Column: Commissiong On Health Care Part II

November 12, 2019

[Opinion column written by Rolfe Commissiong]

Firstly, the evidence at hand:

As you read this and as confirmed by the Ministry of Health there are 5,341 Bermudians, spouses of Bermudians and PRC holders representing approx. 8 percent of our population who are without health insurance. However as noted in part one of this op-ed once one adds in the thousands comprising the underinsured largely on HIP an even more disturbing picture emerges.

Once one combines, the persons who fall into both categories that being the uninsured and underinsured they represent a full 20 percent of our total population. And no surprise here as mentioned in part one, 91% of those persons are black. Racial disparities as they exist throughout our society are replete in just about every health category related to this issue, including those listed below.

As local economist Robert Stubbs has advanced those societies with high levels of income inequality see a growth of relative and real levels of poverty. It primarily ravages those at the bottom of income distribution contributing to these adverse impacts upon their health.

The working poor, low income and lower middle-income persons are most affected and overwhelmingly most of those who disproportionately fall in that category in Bermuda are black Bermudians. Of course, it is also an aspect of this conversation that is considered bad form to acknowledge. A taboo if you will.

The corresponding figure of whites without health insurance is just under 500 persons. You will note that none of the critics of this emerging plan whether the OBA or in the private sector even make mention of this shameful statistic. Certainly then these disparities have become somewhat normalized.

That overall figure of 5,341 also includes – just as shamefully – a small number of children. These relevant stats can be found in our latest census and those provided by the Ministry of Health and the Bermuda Health Council as do those below.

Additional sober reading in terms of the relevant statistics follows:

• According to the Chief Executive Officer of the Bermuda Health Council, Dr Ricky Brathwaite total annual healthcare spending on the island is roughly at $700 million, which amounts to $11,300 per person.

Some of the key drivers bending the cost curve upward as opposed to downward are:

• due to Bermuda’s rapidly aging population as noted Bermuda’s working population will be paying twice as much on healthcare in 20 years as they do today. That however may be a conservative estimate which depends on the cost of healthcare remaining steady. Prognosis: highly unlikely. In 2020 only week’s away Bermuda will achieve a milestone with 20 percent of our population being 65 and over.

• – as to the aforementioned declining health profile -13% is the current rate of diabetes among the general population. However, some physicians remark that this is an underestimate as the real burden they consider to be closer to 30%

• – 215 persons is the number on dialysis due to End-Stage Renal Disease. The dialysis outlays alone for the 215 persons cited is costing more than $30M per year for the service. With the high rate of diabetes particularly stage two – the ranks of those requiring this life-saving service will only grow over the next few decades exponentially by 10 percent per year.

• – in light of the above, there are approximately 1000 people diagnosed with some pre-end stage form of chronic kidney disease as you read this.

• – 75% being the rate of overweight individuals and those suffering from obesity amongst adults in Bermuda. This is accompanied by a significant rate of childhood obesity as well.

• – approximately 1 in 10 seniors exceed their coverage limits for prescription medications

Leading to the often invoked specter of some seniors choosing between highly-priced groceries or purchasing relatively speaking, highly-priced medications.

• – there has also been a significant Increase in the incidences of cancers and stroke.

Its not a pretty picture at all. And it will only get worse…

So, the second question we must consider as a follow up to that posed in part one of this two part series is: if the current system dominated as it is by the private markets in terms of commercially available health insurance and in the provision of medical services by doctors and other health professionals is indeed broken as many contend and as the evidence would indicate – then what model should be implemented as the cornerstone of a new system designed to provide the health care insurance and services that an ageing population in many cases desperately needs.

Will it be one that will provide more equity than that which exist now and which will begin the process of transitioning health care and access to it from that of a privilege dictated largely but not exclusively by those private markets to one which is considered a right of every Bermudian particularly the working poor? Clearly, in most developed countries many of which we constantly compare ourselves to; that day arrived many decades ago.

The government is now advocating that we move to some variation of a single-payer system as a means to i) provide universal care for Bermudians and ii) over time significantly slow down and eventually halt the perennial rate of increase in the cost of health care that we have experienced over the last 15 years at least.

Now there will be many within the healthcare industry along with radical libertarians, some of whom literally camp out on the comments section who will have smoke coming out of the airs upon reading those two terms ‘single-payer’ or ‘universal coverage’. The two are not always synonymous – but let me remind them there are two country’s with a health care system dominated by the fee for service model where there are growing movements to replace those respective models with a system centered around the provision of health insurance that can provide for universal access to healthcare and contain cost. Those two countries? The U.S and Bermuda. And that can only be achieved even as a practical matter by way of a single-payer model or some variation or hybrid of that model in order to provide health care insurance coverage for all. Universal care if you will for all Bermudians.

Secondly, they will also claim as they do in the US that this represents socialism and the sky will fall in if we even think of doing such a thing.

But note that the following countries listed below do not have a fee for service-based system dominating their provision of health care insurance to their citizens. Additionally, all of these so-called developed countries have market-based or capitalist economies.

There are 17 who have adopted a single-payer type model:

As listed in an article written by Kelly Montgomery featured on the informative “Very Well Health” online site, they include – Norway, Japan, the United Kingdom, Kuwait, Sweden, Bahrain, Brunei, Canada, United Arab Emirates, Finland, Slovenia, Italy, Portugal, Cyprus, Spain, and Iceland.

Then there are those countries as featured on the site that offers a variation of the single-payer system. These countries have adopted what is characterized as a so-called two tier system in which the government provides basic health care with secondary coverage available for those who can afford it. They are: Denmark, France, Australia, Ireland, Hong Kong, Singapore, and Israel.

Finally, remember a single-payer type system or its variation is implemented to achieve specific public policy goals. Universal coverage is one of the primary public policy goals of the countries that have adopted it. To date, these are the 18 gold-medal-winning countries that have achieved 100 percent health insurance coverage of its citizens. Those countries are – Australia, Canada, Finland, France, Germany, Hungary, Iceland, Ireland, Israel, the Netherlands, New Zealand, Norway, Portugal, the Slovak Republic, Slovenia, Sweden, Switzerland, and the United Kingdom. Of this list, only Germany does not have a single-payer or hybrid model. There is not one North Korea amongst them.

I have not come across any evidence that any of the countries cited have experienced any protest or political movements seeking to do away with their current government-managed health insurance systems and replace it with a system as exists in either the U.S or Bermuda. Their likely response. A big no thank you.

Which leads me to the conclusion that only root and branch reform can address this growing crisis. Now let’s not be under any illusion there will be some industry players motivated solely by naked self-interest as opposed to the seeking of the public good. They have mostly opposed the current government proposal as an alternative pathway to reforming the system.

But so far we have had more opposition to the health care reform proposed then credible proposals from some of the same industry groups. A vague proposal around “wellness” is more marketing than a substantive proposal. Even if that should be part of the overall reform plan as it is, that component alone will take decades to make a real difference due to entrenched cultural and behavioral norms that took decades to take root in some cases.

Judged by the evidence above we do not have that luxury. This crisis cannot be tweaked away. Their stance may be good for their bottom lines but it is precisely the status quo characterized at heart by a fee for service model which is why the system is irretrievably broken.

One final note, especially for persons who own and manage small to medium-sized businesses and even our larger corporations. This will also be good for you and your bottom lines by reducing the significant outlays that you are mandated to shell out on a monthly basis for the health care of your employees. This will reduce your cost of doing business in Bermuda. No small feat. As a consequence you should be this reforms biggest champions alongside Mr. and Mrs. Bermuda.

Is what the government proposing perfect? No. For example, none of the health insurance plans that will be available have been fixed as yet and will not be until after the current consultation period ends [link]. But the train tracks that those future plans will run on will be one that places all of the insured in Bermuda into one insurance pool.

I support free health care for all. A pure single-payer system paid for by a progressive system of taxation that will shift more of the tax burden on to the wealthy. Neither proposition is doable now. Therefore, I am not prepared to let the perfect be the enemy of the good. But let us not be under any illusions the current status quo is simply untenable and thus this system as graphically outlined is broken. We must be transformational in our approach to this issue and this government is determined to accomplish exactly that.

- Rolfe Commissiong


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Comments (5)

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  1. Things a Gwan says:

    I won’t even read this. I’m sorry but over a year ago you sold us this healthcare reform on the basis that this would lower costs, make the system more efficient which equals making premiums would go down therefore putting more money in our pockets. My policy has already gone up over $120 per month and the plan hasn’t even been fully implemented. I’m told by the insurance company that it is expected to go so as much as $200 more for the same xoverage when this is all said and done.

    Rolffe or some other PLP member if this is a lie and you are convinced that I will get the same for less, please call out the insurance companies on this. However, you should know tgat when your plan is bullied through and made law and premiums do not go down we can call you out on this. Who is the telling the truth here?

  2. Joe Bloggs says:

    “thousands comprising the underinsured largely on HIP”

    If having HIP means being under insured then improve the benefits available under HIP. You are the Government, you can change the law.

    • sandgrownan says:

      Ah..but that would mean taking action, being decisive, dare I say it, being progressive. None of those qualities are in the PLP lexicon unfortunately.

  3. Current System says:

    Great article Rolfe,
    While you are at it in trying to fix what ain’t broke, why don’t you try to fix the Trash pickup, bus schedule and our economy which should be easy with all the research you can do!!!

    Or better still if Obesity is the major culprit driving up our Health Care try educating them with our Sugar Tax money that you are collecting.

  4. Vortex says:

    Nicely written piece.

    There you go Rolfe, not everything is black and white.