THE IMAGE of the humble sheep as somewhat lacking in initiative has been reinforced during the recent debate over the future of public health insurance in Slovakia. “I am not a sheep; I can make a choice on my own,” reads an advertising slogan used by one of the private companies that provides public health insurance to oppose a plan, directed by Prime Minister Robert Fico but overseen by the Health Ministry, to drive them out of the market and create a single, state-owned public health insurance system by 2014.
Despite Fico’s avowed determination to remove them, the two privately-owned insurance companies are not quite ready to quit the public health insurance market and claim that the government’s plan is at odds with the constitution. Meanwhile, representatives of think tanks and non-governmental organisations in Slovakia have launched what they are calling a mass objection to the plan, arguing that a plural system of public health insurers is more competition-friendly and beneficial for patients.
The Health Ministry delivered its draft project for interdepartmental review on September 26, defining three possible ways to achieve a unitary health insurance system: under the first two approaches the government would agree to purchase the private insurance companies’ shares or to ‘rent’ their clients. If this did not turn out to be possible, expropriation, with appropriate reimbursement, is given as the third option.
The ministry says that purchase of shares in the companies is the best alternative, arguing that by winning full management control over the private insurers the state will also end the court cases that the insurers have launched against the state, according to the draft.
While at this point it is unclear how much the plan might cost the state, which is currently struggling to cut the budget deficit, Health Minister Zuzana Zvolenská told a TV talk show that it is the “best possible investment for the future”. Zvolenská also said that she was confident that the process would be completely constitutional.
“We are ready to carry out this process completely in line with the constitution to the benefit of citizens and in accordance with European law,” Zvolenská said during an appearance on public broadcaster Radio and Television of Slovakia (RTVS) on September 30.
If a share purchase works out, the ministry proposes that the country switches to a unitary health insurance system as of January 1, 2014. If this approach fails and the state decides to nationalise the insurers, then the draft project sets a start date for the switch of July 1, 2014.
An audit is supposed to determine the value of the private insurers, but if they do not give their consent for the audit, the state will set their value based on publicly available information, the document reads, as quoted by the SITA newswire.
The whole process should result in the financial and organisational unification of the three existing public health insurers into a single body. The state will be represented either by the state-run Všeobecná Zdravotná Poisťovňa (VšZP) or the Association for Installing the Unitary System, which will be created only for this single goal. According to the Health Ministry, the legal form of the resulting health insurer could range from a joint-stock company to a public institution. Yet, the ministry argues that it is not the legal form that will be the most important factor, rather the regulations applied to ensure that its finances are handled responsibly and under public control, SITA reported.
Three insurers currently provide mandatory public health insurance in Slovakia. The largest, VšZP, is state-owned and has almost 3.5 million subscribers. The other two are private. The larger of these two, Dôvera, has 1.4 million subscribers, while Union covers another 500,000.
Individuals can decide which insurance company provides them with coverage. Payment of public health insurance premiums is obligatory in Slovakia and those in work, or otherwise economically active, pay them via payroll levies. The state pays the health insurance contributions for economically inactive people such as children, pensioners, women on maternity leave, and so on. The insurance companies order services from individual health-care providers and pay for them on behalf of their customers.
Advocates of a plural system
Meanwhile, think tanks and health-care professionals active in the non-governmental sector have filed a mass objection opposing the plan.
“We consider the switch from a plural system to a single-insurer system a step back and a change for the worse which will affect mainly us, the citizens and patients,” reads the mass objection signed by Peter Pažitný, executive director of the Health Policy Institute (HPI), a health-care think tank, his colleagues Tomáš Szalay and Angelika Szalayová, Peter Gonda, director of the Conservative Institute of M. R. Štefánik, Juraj Karpiš, an analyst with the INESS think tank, Peter Goliaš, director of the Institute for Economic and Social Reforms (INEKO), Ján Marušinec, president of M.E.S.A. 10 Centre for Economic and Social Analysis, as well as Branislav Sepeši, president of the Forum of Independent Opinions. Some representatives of the HPI served as advisers under Rudolf Zajac, a health minister under former prime minister Mikuláš Dzurinda.
The signatories argue that citizens will be denied choice, something they will become aware of when they experience dissatisfaction with the single health insurer. They argue that a plural system of health care better fulfils the needs of patients. They also refer to the European Health Consumer Index, which compares European health systems based on their orientation towards patients. It rates Slovakia, along with the Netherlands, as the best country among 27 where private health insurers operate.
They also argue that “positives pursued by the creation of a unitary system will not be achieved due to corruption, for example through tailor-made public procurement”, while the benefits of the existence of multiple health insurers will be removed, at a cost to the state of millions of euros, according to the mass objection posted on the website Changenet.sk.
One of the main arguments that the Health Ministry, in a statement on its website, cites for the creation of a single insurer is what it calls the high profits made by private health insurers.
The ministry argues that between 2006 and 2011 the private health insurers reported aggregate profits of more than half a billion euros, while their operating costs were only €350 million. The ministry argues that by the creation of a single health insurer, it will be possible to re-channel these funds into the health-care system and thus “increase the quality of health-care provision”, according to the official statement.
The private insurers speak out
The two companies that would be affected, Dôvera and Union, are opposed to the plan and have said that if necessary they are ready to take legal action. Dôvera claims that the project is at odds with the constitution and European law. It is not designed to benefit patients and does not secure any extra funds for health care, Dôvera director general, Martin Kultan, said.
“This project is not a normal project to improve the system of health-care provision,” Kultan said, as quoted by SITA.
In his defence of the existing, plural system of health insurers, Kultan referred to an analysis by the Health Consumer Powerhouse which, according to him, found that countries with plural systems secure greater availability of health care for clients and shorter waiting times than unitary systems.
Kultan described the proposed change to bring about a single health insurer as “senseless”, adding that the state should instead foster competition.
Union too announced, via spokeswoman Judita Smatanová, that it supports the continuation of the existing plural system, arguing that there are no relevant reasons to change the system.
