The government insists that the proposed low-cost benefit options (LCBOs) do not adequately cover low-income members of the population, arguing that the proposals would only line the pockets of medical aid schemes.
This is as the multiyear fight by the Board of Healthcare Funders (BHF) to force the Council for Medical Schemes (CMS) to introduce LCBOs looks set to go down to the wire after the Pretoria high court on Tuesday ruled against it in its push to introduce the benefits in the sector.
The government, in its opposition to the legal challenge brought by the BHF, emphasised the centrality of the National Health Insurance (NHI) to health policy. It told the court that now that the contentious NHI has been legislated it will make provision for adequate coverage to low-income members.
The department also argued that in the present context LCBOs will provide “something less than the prescribed minimum benefits”, the government said.
“The result is that after exhaustion of a very limited package of healthcare services, the LCBO will fall back into the public health system.”
The BHF, which represents more than 30 members, including Bonitas, the Government Employees Medical Scheme and Medshield, said it would appeal the decision of the high court, which ruled, among other things, that it is not in the public interest.
The network of healthcare funders pointed out that despite nearly half of SA’s population relying on private healthcare in some form, most of them are forced to pay out of pocket for these services, with 30% of uninsured South Africans using private healthcare providers as their first point of care, according to 2020 survey data by Stats SA.
“Our intention in compelling the CMS to permit medical schemes to offer [LCBOs] is to enable broader access to affordable private medical cover for lower-income South Africans,” the BHF said.
"[LCBOs], which are pared down medical aid packages, represent an immediate, practical and sustainable solution to expand private healthcare access to an additional 10-million South Africans who can’t afford full medical scheme cover, but are paying out of pocket expenses for private healthcare providers.”
The BHF’s legal challenge is based on the argument that the CMS is unlawfully exempting health insurance providers from compliance with the Medical Schemes Act by imposing a moratorium on medical schemes offering LCBOs.
The medical schemes regulator last week announced a two-year extension to the demarcation exemption renewal framework under which a limited group of 11 licensed health insurers may continue selling these policies.
The BHF responded by challenging the CMS in court urging it to make a final call on the future LCBOs and to declare the extension of the demarcation regulations unlawful.
While pundits argue that LCBOs would ease the burden on state healthcare facilities, critics, including health minister Aaron Motsoaledi, have raised concerns about how LCBOs will fit into the state’s NHI ambitions — a theme government stressed in its dispute with the BHF.
The CMS welcomed the judgment. CMS registrar Musa Gumede said it believed the high court’s decision “reaffirms the CMS support to collaborating with the entire private healthcare industry to address policy dimensions concerning primary healthcare in the private healthcare sector”.
The court agreed that BHF had not proved it was “genuinely acting in the public interest of identified medical schemes and their subscribers”, the regulator said.
“The CMS does not necessarily claim or see this as a victorious moment. We have extended a hand to BHF on several occasions to resolve their displeasures with our policy and regulatory decisions as highlighted by the court,” Gumede said.
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