Picture: REUTERS
Picture: REUTERS

As debate rages over the National Health Insurance (NHI) Bill tabled in parliament last month, taking stock of what we know and don't know about what the reforms could mean for your finances and cover in the future can put things in perspective.

The NHI Bill proposes that an NHI Fund be set up, ready to purchase health-care services for you by 2026.

But this target date is widely regarded as ambitious given the debates and legal challenges that the bill may face.

Before it gets up and running, the benefits the fund will offer must be agreed on and costed. There isn't yet even a proposal on what these benefits will be.

Only once the benefits are costed can the National Treasury issue draft proposals, and then a bill to fund them through taxes and the withdrawal of the medical tax credits.

Commenting at this week's Hospital Association of SA conference on whether 2026 isn't too ambitious, Dr Anban Pillay, the deputy director-general for NHI at the department of health, said he did not know if the target date was achievable as this would depend on a number of factors, including economic growth.


67%

Of people in Canada buy complementary cover to top up their national health benefits


When the NHI Fund starts paying for benefits, medical schemes will be expected to offer only complementary cover. Pillay said complementary cover refers to services the NHI Fund will not reimburse. It will be up to medical schemes to decide whether to cover these services.

To access "free" NHI benefits you will have to register with an accredited general practitioner and pharmacy and see a specialist only if a GP refers you to one.

Pillay said your right to use a GP not accredited by the NHI or to go directly to a specialist cannot be taken away from you, but you will incur an additional cost for your own account. You could fund that expense through membership of a scheme that offers such cover, but it will be up to schemes to decide what to cover as NHI services will be removed from the minimum benefits, he said.

Dr Jonathan Broomberg, CEO of Discovery Health, said this means schemes will be able to compete with the NHI Fund in a good way and if the NHI is able to provide accessible, "compelling, good-quality services", people will decide not to contribute to a medical scheme for these benefits but rather to use the government services.

"This is exactly what you have in the UK today with the National Health Service - every citizen pays, but 11% of the population still buys private health insurance because they want choice, want to go to a private hospital or they want to access a surgeon more quickly than they would if they waited for the NHS to provide the service."

But Melanie da Costa, director of strategy and health-care policy at Netcare, told the conference the Medical Schemes Amendment Act published last year appeared to contradict Pillay.

Pillay said anyone who can afford to pay for the NHI as well as private cover for the same benefits would be free to do so. Alternatively they could purchase top-up cover.

Dr Chris Archer, CEO of the Private Practitioners Forum, warned if schemes are left to fund expensive illnesses the NHI cannot afford to cover, the potential for anti-selection (members joining schemes only when they are ill) could cause the demise of schemes.


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There may also be the potential for private insurers to set your contributions in line with the risk you pose - to risk-rate you.

Pillay told Money this has not been "explored much".

Sebastian Zoutendyk, a director of Zestlife, which provides health insurance products such as gap cover, says once NHI is implemented these underwritten or risk-rated health insurance products may be allowed to cover specialist costs, hospital costs, medication, etcetera, but whether these products will be allowed to defray the actual costs is uncertain. It is likely that insurers will be prevented from applying full underwriting for health status and age to enable older, less healthy people to afford these products as is the case now with gap cover.

As the government readies for NHI, the prescribed minimum benefits that all schemes must provide are being reviewed to align them with the yet-to-be-defined NHI benefits, though progress is slow.

This could see schemes offering more cover for primary health-care benefits - largely visits to a general practitioner and prescribed medicines - and also obliging you to see a GP before a specialist.

A member paying for a family of four to belong to a scheme currently enjoys a tax subsidy for contributions of R8,736 a year. Every year there are only inflation-linked increases in the medical tax credits, but contributions typically increase by three percentage points more than inflation.

This is likely to continue. Full withdrawal of the tax credit is up to the Treasury, which Pillay said is likely to remove these credits only when the NHI is offering benefits, and to take care that the changes do not hit lower-income earners and pensioners the hardest.