses are typically unable to afford the cost of private health insurance premiums due to the small number of employees in their group plans.

However, under NHI, more small businesses will be able to afford to pay for health care for their workers.

3. Nobody is dying now from lack of access to healthcare
One of the most astounding things raised in recent weeks is the cry that we as leaders are somewhat and somehow overstating the plight of the Bahamian people.

The detractors of the plan claim that those who need access to care can get it and that nobody is dying because of the lack of access.  They are also saying that access to health services in The Bahamas is equitable.

Mr. Speaker;
While I wish that this were the case, it is simply not true and unfounded. Some of the persons that are speaking out against the plan do not have any idea of what the average working Bahamian is faced with on a daily basis.

The Living Conditions Survey (2001) showed that only 8% of low income residents were able to access a doctor's visit in the preceding 4 weeks vs. 20% of high income residents.

Mr. Speaker;
In the Unites States of America where there is a health financing system very similar to the one we now have, studies show that the death rate in any given year for someone without health insurance is twenty-five per cent higher than for someone with insurance.
Heart-attack victims without health insurance are less likely to receive needed surgery such as angioplasty.  People with pneumonia who don’t have health insurance are less likely to receive X-rays or consultations.

To think that the same is not true here in our own country is to bury our heads in the sand. We must face up to the unfortunate circumstances under which our brothers and sisters are living and have the courage and the political will to change those circumstances.

In addition, the Honourable Member from North Abaco claimed that there are many who currently are entitled to free treatment in the public system, and NHI will provide no benefit to them.

He pointed to civil servants, police officers and members of the Defence Force, who under the Health Services Act are entitled to free care.

I also must ask if the Honourable Member read the Act which is currently before the House as it clearly states in Section 14 that benefits which an employee is receiving cannot be reduced. This is as true for the Government as an employer as for any private employer.

However, in addition, now those praiseworthy men and women who so diligently protect our safety will have their non-working spouses and children also covered for health care benefits.
The cost of their coverage will not be affected by pre-existing illnesses and if and when they leave the government services, they will not lose their insurance coverage.

And you know Mr. Speaker; the truth is that many, if not most civil servants, purchase private health insurance to access the type of service they want. Well, for the most part, NHI will now provide that for them.

Mr. Speaker;
The Honourable Member from North Abaco also indicated that the poor are currently entitled to receive free care under the Health Services Act but access is the right to use; quality is the value of the access.    Having access but not being able to utilize on a timely does not help the situation.   Finding out that you need a procedure and not being able to have that procedure done on a timely basis does not help the situation.

However, there is a major flaw in a system which requires a means assessment at the time when the individual is sick and in need of attention.

To ensure there is not abuse of the system, sufficient checks must be put in place to verify the validity of the patient’s claim that he or she is eligible for free care.

But that process may take a day, or two, or three.
These delays are known to have potentially negative effects on the health of the patient.

With a National Health Insurance system, a prepayment system, the verification is done at the point of registration, not when the individual is in dire need of medical services.

As such, no administrative processes hinder the patients’ access to necessary medical attention. AND, just as importantly, the doctor is free from concern.
The doctor has no concern about whether or not to perform costly services or provide expensive treatments to the patient, as he can rest comfortably in the knowledge that he will be reimbursed for the service provided.

4. The health system will be overloaded and will “breakdown”
Another piece of propaganda which has been widely circulated is that after the NHI system has been implemented, the public health system will be overrun with patients.
The continued repetition of this has me concerned that people simply do not understand one of the basic premises of NHI; that patients will be able to access services in both the public AND private sectors.

Currently, there are thousands of middle-income Bahamians who do not have access to private health insurance because their age or health status makes them ineligible. Without that financial protection of insurance they are unable to access services in the private sector.

After the introduction of NHI, they will be able to afford any small co-payment required of them in the private sector.

As a result, much of the anticipated increase in utilization – which, I must interject, the ILO stated was “well within expected ranges” – will be balanced between both public and private sectors.

This NHI system can be one of the most effective examples of public-private partnerships in the world in health care.  This will be a model for many countries to emulate.

5. Private doctors will lose money
This then brings me to another unfounded criticism of the proposed NHI scheme – that private doctors will somehow be forced into “slavery”, as has been stated on one website.

As I am sure you are all aware, I know better than most the value which the medical profession brings into our lives.

To propose that this administration would bring into being a plan which would lead doctors to abandon The Bahamas is nothing more than a scare tactic.

Again, Canada is often cited as an example of a country where doctors leave because of the supposed harsh economic realities imposed by a NHI plan on the medical profession.  Again, this is simply false.

The Canadian Institute for Health Information released data showing that for both 2004 and 2005 the number of physicians returning to Canada was more than the number leaving.

My doctor friends tell me that as many as 20% of their patients are not able to pay for their services.  Under an NHI system they will be guaranteed payment on behalf of these individuals and it is expected that private care physicians would see more patients than they are currently accustomed.

Seeing 10 patient visits and receiving $80 for 8 of those and $70 for 2 patients ($780) is significantly more money than seeing 10 patient visits and receiving $80 from only 8 ($640) of them.

Once more, I will state that the NHI system as proposed has the potential to be an outstanding example of a public-private partnership in health care.

6. Public run institutions cannot and should not run health insurance systems
Mr. Speaker;
I would like to address one last widely discussed criticism of the NHI plan: that the government should not be involved in the administration of a NHI plan because it will be inefficient.

This criticism seems to be partially built on falsehoods and misunderstandings and only partially on reasonable concerns.  Let me address the reasonable concerns first.

The ILO Actuary, John Woodall, in his Technical and Analytical Review of the Proposal for NHI stated that the “continued viability of the proposed NHI scheme after being inaugurated will depend on management which must be uncompromising as regards matters such as compliance with membership obligations and insistence on payment for medical services in NHI facilities by those who fail to join and contribute.”

This need for tight management was also outlined in the Blue Ribbon Commission Report.  We acknowledge that the current National Insurance Board has room to grow in improving the efficiency of its operations.

The Hay Report focused on management training, management accountability and other key areas related to institutional strengthening.

NIB has already implemented many of the recommendations made in that report

Additionally, experts are of the view that NHI has the capacity to be a powerful agent of change in raising the level of efficiency and effective operations at the National Insurance Board to an even higher plateau.

Because of the archipelagic nature of our country and the challenges this brings as regard staffing, infrastructure and administrative systems, it makes sense to have some level of sharing with and between institutions with similar responsibilities.

NIB, with its buildings and workers throughout the length and breadth of our country, is the logical body to assist the NHI Commission in the collection of contributions and other pre-determined functions.

Provisions will also be made for other entities to provide any additional need for assisting in the scheme’s management and administration.

There is no private provider of health insurance with the infrastructure in place to collect contributions, respond to customer concerns and provide all of the services needed to cater to the needs of Bahamians from Sweeting’s Cay, Grand Bahama all the way to True Blue, Crooked Island and beyond.

However, even if there were private companies with the existing infrastructure, I would still question the wisdom of using such companies. For there is little data to back up this widely held belief that private health insurance companies are more efficient than public administrators.

However, there is an abundance of data to show that the private health insurance companies are, in fact, much more inefficient than the public has been led to believe.

While we do not have data for the local companies, there is much data available for the United States private health insurance companies.  And it is quite eye-opening.

The data from the Kaiser Family Foundation on Trends and Indicators in the Changing Health Care Marketplace show that the cost per enrolee of the non-health related aspects of health insurance – that is, the administrative costs and profits – doubled in the five years from 1998 – 2003.

The private companies keep on raising the cost of the premiums, blaming it on the cost of health services, yet the reality reflects a very different situation.

National Health Insurance is NOT FOR PROFIT!

The second point regarding publicly administered health plans is the global evidence. Canada’s NHI plan has provincial administrative costs at less than 5%, Costa Rica’s is at 3.5% and France’s system is at less that 3%.

The way forward
• Prepare regulations
I have heard the concerns, and I give my full assurance and that of my Government that as we commence the drafting of the regulations, we will give full consideration to the refining of the scheme.
• Specify benefits and payments
• Negotiate and sign provider contracts
• Establish IT Systems
• Register members
• Continue strengthening activities in PHS, NIB and MOSSCD

Conclusion
Mr. Speaker;
We are in the most fertile period of economic potential in the history of the Bahamas. That is now an incontrovertible fact. Billions of dollars are lined up to bring new investment and new growth opportunities to our Bahamas.

We must have a healthy population to take advantage of them. We must have an educated and skilled populace to recognise what’s happening in their country and understand their role.

We need a national sense of urgency so that we will not slumber nor sleep but rather we will prepare ourselves for the good things to come.

We do not need visionless detractors.

We need dedicated teams of selfless stakeholders working together with the government to undergird the progress of the nation and its people, through ongoing communication, genuine dialogue and collaboration, while maintaining focus on a shared vision

We must strive for excellence, remembering always that it does not have to be perfect to be effective.

We must move forward and stay on track without being deterred by detractors!
There are those who say that there is no need for social heath insurance; but the facts tell me differently and the people of the Bahamas know otherwise.

They know that we need to put in place a system to provide equal access to health services for all regardless of their socio-economic status.

They know that that is the right thing to do.

A week after we celebrated the work of Sir Clifford darling, former Governor General of the Bahamas who was the first Minister of National Insurance, many have reflected on the introduction of National Insurance back in 1974, when there was much objection.

Many of the same persons who now oppose NHI, preached gloom and doom then, and said National Insurance would fail.

They were prepared to condemn Bahamians to poverty in their old age, rather than participate in a plan to bring a measure of protection for the elderly population.

Thank God, they have been proven wrong.

Thank God that the success of NIB has been that Bahamians have come to realize the “power” of pooling their resources.

They have come to realize that for some Bahamians, National Insurance is all they have. They acknowledge that today, through pooling our resources, the fund has some $1.5 billion in savings.

They see the value when they collect their sickness benefits, maternity benefits, disability benefits, industrial injury benefits, and thank God, their pension when they retire!

Mr. Speaker;
My Government knows that its duty is to protect everyone in the population against the financial burden of health care.

We know that full protection at best is a long term objective but it need not be elusive.

In any case, we must start somewhere and we must start at some time.

My government has decided that the time is now!

We cannot stay where we are.

The implementation of NHI would be, at this point in our history, the greatest expression of social solidarity.

We need solidarity!

We need to be willing to convince those who have much to share just a little with those who need more.

If we care enough about ourselves, our families, our communities, and our country to help the least of our brethren, then the battle is won.

We cannot allow fellow citizens to live in pain or die for lack of money?

Anyone who has health insurance and thinks that it is too expensive for those who do not have it to get it, they don’t care about the poor.

When they say that they support NHI but not at this time, they only care about themselves.

We should make this thing called National Health Insurance a reality.  We can make it work. We must make it work!