BPJS: Who Benefits the Most?
A fundamental change in BPJS will be a risk for the wider community. To restore BPJS to its condition decades ago after the long journey where BPJS has evolved would be a setback.
Discourse on the need for changes in the management of health care social security funds has been raised lately.
Kompas daily in a relatively close time period published three articles related to this issue. Joko Mulyanto (10/12/2022) discussed the importance of the principle of social insurance, so that the term " Health Insurance for Rich People " would be considered inappropriate. Laksono Trisnantoro (13/12/2022) highlighted injustice and who enjoyed the most benefits of the national health insurance, the Healthy Indonesian Card (JKN-KIS) so far. Then, Ahmad Fuady (2/1/2023) emphasized the risk approach, namely participants with more risk have to pay more.
Understanding and perception
The discourse is getting increasingly louder on social media because there was a celebrity falling ill who had to pay expensive care costs at the hospital. The commercial insurance he had only covered a small portion of the costs.
The steps of the patient's wife who raised funds were criticized by citizens because he was a rich man. Citizens also questioned why they did not use the Social Security Management Agency (BPJS).
According to the writer, the discourse appears because of different understandings and perceptions, as well as mixed ideas, in the concept of health financing.
There are several health-financing systems known in the world. There is a tax-based system and there is a system based on social insurance with mutual cooperation and contributions. There are also countries that are dominated by commercial and multi-payer insurance, such as the United States, or dominated by an out-of-pocket financing system, such as in many developing countries.
Also read:
> Health Insurance for Rich People
> Industry 4.0 and Health Services
In short, in the tax-based health-financing system, the financing is almost all obtained from taxes. Usually, the technical ministry submits the amount of financing needed, which is then sent to the House of Representatives for approval. The amount depends on various factors, including fiscal capacity, global economic condition, needs and interests.
The technical ministry that takes care of it is usually the Health Ministry so that, in terms of equity, this tax system is generally better even though in terms of quality, it becomes a challenge. Citizens are currently demonstrating against the system in the United Kingdom, with a tax-based National Health Service (NHS), which is certainly better than the one in the US, which adheres to the market and multi-payer systems.
The financing of the social health-insurance system, such as JKN in Indonesia, is not sourced from taxes, and also not from commercial-market premiums, but from the contributions of participants with the concept of mutual cooperation. The employers have an obligation to pay contributions for workers, in addition to the workers themselves who also pay contributions as participants.
One is considered a participant if one registers and pays contributions. For those who are poor or underprivileged, contributions are subsidized or paid by the government.
The global economic situation has not much influence on financing in this system because it is more determined by the condition of existing social security funds. The cost of health services every year does not need the approval of the House. The approval is given by the council representing various interest groups, such as employees, entrepreneurs, community leaders and the government.
The owners of the fund are the participants. The manager is not among the owners, but those who are given the trust or mandate to manage the participants’ funds in a nonprofit orientation, in contrast to private insurance, which is oriented toward profit.
Regulators are tasked with maintaining a balance between the social health-insurance organizing agency, health facilities and participants. It is automatic that there is a clear separation between the buyer and the provider of health service so that the quality of service is relatively better.
Social insurance system
The tax-based health financing system can actually budget only for the poor or disadvantaged. In this case it is certainly not appropriate if there is an assumption that the rich are the ones who utilize it more.
Indonesia with the 1945 Constitution Article 34 paragraph 2, Law No. 40/2004, Law No. 24/2011 and various existing laws and regulations has decided and agreed on a health-financing system, especially for individual health, which uses social security programs with the application of social health insurance managed by BPJS.
BPJS does not only manage health, but also other social-protection programs, such as death, work accidents, old age and retirement. Because of the philosophy of funds owned by participants, not the tax budget, it is understood by the law as a direct derivative of the 1945 Constitution, that in an organizational structure, BPJS is directly under the President, by working together and reporting to several ministries and institutions.
BPJS data
The latest BPJS data show who has enjoyed the most benefits of the program. Conclusions were drawn and analyzed from around 95 million advanced health-service utilization data in the November 2021 service month to September 2022. The group of participants included recipients of contribution assistance (PBI), wage recipient workers (PPU), non-wage recipient workers (PBPU) and non-workers (BP).
It can be seen that the group that utilizes the most health services in BPJS is the PBI group with the number of cases of utilization at more than 31 million. BPJS costs incurred for this group are also the largest, more than Rp 27.5 trillion. This is successively followed by PPU, PBPU and BP, such as retirees or celebrities. Even though PBI participants make up the largest group, the utilization of services and costs incurred by this group is also the largest.
Also read:
> Ensuring Healthcare Services
Of course, these data need to be analyzed further. Likewise, the number of cases of heart disease, i.e. a disease with a large cost or catastrophic consequences, also mostly occur in PBI. The biggest costs of heart disease incurred by BPJS Health are greatest for PBI. At first glance, PBI is the most benefited, or at least JKN funds are most widely used for the group of PBI participants.
Not that the issue of equity is no longer a problem, but the current situation is far from the early time when the BPJS was established, especially when there was a deficit and it was considered unfair. The problem of injustice is certainly also linked to the existing regional conditions. The speed of development is different among the regions in Indonesia, and this is what the government continues to overcome.
Government-private sector cooperation
Data show the utilization of BPJS has improved according to the direction and mechanism of mutual cooperation and its targets. Community satisfaction increases sharply, and health facilities are increasingly competing to work together. National, regional and international recognition and appreciation, such as from the ASEAN Social Security Association (ASSA), International Social Security Association (ISSA) with 160 countries, World Bank and Joint Learning Network with about 30 member-countries are increasingly felt.
Even though BPJS is getting better and no longer maintaining a deficit, continuous improvement needs to be done in order to achieve optimal balance and benefits. The support of all parties is needed. The potential for community financing, especially from those who are able, needs to be optimized.
Public-private sector partnership needs to be built better, with coordination of benefit (cooperation among guarantee organizers can be optimized). How can all Indonesian people become BPJS participants, with their health protected? How about those who are able, and those who want to be more able, to move up a class or utilize services that are more than needs?
To restore BPJS to its condition decades ago after the long journey where BPJS has evolved would be a setback.
Comfort and demands for more services can be more accommodated. Innovation and development of services toward personized care in the dense modern medical technology can be achieved. Thus, BPJS and private commercial insurance can work together to strengthen each other to reduce foreign exchange, which amounts to US$11.5 billion per year, because many Indonesian citizens choose to seek treatment abroad.
Data show BPJS is on the right track. This social security program is probably the only form of real mutual cooperation for the nation that is felt by the wider community and it is felt strongly that the state is present in it. A fundamental change in BPJS will be a risk for the wider community. To restore BPJS to its condition decades ago after the long journey where BPJS has evolved would be a setback.
Awareness of all parties is required that improvement is needed, but change should not happen without fundamental thinking and clear rationality, in terms of philosophy, social, judicial and practical.
Ghufron Mukti
Ghufron Mukti, President director of Health Care and Social Security Agency (BPJS Kesehatan), Former head of the preparation team at BPJS
This article was translated by Hyginus Hardoyo.
