who really pays for NHI?

Do you think the working class will not pay for the National Health Insurance (NHI)? As government presses ahead with implementing the controversial fund, a difficult question needs to be asked: who will pay the real price?

Contrary to popular belief, it is not the wealthy elite who will be hardest hit but South Africa’s working class, Thoneshan Naidoo CEO of the Health Funders Association (HFA), warns.

“Medical scheme members are often painted as a privileged minority but the truth is very different. Of the 9.1 million South Africans on medical schemes, more than 6 million (68%) are black and up to 83% of employed members earn under R37 500 per month.

“They are teachers, nurses, police officers, civil servants and union members, the engine of South Africa’s economy. These South Africans make extraordinary sacrifices to secure access to healthcare. Medical schemes are not luxury products and working families are stretching their disposable income to protect themselves and their families.

“Of the 9.1 million beneficiaries, 4.1 million are employed and form a critical part of the country’s taxpayer base. In fact, medical scheme members pay an estimated 74% of South Africa’s personal income tax, amounting to nearly R443 billion in government revenue. These same members also contribute significantly to VAT and other taxes.”

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Free NHI at the point of service, but who pays?

Government promises that the NHI will provide comprehensive, high-quality care for all – free at the point of service. But at what cost?

According to an economic feasibility study by Genesis Analytics, achieving this vision would require personal income taxes to more than double. Taxes would have to increase to 2.2 times the current average rate and healthcare would consume 33% of the national budget.

In less efficient scenarios this could mean tripling taxes and health expenditure consuming up to 44%  of the budget. Naidoo says this is based on the unrealistic assumption that tax increases would be entirely directed to healthcare and that there would be no additional allocations for other urgent social needs such as education, social grants and service delivery.

Even under a shared resources scenario, Naidoo warns that where total healthcare spending remains at today’s R532 billion, personal income taxes would still have to increase by almost 50%, while taxpayers would receive substantially less. Benefit levels would be 43% to 65% lower than the promised comprehensive scenario, he says.

“In short, taxpayers would pay more and get less – less than they currently receive if they are medical scheme members and much less than what has been promised for the scope of NHI services.”

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What about section 33 of the NHI Act that prohibits medical aid?

A lot has been said about section 33 of the NHI Act that the president signed last year. This section prohibits medical schemes from covering any service that the NHI claims to offer. Naidoo says this means that even if you have the means and willingness to buy private cover, you will be barred from doing so if the service is theoretically offered by the NHI.

“Rather than universal access, this is universal restriction and the result is likely to be delays, rationing and deteriorating health outcomes, with no alternative safety net.”

And who will bear the brunt? The working class, Naidoo says.

He warns that the NHI Act risks collapsing the very system that currently supports our healthcare infrastructure. “For the 3.4 million low and middle-income medical scheme members, the impact will be devastating. The NHI Act’s funding model is built on their shoulders through higher taxes, the removal of the medical tax credit and reduced access to care.”

Healthcare cannot be viewed in isolation from the broader economy, Naidoo says. “Draining all available funding into a single centralised system without the infrastructure or capacity to deliver, jeopardises not only health outcomes but also jobs, investment and growth.”

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43% reduction in medical care for scheme members under NHI

He points out that even in the best case shared resources scenario modelled by Genesis, medical scheme beneficiaries would see a 43% reduction in access to care. “Combined with the ban on supplementary cover, the state will actively prevent people from protecting their own families.”

Naidoo cautions that healthcare rationing will become the norm. “This is not speculation. It is already happening. Public hospitals face routine medicine stockouts, long surgery waitlists and severe staff shortages. In Gauteng, thousands of cancer patients were denied timely radiation therapy, with devastating consequences. When care is rationed, lives are lost.”

Section 33 of the NHI Act risks deepening these crises, he says. “It removes a vital layer of protection for millions. Blocking people from using their own resources to access care is not equity, but rather forced dependency.”

However, there is a better way: reform, not ruin, Naidoo says. “South Africa’s constitution guarantees everyone the right to access healthcare. Our courts have recognised the vital role medical schemes play in realising this right. That does not mean collapsing what works, it means improving what does not.”

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Health Market Inquiry

Medical schemes are not perfect and reform is essential. Fortunately, Naidoo says, the blueprint exists. The Health Market Inquiry, initiated by the Competition Commission, laid out clear steps to improve affordability, transparency and efficiency in the private sector that include:

• A supply side (healthcare providers and facilities) regulator for health to oversee negotiated fair reimbursement levels;
• A risk adjustment mechanism, where medical schemes with higher-than-average risk profiles receive funds through an appropriate mechanism from those with lower-than-average risk profiles, to level the playing field;
• Standardised benefit packages;
• Better governance structures to ensure efficient use of resources.

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These steps will ensure more and better medical care for all

Implementing these reforms in a holistic and integrated manner would strengthen the role of medical schemes in a fairer, more accountable health system without tearing down what is working for millions, Naidoo says.

“Most importantly, these improvements could be implemented now, without the massive fiscal burden of a centralised NHI that requires impossible tax increases. The Health Funders Association proposed an alternative, a hybrid multi-fund model that preserves the public private mix, ensures income cross subsidisation and gradually expands coverage.

“This model is based on the NHI Fund working with medical schemes to expand access to healthcare and incorporates key Competition Commission recommendations and would protect the vulnerable while preserving choice and quality.

“South Africa can achieve universal health coverage without banning the opportunity to purchase supplementary cover, overtaxing workers or dismantling functioning systems. The working class has more than paid its share. The question South Africa must ask now is whether government will listen and build a better system or press ahead regardless of the cost.”