National Health Insurance: Protection for Whom?
BPJS Kesehatan must also be given an equal opponent so that its quality continues to improve. It is the duty of the Health Ministry to create such a competitive environment.
The term "BPJS orang kaya" (Security Management Agency for the rich), which was originally coined by Health Minister Budi Gunadi Sadikin, sparked a discourse regarding the management of healthcare and social security funds (DJSK). We need a new formulation for the management of the DJSK and BPJS Kesehatan (Security Management Agency for Health).
Joko Mulyanto in his article (Kompas 10/12/2022) wanted to bring the concept of social insurance back to its basics. Meanwhile, Laksono Trisnantoro (Kompas 13/12/2022) tried to bring the concept of social insurance to reality.
The reality in question is the utilization of health access by BPJS Kesehatan participants from "independent groups (they pay the premium themselves)," a term often used to call "non-paid workers (PBPU)" and "non-workers (BP)," which exceeds the amount of contributions they make. This results in cross subsidization, from the well-to-do group to the poor group, which did not work according to the concept or even the opposite.
Able and rich
First of all, we need to map the terminology precisely. With the current JKN (National Health Insurance) membership scheme, we can only make an analysis based on membership groups, namely contribution assistance recipients (PBI), paid workers (PPU), PBPU and BP. We cannot classify JKN participants based on the economic quintile class in detail.
Those who are JKN participants in the PBPU or BP group are not necessarily from the rich class if what is meant is people in economic quintiles IV-V. This way, the term “rich” used by the public and by ministerial-level authorities is inappropriate and unreliable.
Technically, the classification of “rich” or “financially able” is complicated to formulate. The wild idea of looking at electricity bills (to determine the financial condition) is not practical in everyday technical terms. This approach looks more like a threat than a long-term solution. We need technically clear and enforceable definitions.
Several scientific studies have actually been able to conclude that there is inequality in access to and utilization of health services. Sambodo (2021), for example, shows that Indonesia's health spending is still dominated by more affluent economic groups and are affected by the unequal distribution of health facilities.
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> Health Insurance for Rich People
Two-thirds of the total of 61 high-level hospitals (formerly called Class A) are located on the island of Java and 16 are located in Jakarta. The ENHANCE study (2022) also shows that people in the economically weak group do not have many access options, except for lower quality and limited health facilities.
This is the root of why the DJSK access and utilization is dominated by more affluent economic groups. Even though health services are provided free of charge, JKN participants still have to incur non-health costs, such as transportation, accommodation and even the potential loss of their daily income.
With limited facilities, long-distance travels and high non-medical costs, this group cannot afford or has to think twice before deciding to access health facilities. Meanwhile, more affluent groups benefit from free access and non-medical costs that they can still bear.
Of the approximately 30 million participants in the PBPU group in 2021, only 48 percent were actively paying JKN contributions. This caused the contribution of this group to the DJSK to be low, which was only 8 percent, compared with the PBI group contribution of 34 percent.
Middle class
Is letting go of this “able” group from the JKN membership to private insurance the right and wise thing to do? The low collectability of JKN contributions in the PBPU group is not without reason. Even though they are forced (to pay) through bundling contributions per family card (KK) or imposing fines, the literacy regarding the importance of health insurance is still low.
This is not only happening in Indonesia. Various countries have also experienced how difficult it is to reach this group, which is often referred to as “the missing middle.” When the poor are borne by the state and the extreme rich are able to fund their own treatment, the middle group often places health insurance as a low priority and leaves them unprotected.
It is this middle class that will dominate the contours of Indonesia's population in the next 10-20 years. Mauro Guillen, in his book 2030, predicted the same thing would happen in almost all parts of the world.
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> National Health Architecture
> Turbulence of the 2023 Health Program
People in this class can afford to pay for acute medical expenses themselves, going to an “expensive” specialist doctor or hospital once or twice, seeking the best facilities with the longest queues and the highest recommendation for diagnoses, acute therapy or delivery. However, when they have to deal with chronic and high cost illnesses, they are forced to rely on insurance assistance such as BPJS Kesehatan.
It is this group with access privileges in urban areas that predominantly absorbs the DJSK. BPJS Kesehatan must be recognized as their savior. The JKN scheme is one of the insurances with the lowest contribution in the world. Participants can access almost unlimited services with only Rp 150,000 (US$10). We do not find insurance schemes like this in other places.
However, asking them to leave BPJS membership and become private insurance participants is not the right thing. Sociologically, the consequences are severe. They choose the JKN because of the low contribution. If they switch to private insurance with severe comorbid conditions, such as kidney failure or a history of heart attack or stroke, they will have to pay eight to 10 times as much.
If forced, it is this middle class society that becomes the victim. Their spending on private insurance premiums will swell.
The idea of forcing out this middle group to private insurance would be a blow.
If they opt out or stop accessing health services, social security funds may no longer be in deficit. However, our human capital will be in deficit with many people getting sick and no longer able to access the best health services they can afford. We would be moving backwards.
The idea of forcing out this middle group to private insurance would be a blow. My guess is that half or two thirds of them would choose to stay in the JKN scheme with all the consequences.
If the PBI is given full access to health services, there will be administrative fraud, which we have experienced in the Jamkesmas, Askeskin and certificate of incapacity (SKTM) schemes in the past. There will be a wave of registrations, as the disadvantaged group cannot be properly verified, especially with a chaotic population data collection system.
Social security health funds will remain in deficit. We are just repeating the loop through a different mechanism.
Risk adjustment
An approach that has not been carried out in the JKN scheme is risk adjustment. We base the contributions based on class 1, 2 and 3, which is clearly misguided. While the social health insurance does not normally use risk adjustment, this approach can be the most reasonable solution in the given situation.
Those who have registered and accessed health services in a reasonable manner without risking their health will only need to pay a basic contribution, for example Rp. 150,000. However, this figure may change according to the use of services that are reviewed automatically, periodically and with a set threshold. For example, if someone is diagnosed with kidney failure in the second year of membership and must access dialysis services every two weeks, the fee would be adjusted to Rp 400,000.
This approach has two advantages. First, even if the contributions increase, the impact would not be as severe as if this individual was forced out of the scheme and turned to private insurance. Second, the increase in contributions contributes to the DJSK. Third, equity and justice are ensured; those who access more (health services) contribute more.
Private insurance, which the health minister worried would collapse after the JKN, can also be given room. The Health Ministry must become a regulator in setting standard benefit packages, premium ceilings and compatibility with the JKN. This will provide choices for the middle class society, which will trigger competition and increase the quality of insurance services.
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BPJS Kesehatan must also be given an equal opponent so that its quality continues to improve. It is the duty of the Health Ministry to create such a competitive environment.
This idea, of course, is still to be tested. We need space to think freely and be given sufficient time in order not to rush into making decisions.
Even though the law stipulates a single pooling mechanism through BPJS Kesehatan, it is time to rethink, evaluate and reconstruct our health insurance architecture. Which approach is most effective and efficient in balancing the need for public health protection and the limited funds available?
The use of the term “illness with catastrophic costs,” which has been used so far, is misguided, inconsistent with the philosophy of social protection and provides a distorted policy direction by only focusing on overcoming the DJSK deficit. We must agree that the purpose of health insurance is to protect the community.
They are the first to be protected from unwanted catastrophic costs. If they are fully dependent on the state, it will undermine sustainability. If they fully follow the market, it will kill social justice. We must find the best way to stand in the middle and balance the two sides.
Ahmad Fuady, Lecturer and Researcher at the Faculty of Medicine, University of Indonesia
This article was translated by Kurniawan Siswo.
