Have no illusions: our healthcare system is broken

  • Pending crisis: beds in the emergency room of the acute care wing of King Edward VII Memorial Hospital (File photograph)

    Pending crisis: beds in the emergency room of the acute care wing of King Edward VII Memorial Hospital (File photograph)

  • Rolfe Commissiong is a government backbencher and the MP for Pembroke South East (Constituency 21)

    Rolfe Commissiong is a government backbencher and the MP for Pembroke South East (Constituency 21)

First, 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 permanent resident’s certificate holders representing approximately 8 per cent of our population who are without health insurance. However, as noted in part one, once one adds in the thousands comprising the underinsured largely on the Health Insurance Plan, an even more disturbing picture emerges.

Once one combines the persons who fall into both categories, the uninsured and the underinsured, they represent 20 per cent of our total population. And no surprise here, as mentioned in part one, 91 per cent 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 later.

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 a little less than 500 persons. You will note that none of the critics of this emerging plan, whether it be from the One Bermuda Alliance or from within the private sector, make mention of this shameful statistic. Certainly, then, these disparities have become somewhat normalised.

That overall figure of 5,341 also includes, just as shamefully, a small number of children. These relevant statistics 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 of the Bermuda Health Council, 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:

• Because of Bermuda’s rapidly ageing population as noted, the working population will be paying twice as much on healthcare in 20 years as they do today. However, that may be a conservative estimate, which depends on the cost of healthcare remaining steady. Prognosis: highly unlikely. In 2020, only weeks away, Bermuda will achieve a milestone with 20 per cent of our population being 65 and over

• As to the aforementioned declining health profile — 13 per cent is the existing rate of diabetes among the general population. However, some physicians remark that this is an underestimation, as they consider the real burden to be closer to 30 per cent

• Two hundred and fifteen persons is the number on dialysis because of end-stage renal disease. The dialysis outlays alone for the 215 persons cited is costing more than $30 million 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 and exponentially by 10 per cent per year

• In light of the above, there are approximately 1,000 people who will have had some pre-end-stage form of chronic kidney disease diagnosed as you read this

• Seventy-five per cent being the rate of overweight individuals and those suffering from obesity among 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 spectre of some seniors choosing between highly priced groceries or purchasing, relatively speaking, highly priced medication

• There has also been a significant increase in the incidences of cancer and stroke

It is 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 present system is dominated as it is by the private markets, in terms of commercially available health insurance, and if 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 healthcare insurance and services, that an ageing population, in many cases, desperately needs.

Will it be one that provides more equity than that which exists now and which would begin the process of transitioning healthcare 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 advocating that we move to some variation of a single-payer system as a means to:

1, Provide universal care for Bermudians

2, Over time significantly slow down and eventually halt the perennial rate of increase in the cost of healthcare that we have experienced over the past 15 years and more

Now there will be many within the healthcare industry, along with radical libertarians, some of whom literally camp out on The Royal Gazette’s comments section, who will have smoke coming out of their ears, upon reading those two terms “single-payer” and “universal coverage”.

The two are not always synonymous, but let me remind them there are two countries with a healthcare system dominated by the fee-for-service model, where there are growing movements to replace those respective models with a system centred on the provision of health insurance that allows universal access to healthcare and contains cost.

Those two countries? The United States and Bermuda. And that can be achieved, even as a practical matter, only by way of a single-payer model or some variation/hybrid of that model to provide healthcare insurance coverage for all. Universal care, if you will, for all Bermudians.

Second, 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 healthcare 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, Britain, 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 characterised as a so-called two-tier system in which the Government provides basic healthcare 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 per cent health insurance coverage of its citizens. Those countries are Australia, Canada, Finland, France, Germany, Hungary, Iceland, Ireland, Israel, the Netherlands, New Zealand, Norway, Portugal, Slovakia, Slovenia, Sweden, Switzerland and Britain.

Of this list, only Germany does not have a single-payer or hybrid model. There is not one North Korea among 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 government-managed health insurance systems and replace them with a system as exists in either the US 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 present government proposal as an alternative pathway to reforming the system. But so far, we have had more opposition to the healthcare reform proposed than 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, because of entrenched cultural and behavioural 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 characterised 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 healthcare of your employees. This will reduce your cost of doing business in Bermuda. No small feat. As a consequence, you should be this reform’s biggest champions, alongside Mr and Mrs Bermuda.

Is what the Government is 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 consultation period ends. But the train tracks that those future plans will run on will be ones that place all of the insured in Bermuda into one insurance pool.

I support free healthcare 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 present 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 is a government backbencher and the MP for Pembroke South East (Constituency 21)

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Published Nov 21, 2019 at 8:00 am (Updated Nov 21, 2019 at 7:52 am)

Have no illusions: our healthcare system is broken

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