Doctors Oppose Bahamas Health Plan

by Larry Smith

The sputtering debate over the government’s proposed national health plan is “as important as religion and more important than politics” according to Bahamian heart surgeon Dr Duane Sands.

And, he added in a talk to the East Nassau Rotary Club recently, Bahamian healthcare goals “will not be achieved with this plan...(which) will likely cause far more damage than ever anticipated.”

According to Dr Sands, a ‘one size fits all’ tax-funded health plan will be a virtual disaster for the Bahamas: “As responsible senior physicians we feel it is our duty to ensure that the plan is either not implemented or is modified substantially.”

Dr Sands has been a spokesman for the Medical Association of the Bahamas on this issue. The doctors have joined local pharmacists and insurance brokers in opposing the tax-funded plan put forward by the government’s Blue Ribbon Commission.

At the beginning of the 21st century, the Bahamas was at a crossroads and in a state of confusion over the strategic direction healthcare should take. The big question was whether we should we move from the present mixed system towards a public- or private sector-dominated system.

“The challenge is to take the right decision about which road to follow,” a team from the International Labour Organisation reported a few years ago. One option was to levy a health tax that would go towards a special fund to finance medical care that could not be provided by the public sector or afforded in the private sector.

In addition to this catastrophic insurance, the ILO also proposed a scheme based on the Swiss approach – combining mandated private group health insurance (with a minimum defined package of services) and an earmarked health tax to finance care for those unable to pay.

But in 2004, after a two-year study, the government’s Blue Ribbon Commission advocated a sweeping restructuring of healthcare to provide universal coverage within a tax-funded, government-run system.

Critics, like Dr Sands, say such a system will be unsustainable and therefore unlikely to provide equitable access to quality care in the long run. And it should be stressed here that almost no-one denies the need for a safety net to protect the most vulnerable groups in our society.

Industrialized nations are already wrestling with costs that threaten the sustainability of their health systems. As a recent OECD report concludes: "Ultimately, increasing efficiency may be the only way of reconciling rising demands for healthcare with public financing constraints.”

No-one in their right mind – including the Medical Association - is opposed to healthcare reform, even if it comes in the way of a well-considered national health plan. Doctors agree that more funding is needed, but they are adamant that the Commission’s proposal won’t achieve the desired result.

Government funding and management is the main reason. The commission proposes a total annual National Health Insurance budget of $231 million (up from current government spending of about $200 million), with the government’s contribution cut roughly in half and the balance contributed by wage earners at a rate of 5,3 per cent of income (split evenly between employers and employees).

The remaining part of the government’s current allocation for healthcare would be diverted to environmental health services and public administration – meaning the civil servants and buildings at the Ministry of Health.

Dr Sands maintains that all options for achieving healthcare reform have not been considered because the Commission’s consultations have been partisan – in other words, they have excluded those with opposing views.

“Many of the assumptions used to arrive at the conclusions are so tenuous, incorrect or imprecise that they cannot be relied upon for such critical decisions,” he told Rotarians.

For example, the Commission’s scheme says all non-members should pay in full for healthcare services. But the government guarantees healthcare for all, whether paid or unpaid, legal or illegal. And most Bahamians and immigrants accessing the current government-run system don’t pay for the services they receive – to the tune of more than a hundred million dollars a year.

“As physicians play a substantive role in the delivery of healthcare and have been instrumental in most of the recent advances in healthcare, we are vitally important to the success of this project,” Dr Sands said, arguing that the their views have largely been ignored.

He characterised the political spin placed on the Commission’s proposal as “perhaps the greatest tragedy.” In order to sell an idea intended to increase taxes, many promises are being made that cannot be fulfilled – such as unlimited coverage and shorter waiting lists.

“This pork barrel politicking detracts from the thoughtful consideration of an important discussion by creating unreasonable expectations in a public that already functions with an institutionalised and politically supported incongruence between desire and capacity. Simply put, Bahamians want first world medicine at a third world price.”

Successive governments have been unwilling to admit that the public health system is limited, and cannot provide everything to everyone, because they fear the political fallout.

“Bahamians have been led to believe that the difference in charges in the private sector is largely the result of the greed of healthcare providers (rather than) critically evaluating the real costs. Now we are about to make the situation worse even as we strive to make it better,” Dr Sands said.

“Capacity in the public system is stretched to the limit and creating serious inefficiencies. We are handicapped by an undercapitalised infrastructure that has not been able to invest in needed technology upgrades or repairs.”

He estimated an accrued deficit of some $500 million. And this is the amount that would be needed to achieve the healthcare targets outlined by the Commission. Huge sums will have to be found to invest in new services and treatments, expanded facilities, improved maintenance, and upgraded information technologies.

But the public sector has proven itself to be grossly inefficient, with excessive overheads that will not decline even if more funds are pumped into the system.

“The current rationing of services due to limited capacity will be less tolerated by the public because they are being further taxed for healthcare. They will demand healthcare of a standard that is found in the United States. We need to honestly manage expectations and usage if we are to achieve sustainability.”

It is a question of ‘too good to be true’. And even if the actuarial data might seem to support the Commission’s numbers, actual experience indicates otherwise, he claimed.

“The free market defines cost, not the government. The current cost of living in the Bahamas drives the cost of healthcare and cannot be arbitrarily reduced without significant repercussions. The added cost of providing and paying for (the Commission’s proposal) will lead to increases in healthcare charges and ultimately reduce access.”

As for the elimination of cookouts, Dr Sands said there will always be catastrophes that elude the capacity of our healthcare system. The extra tax es will lead to more spending on ambiance, service and other non-essentials that are currently given a low priority because of the need to use limited funds for direct patient care needs.

“Shoddy paint, dirty bathrooms, inadequate vector control, infrequent garbage collection, limited parking and access will not be tolerated by a public that has surrendered significant amounts of disposable income.”

Dr Sands also touched on the issue of responsibility for one’s own health: Some people sacrifice for a quality education or a more secure home. Similarly, they recognise the value of adequate insurance and are willing to pay for it if they can. Others do not, and will look to public relief at a time of loss: “Personal choice cannot be legislated.”

And simply increasing funding without spelling out the scope of reform will only exacerbate existing inefficiencies. True reform should focus on quality issues rather than incremental funding increases, he said.

So what’s the answer?

“All patients should ideally be private patients with rigidly managed lengths of stay, quality controls and cost containment. A clearly defined minimum level of care should be the goal of the public sector. Passengers can fly to London in first class, business class or economy, but the destination and safety factor is the same.

“One size does not fit all. The idea that we should create an inflated public sector in the interest of improved quality is as close as we can get to George Orwell’s ‘Animal Farm’. It is a frighteningly retrogressive step and will lead to less accountability, longer waiting lines and lower quality.”