TAK NAK 1CARE!

Healthcare "reforms" called 1Care for 1Malaysia are upon us and it's a truly frightening prospect.

The BN government has been selling 1Care in the MSM throughout 2011, describing it it glowing terms without giving away any details at all. A concerned citizens group called #taknak1care managed to get hold of some insider information and started a Tak Nak 1Care facebook campaign that's picking up steam.

The revelations on their Tak Nak 1Care Facebook page worried the authorities enough that the Deputy Director General of the Ministry of Health, Datuk Dr Hisham Abdullah joined in the discussions on the page to try and do some damage control. However, he has so far been unable to answer or categorically refute any of the information revealed on the page and has been reduced to repeating the mantra of "nothing has been decided yet, but whatever it is will benefit the rakyat".

But interestingly, the Dep DG has acknowledged is that Malaysia is currently about halfway through the 1Care implementation process. This blogger wonders how you can be halfway implementing something that doesn't exist yet?!

As I understand it, 2012 is when the implementation is supposed to be stepped up. Already we see various articles in the mainstream media about the drawbacks of our current healthcare system. This is done so that the rakyat will be conditioned to accept the need for healthcare reform. The laws authorising the 1Care reforms may even be passed this year. So we don't have much time to stop this train wreck from happening.

I won't be discussing the structure of 1Care in this article. For that, please “Like” the #taknak1care facebook page. There is a wealth of information about 1Care there, several intelligent discussions including long discussions with the Dep DG of MOH himself, and new information is posted often. You can also search Youtube for the Tak Nak 1Care videos.

For now, I would just like to explore the problems and questions that arise from 1Care "reforms".

Firstly, I believe 1Care is based on some fundamentally flawed assumptions.

Assumption 1:
The Malaysian government cannot afford public healthcare anymore.

Although the BN government spends significantly less on healthcare (only about 2% of GDP) compared to similarly developed countries, Malaysia is internationally acknowledged for our relatively high level of healthcare. This low cost and high effectiveness shows that Malaysia already has an internationally praised, reasonably efficient healthcare system already in place now. (This is a very important point to remember as you read the rest of this post.)

But despite the low, low government expenditure, the BN government is saying that it can no longer finance even the 2% of GDP for healthcare. It plans to force all rakyat to pay up to about 10% of their monthly income into a Social Health Insurance (SHI) to share the cost. This is ridiculous! Isn't the government's healthcare expenditure funded from taxpayers hard earned money? Why are we being asked to pay again?

The BN government should first solve the problems of leakages, wastages, corruption and runaway outsourcing costs instead of forcing the rakyat to finance their irresponsible ways.

Instead, we see the BN government spending taxpayers on more "important" projects such as the:

- RM 1 billion Mega Tower,
- RM 12 billion PKFZ fiasco,
- RM 3 billion submarines that don't work,
- RM 50 billion MRT project that only covers a few km, etc.

And let's not forget
- the RM 1 trillion in illicit capital outflow from the country.

If the government recovered even a fraction of all these wasted resources, our country would be able to easily finance even expand our public healthcare system for generations to come! But as it is, we can see that the BN government has no intention of halting its wasteful and corrupt practices. They clearly do not have the rakyat's interest as its priorities.

Assumption 2:
The healthcare system needs a complete overhaul

Malaysia currently has a somewhat efficient dual system. There seems to be an unwritten rule among the rakyat that those who can afford it, go to private healthcare providers. Those who can't, go to public providers. The wealthier taxpayers (only 10% of the population) take care of themselves and willingly pay taxes to provide free healthcare for the poorer 90%.

This dual system has worked well for decades (and internationally acknowledged, remember) although it has some problems. But most of these problems can be traced back to government policies and lack of regulation / standards enforcement. These can easily be solved by conscientious government intervention.

The most urgent healthcare problems now are runaway profits and irresponsible public financial management. Solving these two problems should be the first step to any reform. However, it would seem that the govt has little intention to go in that direction. Instead it wants to implement a SHI to wash its hands of its already low healthcare expenditure.

But for the sake of argument, let's assume that the Malaysian healthcare system is really so bad it needs a complete restructuring. There are many other countries whose models have worked very well with little financial burden to the rakyat. But our govt seems to have not explored any other model for the last two decades except privatisation and creating an SHI to pay for it.

Assumption 3:
Privatisation and SHI are the best reform option

In highly privatised places like America, reforms in the shape of an SHI could be a welcome relief. In a privatised system, healthcare is a product, and pricing strategies maximise profits. But healthcare is not normal product – you can choose not to buy a car, but you cannot choose not to have a heart attack. You can return a blouse for a refund, but you cannot return a surgery. These conditions guarantee that healthcare providers will forever enjoy a seller's market!

In such a context, SHI promises affordable universal healthcare in time of need, as long as people put up with a little less spending money every month after the deductions. It's a viable alternative to costly GP visits / prescriptions, long-term care like diabetes, or sudden catastrophic healthcare spending in cases like cancer or accidents.

A well implemented SHI could also function as a disciplinary tool for healthcare providers. SHIs can demand quality and accountability from healthcare by limiting payments for bad healthcare practices and irresponsible finances. Of course, it has its drawbacks, but it's still better than private healthcare being priced out of many people's affordability.

But Malaysia does NOT have a completely privatised healthcare system that an starting an SHI would improve. So, in order to justify this fundamental policy shift, the BN government is now CREATING the necessary conditions for it by essentially privatising the entire healthcare system through 1Care!! It's like banging your head with a hammer so that you have an excuse to buy Panadol!

Ridiculous!

Of course, now they won't dare to use the “P” word as the rakyat had put up with so much hardship due to past privatisation policies. The popular euphemism now is “AUTONOMY” which allows indivdual government units to decide policies independently without government interference – like pricing policies, for example.

If that's the case, what's to stop government healthcare facilities from acting like for-profit organisations?

Assumption 4:
There will be enough high income earners to significantly contribute to the SHI.

Using GDP growth and macro economic data as an indication of citizens' financial fitness for implementing SHI is flawed. We must take into consideration grassroots conditions such as income disparity, inflation and cost of living as well. Right now, the income disparity is widening, cost of living is skyrocketing and official inflation rates do not reflect the realities on the ground. But looking at macro economic indicators may give the impression that there is a large middle class that can afford a compulsory SHI.

Plus, the government's economic indicators are highly suspect. The official poverty level is determined as RM800/mth household income. But in Budget 2012, the PM acknowledges that households earning less than RM3000/mth have trouble making ends meet. Official figures show inflation at about 3%, but independent studies show that urban inflation is probably at a rate of 10%. This difference is because the government measures inflation rate with prices of goods that are not typical purchases of most Malaysians.

Implementing a univeral SHI based on such vague and confusing financial data could prove disastrous to the rakyat who are already burdened by high costs of living!

The BN government's rush to implement 1Care based on flawed financial assumptions without a proper study of the rakyat's situation only demonstrates their insensitivity and misplaced priorities. Clearly, the rakyat's interest are the furthest from their minds.

Besides the problems these flawed assumptions create, 1Care throws up several issues of concern as well.

Issue 1:
Double taxation, zero additional benefit

The SHI concept itself is ridiculous within the Malaysian context. As explained earlier, we are internationally acknowledged as having achieved a reasonably efficient healthcare system at very low expenditure.

With the introduction of 1Care, Malaysians will now be paying taxes, AND the SHI, AND their private insurance premiums. If the SHI rates were reasonable and the benefits package covered all healthcare needs, many people would probably have no problem with that. The only people unhappy would be the private insurers as they will lose business to the SHI.

But insiders have revealed that insurance companies are included in the MOH's 1Care Technical Working Groups working out the details of 1Care implementation. And since we do not hear any complaints from them even when 1Care implementation is halfway through, we can safely assume that their business has not been threatened.

Insiders also reveal that all our monthly payments to 1Care's SHI only gets us Primary Healthcare (General Practioners / Clinics). Even then, the rakyat STILL has to share the cost (co-pay) for medicines and medical accessories. And tertiary care (hospital / specialist services) is NOT COVERED AT ALL by the SHI. So the rakyat will STILL have to pay out of pocket or depend on private insurance, just like we are already doing now. No wonder private healthcare insurers' are not complaining - their market remains undisturbed by 1Care, right!

How is this supposed to be an improvement over our present system?! Does the BN government really expect the rakyat to roll over and accept being forced to pay twice for a “reformed” system that burdens them with higher healthcare costs but delivers zero extra benefit? 

Issue 2:
Integrating public/private healthcare sectors will drive costs up

Since 1Care integrates public and private primary care services and standardises their fees, there will essentially no longer be any "public" GPs. All GPs will be paid private rates under 1Care (latest information is that it will cost RM60 per visit, billed to the SHI). So we can definitely expect primary healthcare costs to suddenly rise significantly.

1Care GPs are also required to be "jaga pintu" (gatekeepers). No one can see any specialist or be admitted into any hospital without a 1Care GP's say-so. This leads to the big question – since public GP services and rates have been rationalised, will public hospital/specialist services also be integrated and their charges standardised?

This is very likely as it would not be “fair” for government specialists to be paid less than their private counterparts in this new integrated system. The Dep DG of MOH himself hinted at this in one of his comments on the #taknak1care page. Specifically he commented that:

"For a specialist or doctor if I see 10 patients a day or I see 100 patients the salary is the same. If you are efficient you be given more work. This is the system we have now."

Since 78% of hospital beds in Malaysia belong to the government who also handles 74% of admissions, imagine what would happen when all these government facilities start charging private rates under 1Care. Healthcare costs will shoot through the roof! It is also reasonable to assume that most of our uninsured population would no longer be able to afford healthcare under this new 1Care scheme.

What's more, this development will have multiplier effects. One of the effects I foresee is in the insurance sector. Since 1Care's SHI benefits only cover limited GP services, private insurers will have to raise their premiums and limit their payouts to ensure their profitability is not affected by the tsunami of rising costs in tertiary healthcare.

Clearly, the BN government's 1Care reforms will dump the rakyat in the wayside in pursuit of a system that values money more than life.

Issue 3:

Social safety net disappears

Our public healthcare system has always been the primary choice for lower income groups. It is their chance to get good, almost-free healthcare. However, even before 1Care is fully implemented, government hospital charges are now no longer “negligible”. Rooms in some government hospitals now cost as much as private hospitals. Other fees may be much lower than the private sector, but can still run into thousands for a even simple surgical procedure.As it is now, many poor household find it hard to pay for public healthcare - and 1Care hasn't even been fully implemented yet!

In Budget 2012, the PM acknowledged that households earning less than RM3000/mth have trouble making ends meet and a RM500 one-off cash aid makes a big difference. With roughly 60% of Malaysian households earning below this threshold, how can they be expected to contribute up to 10% of their income into 1Care's SHI? How will they be able to afford expensive long-term / tertiary care if there is no longer a public healthcare system? Where do they go if they have cancer, diabetes or are seriously injured in an accident - back to the dukun and sinsei in the villages?

With the floodgates of privatised rates thrown opened, what's to stop our “reformed” 1Care system from going the the free-for-all American way, where any service within the healthcare industry has the potential to be monetised, subdivided and monetised again? Now that the “autonomy” concept seems to be given free reign, government owned units can freely make such decisions without interference from the government and the rakyat won't be able to do anything about it.

Conclusion

These and many other disturbing issues and concerns are turning up bit by bit, as the scope and structure of 1Care are revealed. But so far, the BN government has no answers for the rakyat.

The information gathered (many from documents available online, including government websites) indicates that 1Care will create more problems than it solves. In fact, the implementation of 1Care's SHI concept will actually destroy the efficient system we have now, reverse-engineer for us all the problems of the American privatised healthcare system AND create ALL-NEW problems because of its very limited coverage. 1Care could be the most dangerously ridiculous case of putting the cart before the horse that Malaysians have ever been subjected to by the BN government!

The BN government should fix its own fundamental flaws and get its priorites right first before subjecting the rakyat to such dubious reforms! The BN government should remember that they owe it to the rakyat to provide healthcare and other essential services, instead of washing their hands in the privatisation basin and kicking back to enjoy less work and more money. We've had enough of privatisation policies that forced rakyat to pay through their nose for inefficient monopolies that control phone services, water, electricity, sewerage, waste disposal, postal service, public transport, and the list goes on... Now the BN government wants to privatise and monetise another essential service - healthcare!

The rakyat should not take this lying down anymore. We must not be held ransom to this "You Money Or Your Life" 1Care system. We owe it to ourselves and our children to make sure 1Care is stopped dead in its tracks!

TAK NAK 1CARE! Join the movement, spread the word.