The Lebanese health care coverage landscape is an imperfect patchwork. The Health Ministry covers those who lack any coverage or are ineligible for coverage, estimated at 1.4 million citizens, the National Social Security Fund covers private sector employees and their dependents, the Civil Servants Cooperative covers public sector workers and their families, the Army and various security forces each have their own cooperatives. For those able to afford private insurance premiums, choices abound when you’re young and fit, but they tend to narrow as you age.As our population ages, along with many others in the developing world, Lebanon will face ever rising health care costs.
The elderly, retired employees or those at the lower end of the socio-economic scale can barely afford the ever-rising cost of premiums that private insurers impose, few elderly persons are eligible for coverage and if they are eligible it’s often with many exclusions due to pre-existing conditions.
Caretaker Health Minister Ghassan Hasbani told The Daily Star that it was unlikely the country would achieve universal health coverage for its uninsured population during his lifetime.
Out of the LL650 billion ($433 million) budget his ministry asked for, it got just LL400 billion.
But during his tenure, Hasbani remains committed to former Health Minister Wael Abu Faour’s commitment to cover 100 percent of the medical bills of uninsured elderly citizens over 64 years old.
“A very significant number [of the uninsured elderly population] will end up hospitalized at the expense of the government, which will add exponentially to the cost of health care over the next 20 years,” Hasbani said.
According to figures published in the ministry’s Health Strategic Plan 2016-2020, total health expenditure for 2012 (the latest figures on the Health Ministry website) topped LL4.6 trillion. This includes out-of-pocket payments, contributions and premiums from individuals and employers, treasury expenditures and extra-budgetary donations or loans.
The Health Ministry accounted for 31 percent of total expenditure on health care that year (LL647 billion).
Dr. Ghassan Maalouf, vice president of medical affairs at Bellevue Medical Center hospital in Mansourieh, and an orthopedic surgeon with particular interest in geriatric care, said that the global population was aging, and that by 2025 1.2 billion people would be over 65 years old, and by 2050, that number would rise to 2 billion.
“Seventy-five percent of this aging population will be in the developing world and it’s already a financial burden. This demographic transition requires a shift in care systems toward preventive medicine and addressing the needs of elderly patients,” Maalouf said.
According to the ministry’s Health Strategic Plan 2016-2020, health care expenditures did come down in recent years from 12.4 percent of GDP in 1998 to 7.4 percent of GDP. Out-of-pocket contributions have also come down from 60 percent to 37 percent of total health care expenditure. This was achieved due to a targeted strategy that saw strengthening of primary health care and the creation of a unified beneficiaries’ database as well as setting a financial ceiling for every contract between the Healthy Ministry and private hospitals.
Hasbani stressed that Lebanon ranked 32nd worldwide in quality of health care services and was ranked first in the Middle East. This year saw 380,000 hospital admissions at the expense of the Health Ministry so far. “We received reports of 2,000 problematic cases, either people refused entry or having problems with entry to hospital,” Hasbani said, adding that in many cases the particular hospital’s financial ceiling under the Health Ministry contract had been reached, or the patient did not require hospitalization or the patient had other coverage and was ineligible for Health Ministry cover. He stressed that these cases accounted for less than 1 percent of hospital admissions under Health Ministry cover.
Sensing a need in the market, health mutual funds have stepped in to meet the needs of those no longer covered by the NSSF, the CSC or other professional cooperatives, those who cannot afford to pay full commercial insurance rates, but who do not want to risk not being covered and to be at the mercy of the hospital-Health Ministry relationship and financial ceilings.
Ghassan Daou, president of the Union of Health Mutual Funds in Lebanon, said there were 64 health mutual funds in Lebanon today serving between 360,000 to 370,000 subscribers/members who would otherwise be without coverage and an added burden on the Health Ministry. “We were set up to serve the needs of the people who are worried about lack of coverage and are unable to afford the high cost of commercial premiums,” Daou said. Being a not-for-profit organization, a health mutual fund is not subject to taxation and does not have high profit margins to satisfy shareholders, this gives such funds a competitive edge.
“If the government did its job in providing universal health coverage, we wouldn’t be here,” Daou said. Asked about the Health Ministry pledge to cover the total health costs of the over-64s who are without coverage, Daou said: “There is a big gap between theory and application. Will hospitals accept [Health Minitry] patients considering the ministry still owes hospitals LL780 billion in unpaid dues?”
Daou is director of the Social Democratic Health Mutual Fund, which was set up in the early 1990s. Today it has between 7,000 and 8,000 subscribers. Health Mutual Funds were set up under Presidential Decree 35/77 which allowed groups of people to form cooperatives to arrange medical coverage for all members at affordable rates through commercial insurers and reinsurers. Such funds rely on subscriber contributions and aim to create a balance between young and elderly members. They often require an elderly member to join as part of a family group that includes younger members. This ensures that the money coming in is sufficient to cover the health care and hospitalization needs of all its members, which tend to be higher among elderly members.
“When we are talking about health care coverage the integral factor has to be funding. Today, people belonging to mutual health funds account for 9 percent of the covered population in the country,” Daou said. These types of funds are quickly gaining popularity in Lebanon, especially among the elderly segment of the population, for whom affordable coverage is difficult to get.
“As rates go up with each passing year and since NSSF health coverage stops at retirement, it leaves many elderly people uncovered,” Daou said. Premiums typically charged by these funds are lower than those charged by commercial insurers to individual applicants. Health care premiums for those over 80 years old can go as high as $5,000 a year, and sometimes more, which many retired people living on a tight budget can barely afford.
“We fought hard with reinsurers to remove exclusions for pre-existing conditions for our subscribers, and instead we just placed monetary limits on payouts for certain conditions,” Daou said, admitting that monetary limits are also placed on new subscribers to the fund who haven’t contributed as much to the fund as existing long-standing subscribers.
Dr. Maalouf pointed to the need for both private and public health care providers to work together to improve quality of life for the elderly, a segment of the population for which comorbidity increases and costs are very high.
Dr. Maalouf said he was working hard to promote multidisciplinary geriatric medicine in the country, promoting primary prevention by creating awareness among the elderly, hygiene, exercise and a healthy lifestyle, recommending an increase in the number of nursing homes and beds in the country. Both Dr. Maalouf and BMC firmly believe in person-centered care. BMC is the first hospital in Lebanon and the second in the Middle East to achieve Planetree certification for person-centered care.
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