#BTEditorial – On universal healthcare

Since the 1950s, we have satisfied ourselves with the shibboleth that Barbados enjoys free health care. What is often derisively called socialised medicine has been no less integral to our democratic socialist governments than free education.

And rightly so. Unlike our American neighbours, Barbadians do not need convincing that as health is a basic human need, access to primary care is a basic human right.

We have long had what the world’s richest nation has only dreamed of – a single-payer health care system, in which a general hospital and a network of clinics have provided primary health care to Barbadians free of cost at the point of delivery – but paid for by our tax dollars.

But this is where the shibboleth raises its aged head.

Yes, we have had services free at the point of delivery for decades. Not merely emergency care but neonatal care, preventive care, drug prescriptions, even dental and eye care, major elective and non-elective surgery and outpatient clinics treating a variety of ailments. The overall standard of our health care has sustained our total life expectancy at birth of 75 years, among the highest in the Caribbean Community.

Nice service, if you can get it, or afford to wait for it.

Barbadians are only too well aware of the excruciatingly painful wait for service at outpatient clinics or the seeming sloth of inattentive carers in polyclinics. Or the incredibly long queue, whether ultimately for painkillers for the flu or for surgical operations.

It is an open secret that Barbadians routinely jump that queue to better care – if they have the means to do so.But what is spoken of in hushed tones, if at all, is the rate at which illness bankrupts families in Barbados – whether disease or injury strikes a dependent or a provider.

And while many here can rattle off the key components of America’s market-based health care system, dubbed Obamacare, most are blithely ignorant that in Barbados, insurance companies routinely if not reflexively deny coverage owing to a pre-existing condition.

Indeed, according to Barbados’ first national health accounts study in 2014, private health insurance paid only five per cent of the roughly $700 million spent on health care. Out-of-pocket spending by households accounted for 38 per cent, with the Government picking up 55 per cent of the tab.

Two out of three working Barbadians are not covered by health insurance – an expensive proposition with the many co-pays and deductibles that must be found in cash upfront before partial reimbursement at a later date.

In declaring its support for universal health coverage, the Government has announced a health care financing commission to consult with stakeholders, we are told. The goal is to pay sustainably for the same high level of care commensurate with our needs but not dictated by our means.

We hope these “stakeholders” will include the ultimate consumers of health care – not private insurers and the medical practitioners who love them – but citizens and patients who believe that each of us has a right to live a healthy, happy and productive life, no matter our station in it.

We envisage a national health insurance system in which the nation’s GPs continue to serve their patients but are paid through the NIS for providing service. They will not like the term ‘capitation’ but you will. It means that doctors are guaranteed a flat fee for service to patients. Doctors might not get rich so quickly but they will see more of us and we will see more of them, thus improving our own health odds through greater preventive care and treatment.

We do not want to see a discussion dominated by bean counters and economists. Yes, good health care is not cheap but it must not be determined by market forces and a private sector keen to profit from disease, as distinguished by the American example of health for the haves and ill health for the have nots.

But just as we ought not to have a discussion of paying for health care merely as a nation reluctant to pay a big bill, we must not cede the floor to physicians either.

In every known instance in which universal health care has been introduced, doctors have found invariably themselves on the wrong side of the history – whether in the UK through the unceasing efforts of Minister of Health Aneurin Bevan in creating the now-beloved National Health Service in 1948, or in Saskatchewan, the pioneering province of socialised medicine in Canada under premier Tommy Douglas in 1962. Closer to home, doctors have either used health care financing to seek a pay raise or viewed it as an existential threat to their private clinics, hospitals and board memberships.

We support PAHO’s vision of universal health care, whether this is ultimately financed by a system of individual health accounts, national health insurance, a hybrid market of private and public insurers or a single-payer, public health care service.

“Universal health is not just about ensuring everyone is covered, but that everyone has access to care when they need it, wherever they are,” THE Pan American Health Organisation’s representative here, Dr Godfrey Xuereb Xuereb said.

We say it also means being able to promote good physical and mental health, through education and policy changes for healthy choices and healthy lifestyles.

It means paying for medical education so that our doctors graduate, perhaps poor but not in debt, unlike their American counterparts – poor and under a mountain of debt.

It means providing not merely more ambulances but more ambulatory care, a system in which health care is delivered outside of hospitals and ultimately in people’s homes.

We note the emergence of an American-styled growth industry in medical care, with treatment clinics, private operating theatres and yes, medical schools, supported by profit-making insurance companies and fronted by profit-seeking surgeons and physicians, who grow fat on nations sickened by chronic lifestyle diseases.

They have reasoned: why prevent cuts and burns when we make a killing selling bandages and plasters?

Beware such figures, for they have powerful connections to business and political power, and they will seek to take control of the podium in any debate on providing health care not on the basis of affordability, access, quality and equity but on the basis of profit and loss.

We will have more to say on universal health care as the discussion begins in earnest in Barbados. Hopefully, it will be centred not on rationing treatment according to means or only to the very young, very old and very poor but on how to meet the central need of all members of the human community on this rock – to be in good health.