Here’s how the NHI will affect you – including new rules about seeing a specialist

August 14, 2019

The National Health Insurance bill was finally introduced last week, and – despite many, many concerns – it looks as if government will be pushing ahead to start implementing the new healthcare regime. In a nutshell, this is what will happen: medical schemes as we know it will disappear, and your doctor will be paid by government. Instead of paying your monthly membership, you will pay a similar amount of extra tax on your income. The government will use that money, and some of its health budget, to buy healthcare for all South Africans. That means that even those without medical schemes may be treated by private doctors and in private hospitals. Most healthcare – including doctors’ visits, medicines, operations and hospital stays – will be free, for everyone. Government says the aim of the NHI is to help medical scheme members with their high out-of-pocket costs. At the same time, it also acknowledges that state medical staff and hospitals can’t cope with treating the 83% of South Africans who don’t have medical aid. There is a general acceptance that South African needs national, universal healthcare, says Dr Ernst Marais, COO of ICON Oncology (ICON), which represents more than 80% of oncologists in SA. Currently around 8% of South Africa’s GDP is spent on healthcare, with roughly 50% of that amount going towards the nine million people who are on medical aid, while the other 50% is spent on 51 million people.The healthcare system remains unsustainably lopsided.” Also, Marais says, there is an oversupply of private sector hospitals, which can help government treat patients without medical schemes. But there remain huge reservations about whether government can afford, and manage, its NHI plans. While the latest bill remains a bit sketchy, here’s what we now know with some certainty: 1. You will become a member of the NHI Fund. The fund will be a massive state-run medical scheme, and all South Africans will be members – you won’t have a choice. 2. If you earn an income, you will contribute towards the NHI Fund. Government will levy an extra tax on your personal income, and use the money it will save by not giving you tax credits for being a member of a medical scheme. There may also be a tax levied on your employer. Previously it was speculated that an “NHI tax” of between 3.5% and 5% could be levied on your salary. 3. All contributions will go into a pool. Government will use your tax money, as well as some of its healthcare budget, to buy services from public and private doctors, specialists, and hospitals that are accredited with the state. 4. The fund will cover a range of medical services, treatments, and procedures. All of these will be for free, without any co-payments. However, the fund will not cover treatments if it’s not a “medical necessity” and where there isn’t a “cost-effective intervention”. If the fund refuses to pay for a health care, it will issue you a notice of the refusal and give you reasonable opportunity to appeal this decision. Every year, government will determine what prices will be paid for by specific services. 5. You will probably have to register with a GP who is contracted with the state. While this was not clearly stated in the bill, it is expected that each contracted GP will have a set number of patients who they will “service” for the NHI Fund. You could be limited to how often you see a GP. 6. There will be strict rules about seeing specialists. You won’t be able to go directly to a specialist, but will have to get a referral first. A visit to specialists, like paediatricians or gynaecologists, may require longer waiting lists, as all South Africans – including the 83% of the population who are not currently medical scheme members – will now have access to private-sector specialists. It could also, for example, mean far fewer Caesarean sections in South Africa, as the health system is expected to rely more on non-specialists like midwives. In 2017, some 69% of South African babies were delivered via C-section in private hospitals. (The World Health Organisation advises a maximum of 15%, and in public hospitals, only 26% of births are C-sections.) Also, you may not be able to get easy access to a private hospital that is accredited with the state, given that more people will be admitted. 8. The state will buy medicines for everyone Instead of the private sector buying medicines for its patients, and the state securing treatments for public-sector patients, government will buy medicines for all patients. 9. Medical schemes may disappear Marais expects that instead of the current medical schemes, medical insurance will become more common. To ensure that they will still have direct access to a specialist, and no waiting times for treatments, wealthier people will – on top of their NHI contribution every month – probably take out medical insurance. New specific types of top-up medical insurance– for orthodontics, or for cancer treatment – will probably be created. 9. Foreigners won’t be covered Adult asylum seeker or illegal foreigner will only get emergency medical services; and “services for notifiable conditions of public health concern”. The children of asylum seekers and illegal foreigners will be entitled to basic health care services. Foreigners visiting South Africa must have travel insurance to receive health care services through the NHI Fund. 10. You will have access to all your medical records You will be able to access any information or records relating to your health kept by the fund. 11. The fund will be run by a CEO and a Board The fund will be managed by a CEO, who will be appointed by the minister of health, and can serve for a maximum of ten years. He will be supported by a board of 11 persons, also appointed by the minister.