Dear Aaron

Dear Aaron

I have been meaning to write you for quite a while but things happened, as they tend to do.  We never talk anymore!  Anyways, I saw you on the Business Briefing on SABC2 a while ago and wanted to have a little chat about that and some other issues, on behalf of the Council Against Medical Schemes.

As always I found your televised talk and the subsequent interview very engaging and you made your case very well.  That said, I did pick up a few issues.

The first is that, while good, the contents of your speeches and presentations have not really changed in quite a long time.  People tend to notice this kind of thing.  Their inevitable boredom and annoyance means that the message isn’t received as clearly as it should be.  I suggest that you put some time into updating your presentation and research.  We expect our Ministers to be up to date.

The second problem is that you sometimes come across as more of a promoter than a leader.  Let’s take it as read that universal healthcare is the destination we are travelling to and ignore those who are against the concept, such as U.S. Republicans and other misanthropes.  The questions we have for you is then not “is universal healthcare going to happen?” but “how are we going to achieve universal coverage?”  You seem to be skirting around the issue, constantly kicking for touch by stating that the public healthcare system needs to be fixed first.

It is also been a long, long time since the disappointing NHI green paper came out (when I was younger I always thought it would be printed on actual green pages).  While there have been promises that the white paper is “imminent” we are starting to grow weary of waiting.  Policy uncertainty is never a good thing.  Ever.

You made an interesting observation; pointing out that you are the Minister of Health and not the Minister of Public Health.  As I recall this was in response to some greedy devils telling the government to stay out of their business.  I agree, by definition your job description and mandate is that of the Minister of all South African Health.  But son, you have been acting like the Minister of Public Health.

Look, I understand.  You only have so many hours in a day and your department has limited resources.  On top of that the status of the provincial health departments range from troublesome (at best) to dysfunctional and sometimes completely and utterly borked.  I’m thinking of Limpopo and the Eastern Cape especially.   As you also hasten to point out this is the system that 86% of South Africans, because of poverty, have no choice but to rely on and so you must prioritise the public healthcare system.  You have also been mandated to implement universal healthcare, with the ultimate aim of giving all South Africans access to quality healthcare.

Next year is also an election year and we all know that means making a show of paying attention to the things ANC voters care about.

Of course this universal healthcare goodness isn’t going to happen any time soon.  You said that we are still 14 years away from implementing NHI because the underlying healthcare system needs to be fixed first and that job has many aspects, from training of doctors and nurses to infrastructure, resource allocation and improved management.  I feel bad having to remind you that you said the exact same thing two years ago.  It should therefore not be surprising to learn that most of my colleagues agree with me in predicting that NHI is going to be 14 years in the future for a couple of years more, at least.  It turned out that turning the decrepit public health beast around is much more difficult than anyone anticipated, hasn’t it?

The people who first thought up NHI argued that its very implementation would magically fix these problems but you and I know better.  Magic doesn’t work like that.

Now I have to be honest with you.  We here at the Council Against Medical Schemes tend to be more concerned with what happens to these strange not-for-profit entities called medical schemes that spend so much money to provide healthcare for so few.  Let’s talk about that.

It is good to see that the Minister is giving some attention to the private healthcare industry.  You managed to convince the Competition Commission to put on some latex gloves and give the private healthcare industry a thorough inspection.  This is long overdue – everyone except greedy devils agree that the Commission’s ruling ten years ago has had the exact opposite effect from what was intended.

Kudos for showing some insight when you state that many of the problems in the private healthcare space have come about because the funding side is heavily regulated but that there is no regulation of the private provider side, which is an extremely silly way to run things.  So your natural instinct is to go looking for tools to reign in the hospitals and specialists.

Certainly there is, at the moment, not much you can do about providers.  The idea that the market would regulate itself has gone the way of the dodo and the ethical tariff guidelines.

Some people are a bit puzzled then; since you are the Minister of Health there is little apparent reason for you not to simply have the appropriate legislation drawn up.   I am however concerned that, while you focus all your attention on reforming the public healthcare system and waiting for the Competition Commission to write a thick report so that you can then throw the book at private healthcare providers, you are in dereliction of your responsibilities to those “rich” bastards who can afford to belong to medical schemes.

Listening to the little jibes you drop into your speeches you really seem to hate the “rich”.  Is this pandering to your audience or do you really loath the very people whose buy-in is vital to achieving your goals, particularly as they are going to be paying for them?  One of the lessons you should take away from the e-tolling saga is that the people with the money are starting to resist your government imposing all kinds of costs and taxes on them on the basis of them being rich and therefore having the ability and even moral obligation to put up and shut up.  What will you do when there are no more rich people left?

In any case, at this year’s BHF Conference in Cape Town the Impish Actuary  (apparently he really hates it when I call him that) described, in simple and understandable terms, just how messed up the current medical scheme regulatory environment is.  It is a pity that you couldn’t attend as you were still recovering from your surgery.  How is the healing coming along, by the way?

Anyways, the Imp explained that the medical schemes regulations have been in a kind of regulatory limbo for a long time.  They were taking South Africa down a different road towards universal healthcare called SHI, which has now been abandoned in favour of NHI.  This leaves medical schemes stranded on a deserted road with no defence against profiteering bandits.

I must disagree with the Imp on his conclusion.  He said that there is a danger of the medical schemes industry becoming a regulatory orphan.  It already is, thanks to you and your department studiously ignoring the problems and not lifting a finger to fix it.

Maybe you don’t understand, in which case I strongly suggest that you invite the Imp to come make his presentation to you and your department.  You must educate yourself, young man.  Maybe you do understand and don’t care, in which case I am very, very disappointed in your myopia.

You see, while it may be politically expedient to bash the “rich” medical scheme members the truth is that many medical scheme members aren’t rich.  As the contribution costs keep escalating to keep up with rampant medical inflation they have to cut out other expenditure to compensate.  Or they forego cover completely, which leaves them at risk.  And so they fall between the cracks.

You criticise the medical schemes industry for not doing enough to provide affordable healthcare to more South Africans.  That is unfair, to say the least.   Your Department has overseen the creation of a regulatory environment that makes it virtually impossible for them to provide sustainable and affordable low cost medical scheme options.  PMBs are a problem, no matter what the Registrar for Medical Schemes says.  The open enrollment and community rating provisions, without risk equalisation, ensure that schemes have no other choice but to compete based on the profile of their beneficiary pools.  This means that, while they cannot turn away the high claiming members, schemes will find every legal and practical way of making it difficult for them to joinThe rules by which medical schemes must play entrenches systematic discrimination against the old and sick.  On top of that there are matters such as the crude solvency requirements that add even more to the affordability challenge of medical schemes.

Now you may point out that there are provisions that aim to outlaw such discrimination but, as a medical professional, you will understand that it is far better to treat the underlying condition rather than the symptoms.  Given that an accurate diagnosis is available I think it would be entirely fair for the pensioners who have to live on cat food in order to afford their medical scheme contributions to blame it all on you.

Alex van den Heever, at the same BHF conference, predicted that schemes would increasingly clamour for the more onerous regulatory restrictions to be relaxed, going on the state that this must be resisted at all costs.   I find his position perplexing.  If we know that we aren’t going to complete the SHI path, if the industry cannot survive, never mind thrive, in the current regulatory limbo and under no circumstances can it be allowed to go back, then what choices do we have left?  It reminds me of a funny bit from a Douglas Adams novel:

“Not unnaturally, many elevators imbued with intelligence and precognition became terribly frustrated with the mindless business of going up and down, up and down, experimented briefly with the notion of going sideways, as a sort of existential protest, demanded participation in the decision-making process and finally took to squatting in basements sulking.

An impoverished hitch-hiker visiting any planets in the Sirius star system these days can pick up easy money working as a counsellor for neurotic elevators.”

Medical schemes are like elevators stuck between floors and their members have been trapped there, with no access to bathroom facilities, for far too long.

So my question to you, young man, is this: what are you going to do?  Will you show some initiative and give us policy direction?  Will you fix some of the most glaring problems in medical scheme regulation, even only the ones that can be addressed by means of a simple change to the regulations?  Or will you continue to be in dereliction of your duty to medical scheme members?  Lest you forget: you are the Minister of all Health in South Africa.



Professor R.C. Whiddens, DM (6th), D.Thau., B.Occ., M.Coll.

Chair of the Institute of Incoherently Applied Policy

Bursar of the Council Against Medical Schemes


One thought on “Dear Aaron

  1. Government, with all the tax billions set aside year in and year out for health, has failed to maintain a well-functioning public health system, which is now dysfunctional.
    Open and closed medical schemes co-existed and functioned harmoniously until the advent of CMS. Now medical schemes are going belly-up and merging at an alarming rate to the detriment of the very people CMS was designed to protect. But then again, I state the obvious.

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