I wish to thank you, premier, for agreeing to meet with us, a small delegation from the NHI Concerned Citizens and Residents, to receive our petition and afford us an audience. Let me also express gratitude and appreciation to governments past and present for their efforts in attempting to provide the people of the Virgin Islands with affordable universal health care.
While we believe in the ideal of universal health care, we found some difficulty with the National Health Insurance system as proposed and decided to mount a petition drive to see if the government would agree to go back to the drawing board or, as some would put it, “wheel and come again.” We followed this line because we felt that some of the problems could not be easily cured and that a second look would have been necessary. Our efforts found resonance with the public, and the petition drive was inaugurated.
The petition
Let me say something about our petition. Firstly, the problems noted are not an exhaustive list, but they were sufficient to get the public’s attention. Secondly, as more analysis was done and government continued to make more information available, additional concerns were unearthed. Some of those concerns are captured in this letter.
Thirdly, we do not profess that we have the answers to the problems and concerns, but we believe that we have a role, perhaps as a catalyst, in getting government’s attention and encouraging them to seek the views of all stakeholders, including the public at large, the business community, and, of course, the government itself. We believe that if these three groups can be mobilised, an optimal solution will be found. That, then, is our goal and the goal of our petition drive.
Problems with NHI
There are many issues that can be highlighted, but the most egregious are as follows:
1) The system is mandatory. This is anathema to most persons because it takes away their choice to decide for themselves on the way forward for their own lives and those of their family members. Perhaps most importantly, it flies in the face of the Universal Declaration of Human Rights as promulgated by the United Nations in 1948, Chapter Two of the BVI Constitutional Order 2007 (based on the UN Declaration), and our traditional and accustomed democratic way of life.
To this the people are saying an emphatic, “No,” and are saying, in addition, that their freedom of choice should be jealously guarded, defended and maintained.
2) It is alleged that the statistical underpinnings upon which the main study was conducted were flawed and gave incorrect figures for the percentages of insured and uninsured persons in the territory. It therefore follows that if your premise is wrong whatever is done in the name of that premise will similarly be wrong. If your shirt is buttoned out of sync, the only true remedy is to start all over again. Accordingly, we do not believe that corrections can resolve the difficulties without a return to basics.
3) Individuals and families will be affected in various ways:
• Individuals will most likely lose their private insurance and the life insurance attached to it.
• Some employees, in all likelihood, will be laid off.
• Some individuals may not be able to afford the deductions for both private insurance and NHI or even NHI alone. Consider, for example, that unemployed spouses will have to be covered by their partners, whereas an unmarried unemployed person is covered by the state.
• Individuals and families will find that overseas health care will be greatly restricted as all such care must be preapproved, and this must only be approved if the services are not available locally.
• Women will be forced to birth babies at Peebles Hospital as the cost of overseas delivery will only be paid by the NHI in the event of a medical complication.
• Individuals and families will lose their democratic right to choose or retain their overseas doctors.
Secrecy
4) There is a persistent culture of secrecy surrounding NHI. This still seems to linger despite all the discussions about transparency, as documents and reports have not always been made available publicly. Also, there are delays in approving various regulations needed for the effective management of NHI.
5) The economic viability of the system is in question. A study concludes that by year four of operation, there could be a deficit somewhere between $45 million to $200 million, which does not take into consideration lawsuits over confidentiality, malpractice and errors and omissions, which can account for an additional $200 for the same period, thus combining for $400 million in the worst case scenario.
Three pillars are needed for a viable system:
• A sufficiently large population is needed to ensure the maximum utilisation of the service.
• Operational facilities must be of a certain standard. The VI is aware of deficits in this regard and efforts are being made to overcome them.
• Adequate administration needs to be upgraded.
Economy
6) The economy will be adversely impacted as well:
• Businesses may be unable to meet additional charges and may have to close.
• Businesses may pass additional costs on to consumers, thereby forcing the cost of living to increase.
• Shuttered businesses will lead to sudden increases in job losses or underemployment.
• Some insurance businesses may increase the cost of other types of insurance (car, boat, house) to offset the losses under their health insurance portfolio.
• High-powered expatriate executives may either leave positions in the financial services and tourism sector, or prospective employees may refuse to come to the VI because of the adverse insurance situation.
Alternatives
Fortunately, alternatives to the NHI exist.
As one option, everyone could be registered under a private coinsurance pool. The insurance industry can be engaged to partner with government to develop the NHI. The insurance industry should come together and write a coinsurance policy with each carrier participating based on the current market share they have in the health insurance industry (this information is available at the Financial Services Commission). By making this agreement, the plan would have access to all networks of all companies, and anyone would be able to get worldwide access instead of limited access provided under the JIPA network.
Additionally, as a group, the companies would be able to buy adequate reinsurance at a reasonable price. Also, putting a large deductible programme in place would make the plan even more affordable. The way the plan would work is for the government to commit to covering the first $8-$10 million in claims, and the remaining cost will be borne by the insurance companies and reinsurers. By activating a large deductible programme and instituting risk management programmes, it would cause the cost of insurance being purchased to be cheaper without any compromise on quality of care while still providing access to the NHI.
Administratively, this would facilitate the smooth transition from registration, policy issuance and reinsurance placement to claims handling. Social Security staff transferred will collect the monies. The board should consist of the following persons: one member from each insurance company, the deputy director of Social Security, a representative from the BVI Health Services Authority, the financial secretary, and an independent businessperson.
Another option
For option two, the uninsured should be registered, and individuals with insurance that is equivalent or superior to the NHI should be exempted. However, insured persons can be taxed one to two percent of their salary to pay for the uninsured.
First of all, the uninsured can be registered to get a true picture of how many people are insured in the VI. The figures given by the insurance companies are real figures gathered from their collective records. Their records, however, do not take into account expatriates who have insurance from outside the territory. If these were included as insured, the uninsured population could be anywhere within the range of 20 to 30 percent of the population. It also should not come as a shock to anyone that most of the uninsured would be minimum wage earners. Considering that these numbers are smaller than those reported, the full 7.5 percent contributions by employers and employees would not be needed, and the uninsured can still use the JIPA network.
Once this number is ascertained, individuals with private health insurance coverage that is equal or superior to the NHI can be exempted from the NHI. By doing this, private insurance policy holders would not have to be subjected to NHI board approval to receive treatment overseas. For this privilege, these policy holders may be subjected to a one-to-two percent tax of their monthly income to pay for the uninsured.
Number three, four
As a third option, we can use the Dutch model of providing health insurance coverage for the population. The Dutch model consists of a partnership between private health insurers and government to cover the entire population. Rather than working in opposition, private insurers and government recognise the crucial role each plays in providing universal coverage and access to quality health care.
Finally, as a fourth option, we can expand the remit of Social Security. In addition to all the benefits currently offered by Social Security, we can include a benefit to insure the small percentage of residents. To pay for this, we can increase the social security deductions by one to two percent.
Conclusion
We wish to express our appreciation of the University of the West Indies’ Health Economic Unit and the point man, Dr. Karl Theodore, for the service rendered in the preparation of this project. We also wish to think the Ministry of Health, and the implementation team under the guidance of Roy Barry for their equally stellar service. We wish them all to know that their service has been appreciated and the fact that the project is being challenged is not to impugn their professionalism; instead, it is an earnest attempt to get optimal value for the people of the VI. Optimum is what we want and optimum is what we intend to get.
We also wish to thank all those persons who signed the petition, which was, indeed, a clear indication of democracy in action and which continues to show what can be achieved when we come together as one. Therefore, let this action go forth as a beacon to guide and inspire us for the future. We cannot, of course, fail to mention the foot soldiers for the time and effort they expended in collecting the signatures. Their work was an indispensable part of the project, and we thank them.
We thank also the ad hoc coalition of individuals who make up the NHI Concerned Citizens and Residents Group for their service, be it on radio, television, or in the many meetings held. We give a big thank you to everyone.
Finally, I wish to thank you, Mr. Premier, for your willingness to meet with us to receive our petition and to give us an audience.
We know that you and your colleagues will examine and scrutinise our submission with a view to seeing how our suggestions might be incorporated so that, at the end of the day, we may receive an optimal system. We honestly believe that it is possible to chart a new way forward based on our collaborative efforts, comprising the brain power of the people of these islands, the business acumen and professionalism of our corporate partners, and the law making and leadership of our government.
With this triumvirate approach to problem solving, absolutely nothing is beyond our reach. We stand by ready, willing and able to assist, and we await your call in this collaborative effort.
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