In light of the Supreme Court ruling yesterday, to uphold the Affordable Care Act of the United States, popularly called Obamacare, social media exploded, with lots of views and perspectives on what Obamacare actually means to people.

Nigerian twitter came alive with different perspectives, and of course some extreme reactions wondering why Nigerians should even care or become so engrossed in discussing the pros and cons or any implications of Obamacare.

Computers on, research modes activated and let us see, how Obamacare concerns us and could affect our lives over the coming decade!

Over the last years, the International Health Community and all global health enthusiasts have been ceaselessly working on Universal Health Coverage (UHC). UHC requires that all people get the health services they need without the risk of severe financial problems linked to paying for them. At the same time, the health services people receive need to be of good quality.

UHC with needed health services maintains and improves health. Good health allows children to learn and adults to earn. It helps people escape from poverty and provides the basis for long-term economic development. At the same time, financial risk protection in health prevents people from being pushed into poverty because unexpected illness requires them to use up their life savings, sell assets, or borrow – destroying their own futures and often those of their children. UHC is therefore a critical component of sustainable development.

The three identified impediments to UHC are (i) the availability of resources to any government, (ii) over-reliance on direct payment for health services and (iii) inefficient and inequitable use of resources. The path to universal coverage, then, is relatively simple – at least on paper. Countries must raise sufficient funds, reduce the reliance on direct payments to finance services, and improve efficiency and equity

The 2010 World Health Report, produced by the World Health Organization (WHO) focuses on transforming the evidence, gathered from studies in a diversity of settings, into a menu of options for raising sufficient resources and removing financial barriers to access, especially for the poor. Moving towards universal coverage is the emphasis of this report, a goal currently at the center of debates about health service provision. Promoting and protecting health is indeed essential to human welfare and sustained economic and social development. This was recognized more than 30 years ago by the Alma-Ata Declaration signatories, who noted “Health for All would contribute both to a better quality of life and also to global peace and security”. Health financing is therefore an important part of broader efforts to ensure social protection in health.

The International Health Community unequivocally agrees that continued reliance on direct payments, including user fees, is by far the greatest obstacle to progress in universal health coverage. According to the WHO, abundant evidence shows that raising funds through required prepayment is the most efficient and equitable base for increasing population coverage. In effect, such mechanisms mean that the rich subsidize the poor, and the healthy subsidize the sick. Documented experience shows this approach works best when prepayment comes from a large number of people, with subsequent pooling of funds to cover everyone’s health-care costs.

The obligation to pay directly for services at the moment of need – whether that payment is made on a formal or informal (under the table) basis – prevents millions of people receiving health care when they need it. For those who do seek treatment, it can result in severe financial hardship, even impoverishment. The World Health Assembly resolution 58.33 from 2005 says, “everyone should be able to access health services and not be subject to financial hardship in doing so”. On both counts, the world is still a long way from universal coverage. In some countries, up to 11% of the population suffers severe financial hardship each year, and up to 5% is forced into poverty due to direct payment healthcare costs. Globally, about 150 million people suffer financial catastrophe annually while 100 million are pushed below the poverty line.

The only way to reduce reliance on direct payments is for governments to encourage the risk pooling, prepayment approach, the path chosen by most of the countries that have come closest to universal coverage. When a population has access to prepayment and pooling mechanisms, the goal of universal health coverage becomes more realistic.

To remove financial risk and barriers to access, the WHO maintains that country experience reveals three broad lessons to be considered when formulating policies. First, in every country a proportion of the population is too poor to contribute via income taxes or insurance premiums. They will need to be subsidized from pooled funds, generally government revenues. Second, contributions need to be compulsory, otherwise the rich and healthy will opt out and there will be insufficient funding to cover the needs of the poor and sick. While voluntary insurance schemes can raise some funds in the absence of widespread prepayment and pooling, and also help to familiarize people with the benefits of insurance, they have a limited ability to cover a range of services for those too poor to pay premiums. Third, pools that protect the health needs of a small number of people are not viable in the long run. A few episodes of expensive illness will wipe them out.

Let us now consider ten of the most important benefits, captured in the Affordable Care Act (Obamacare):

  1. Prohibit pre-existing condition exclusions for children in all new plans.
  2. Provide immediate access to insurance for uninsured Americans who are uninsured because of a pre-existing condition through a temporary high-risk pool.
  3. Prohibit dropping people from coverage when they get sick in all individual plans
  4. Lower seniors’ prescription-drug prices
  5. Offer tax credits to small businesses to purchase coverage
  6. Eliminate lifetime limits and restrictive annual limits on benefits in all plans
  7. Require plans to cover an enrollee’s dependent children until age 26
  8. Require new plans to cover preventive services and immunizations without cost-sharing
  9. Ensure consumers have access to an effective internal and external appeals process to appeal new insurance plan decisions
  10. Require premium rebates to enrollees from insurers with high administrative expenditures and require public disclosure of the percent of premiums applied to overhead costs.

The fear of many, and mostly the members of the Middle to Upper class, stem from the expected increase in cost of maintaining their health insurance. This is a typically self-centered reaction of the rich, in my opinion. And with the typical verve and audience they command, all attention is now focused on how Obamacare will potentially increase the cost of healthcare for the middle to upper class. No one seems to have his or her eyes on the real price. A huge barrier on access to care is being removed. More people will have access to insurance or health pre-payments and fewer families will be driven into impoverishment for paying for healthcare. More people will take up a proactive approach to care, by putting aside a dollar today, rather than waiting to borrow exponentially a hundred times more, when they get sick. Your insurance plan is now required to spend at least 80 percent of the premium costs you pay for health insurance premiums on health care or improving the quality of care. If an insurance company spends less than this amount, it must provide a rebate or additional services. The resource pool for providing care, at high quality to all Americans just got bigger.

Obamacare is therefore the first of hopefully many new, high-profile policy decisions that aggressively work towards achieving health for all. Many low- and middle-income countries have shown over the past decade that moving closer to universal coverage is not the prerogative of high-income countries. Brazil, Mexico, Chile, China, Rwanda and Thailand have all taken giant policy steps in addressing the three main impediments to UHC. Gabon, Cambodia, Lebanon and Ghana have all taken steps to address at least one of the key impediments. A high-profile entrant like the US, draws a lot of international attention to UHC, and will serve as lobby loci, to encourage other countries to seriously reconsider their health policies and begin to strive towards UHC.


Where does Nigeria come in?

The Nigerian National Health Bill. Debated by National Assembly (NASS) for over seven years, during which the Nigerian Medical Association (NMA) estimated that 7 million children and 385,000 mothers died, while the bill was debated by NASS. Passed and adopted by NASS in May 2011. Still not signed into law by the President, 13 months later.

Constitutionally, NASS are empowered to push the bill into law, in the face of Presidential delay of signing the bill after a certain number of months. However, the Executive arm of government can veto this move. Some conundrum. I stand corrected on this issue of legislative procedure.

In 2008, Prof. Adenike Grange, in describing the issue of a National health policy, said:

“….the absence of a National Health Act to back up the National Health Policy has been a fundamental weakness which needed to be tackled frontally. This weakness means that there is no health legislation describing the national health system and defining the roles and responsibilities of the three tiers of government and other stakeholders in the system. This has led to confusion, duplication of functions and sometimes lapses in the performance of essential public health functions”

The National Health bill in summary:

  • Seeks to define, streamline and provide a framework for standard and regulation of health services in the country
  • Spells out rights and duties of healthcare providers, health workers, health agencies and users
  • Serves as a guide in the development, promotion and formulation of national and health policies amongst others.
  • Promises to provide all Nigerians with a basic minimum package of health services.
  • Pledges to develop a national health policy that includes 60 billion naira (about US$380 million) devoted to primary health care each year, provision of essential drugs, and comprehensive vaccination programs for pregnant women and children younger than 5 years of age

So, the National Health Bill, is our own equivalent of Policy that can bring us progress as a country, towards Universal Health Coverage, by tackling at least two of the three impediments to health for all, among the other highlighted benefits.

As Obamacare is upheld as law, there can never be a better time to reconvene and lobby for our National Health Bill to be signed into law. This high profile global health success must be milked by all of us, to see that an oversight legislature exists, to improve access to healthcare within this country.

Let us all celebrate this global health success, with the American people and the most vulnerable members of their society. Let us also use it as a stepping stone, to drive efforts to improve our own health through appropriate policy making and implementation!



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