Is a combination of minimal user fees, taxes and insurance the answer to Government’s continued health care financing challenges in the face of dwindling public resources and the Barbadian population’s growing medical needs?
Queen Elizabeth Hospital Consultant, Dr Reginald King, believes this is the way forward and even has a formula for its implementation. User fees represent the actual cost of care billed to the patient and King foresees Barbados getting to that ‘in some proportion’ whether all paid by users, taxes and insurance or with some quantity being footed by the patient.
Asserting that health care is a human right, Dr King has made clear that his suggestion will not deny any Barbadians access to health care. “I don’t think we could go back to any stage where people don’t get health care because they can’t afford it,” he said.
Dr King, a consultant in the QEH’s Accident and Emergency Unit, put forward his limited user fees idea at the University of the West Indies, Cave Hill Campus, Henry Fraser Lecture Theatre, where a team of health care administrators and practitioners along with, a social activist and an economist, led off a symposium on, Universal Health Coverage: A Privilege or a Right.
They met for this fourth such QEH-sponsored forum against the backdrop of what some describe as a crumbling health care system, but on which all are agreed there is need for change in the way services are delivered and received.
That background of a degenerating system puts Barbados in a particular bind because, as QEH Chief Executive Officer Dr Dexter James explained, this island, like many other developing countries, has signed on to the concept of universal health coverage.
“Universal health coverage in its broadest sense [says] countries must develop their health financing systems so that all – not some – people have access to services and in so doing should not endure financial hardship in paying for them,” James said at the forum, explaining that this involves matters of access and equity, affordability and sustainability.
He warned that the “question of health financing is grounded in a lot of tensions and politics, and political ideology,” and pointed to the current debate in the United States on Obama-care, officially known as the Affordable Care Act, that was introduced by former president Barack Obama as an example.
President of the Barbados Association of Medical Practitioners, Dr Abdon DaSilva, supported Dr James’ point on Barbados’ commitment to universal health coverage. He pointed to the United Nations declaration that states, “everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care”.
But in expressing uncertainty on where does the Barbados legal framework stand on the matter, Dr DaSilva asked: “If legislation falls short of ensuring health care as a right, does that mean the public will be comfortable with the idea of health care as a privilege?”
Nonetheless, he said, “whether health care is a right or privilege does not alter the fundamental challenge of allocating scarce resources in the health care system. Either way as a country, we must deal with the fact that the health care workforce, the facilities and the funds are available only in finite qualities”.
It was in recognition of the limited nature of health care facilities and funds that Dr King said: “We have two choices. We match our services with the money that we have. As we run out of money, then we will have to run out of services, which will mean that the expensive services disappear.”
Explaining the consequences of disappearing expensive services for Barbadians, he said, “that means not doing resuscitation of people who come in to A&E. They are high expense patients because they then go from A&E to ICU (Intensive Care Unit). They are in hospital for weeks to months and have varying levels of recovery, so we will leave those out”.
Continuing with his examples of curtailed expensive services, Dr King said, “we limit severely the access to ICU care which is $2,500 a day”. Added to that, he said administrators will cut down on dialysis treatment by declaring diabetics, amputees, and the blind ‘not suitable’.
After painting the worst case scenario, Dr King posited that there are only three options for the money: the public purse, insurance, and user fees. “It could be a part payment, but you should get some credit for taxes paid because only a small proportion of our population that earns pays income tax,” he said. “There should be some part payment for having health insurance, and then any uncovered cost would be met by user fee .
“There would be the option of means testing to determine whether an individual could or could not afford to pay user fees, whether fully or in part,” he also said.
Detailing how the system would work, he explained: “The patient presents to A&E. No one is denied access. They’re just told that a fee would apply, care is provided as is necessary. A bill is generated and the fee may be decreased or waived based on means, and the fee is paid either in full or by part payment over time, like hire-purchase health care”.
His proposed option for those with non-urgent conditions is to “have an elective procedure plan, and an elective admission plan.” He explained: “The elective cost is explained [by medical administrators]. On application they’ll decide what your bill should be. A payment plan is set up which you either pay before you go in, or after you come out, depending on how urgent your procedure is. And care is provided.
“In order not to be a hardship … payment should be less than 10 per cent of your monthly disposable income,” he said. “It may mean that we collect money in dribs and drabs but it is more money than we collect now.”