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Jakarta Post

COVID-19 exposes flaws in Indonesia’s health insurance program

  • Marchio Irfan Gorbiano and Adrian Wa’il Akhlas

    The Jakarta Post

Jakarta   /   Wed, April 8, 2020   /   09:56 am
COVID-19 exposes flaws in Indonesia’s health insurance program Residents wait in line at the Health Care and Security Agency (BPJS Kesehatan) office in Matraman, Central Jakarta On Nov. 11, 2019. (JP/Dhoni Setiawan)

The COVID-19 outbreak has exposed major flaws in Indonesia’s creaking national health insurance program, which has not been able to properly provide services in these desperate times.

With an infectious disease spreading fast across the archipelago, the government has been forced to devise a workaround to ensure that the Health Care and Social Security Agency (BPJS Kesehatan), which administers the government’s National Health Insurance (JKN) program, can reassure the public of its role in the pandemic despite coming up against legal barriers.

Article 52 of Government Regulation (PP) No. 82/2018 on health insurance stipulates that healthcare services are excluded from BPJS Kesehatan’s premium benefits at a time of emergency and extraordinary circumstances (KLB).

With the regulation barring the use of JKN funds to treat COVID-19 patients, Coordinating Human Development and Culture Minister Muhadjir Effendy has instructed BPJS Kesehatan to verify claims of medical bills from hospitals that treat COVID-19 patients and coordinate with the Health Ministry to process the payment of the bills, according to a March 27 letter to BPJS Kesehatan, a copy of which has been obtained by The Jakarta Post.

Muhadjir also instructed BPJS Kesehatan to ensure that COVID-19 patients can get access to medical services, given that many hospitals have secured arrangements with BPJS to treat the insurance scheme’s participants, which could further drain valuable resources required for treating infected patients.

BPJS Kesehatan spokesperson M. Iqbal Anas Maruf said BPJS Kesehatan stood ready to implement Muhadjir’s instruction to ensure hospitals could continue treating COVID-19 patients.

“We’ll obey the Coordinating Human Development and Culture Minister’s decision,” Iqbal told the Post over the phone on Monday. He also said BPJS had allowed hospitals that have existing cooperation agreements with them to direct resources toward treating COVID-19 patients.

The spokesman also pointed to a decree issued by Health Minister Terawan Agus Putranto on Feb. 4 requiring that all costs incurred in treating COVID-19 patients would be paid for by the ministry, regional administrations and any other sources allowed by law, which would ensure that the financial burden of treating the respiratory disease would not be borne by patients.

BPJS Watch advocacy coordinator Timboel Siregar said the provision was included in the government regulation as a result of a preexisting regulation, namely Law No. 24/2007 on disaster mitigation, which requires the government, using its allocated state budget, to guarantee the rights of disaster-stricken citizens. A pandemic is listed as such a disaster.

He said further that BPJS Kesehatan’s hands were tied because of provisions in Law No. 40/2004 on the national healthcare system, which stipulates that the agency can only provide insurance benefits to paying members.

As of March 31, BPJS Kesehatan insured some 222.38 million Indonesians, or 85 percent of the 260 million population.

Technicalities aside, the government must provide assurances to the public that they will not have to bear the cost of medical bills to treat COVID-19, Timboel said.

“We are merely asking BPJS Kesehatan or the government to take responsibility for [COVID-19 patients] who are also participants in [the national insurance scheme],” said Timboel, noting that BPJS participants who were treated as suspected COVID-19 cases but were not yet confirmed cases may find themselves in a gray area when it came to footing the bills.

Indonesian Hospital Association (PERSI) secretary general Lia Gardenia Partakusuma said that hospitals were currently prioritizing the treatment of COVID-19 patients, but the association had yet to receive any reports about hospitals processing claims for infected patients’ medical bills.

She did, however, note that BPJS Kesehatan could help hospitals by footing the bill for insured patients.

“PERSI had received messages from hospitals asking [BPJS] to pay for medical services administered before the COVID-19 outbreak, because they are currently bearing many unexpected expenses,” Lia said.

On World Health Day, which fell on Tuesday this year, the absence of Indonesia’s national insurer from the pandemic response presented another challenge to Indonesia’s struggling healthcare system, as the government scrambled to curb the spread of the contagious COVID-19 disease. As of Tuesday, there were 2,738 confirmed infections and 221 deaths, according to an official tally.

BPJS Kesehatan has had to contend with bleeding finances since its inception in 2014. This took a turn for the worse after the Supreme Court overturned a premium hike for its nonwage recipients (PBPU) scheme.

The PBPU scheme requires workers to independently pay out their monthly fees to the agency, as opposed to the automatic deduction arrangement between workers and employers or direct subsidies from the government.

The court ruling meant that Presidential Regulation (Perpres) No. 75/2019, which President Joko “Jokowi” Widodo signed last year and which had come into effect in January this year, will need to be revised.

Under the presidential regulation, the government doubled premiums for first-class services to Rp 160,000 (US$9.69) per month per person, while more than doubling the monthly premium for second-class services from Rp 51,000 to Rp 110,000 per person.

The premium for third-class services increased by 64 percent from Rp 25,000 to Rp 42,000 per month per person.

The Perpres was issued as part of the government’s efforts to address the persistent financial woes suffered by the agency, which was caused by, among other factors, underpriced premiums, according to a Development Finance Comptroller (BPKP) study last year.

Iqbal of the BPJS said the insurer was ready to abide by the Supreme Court ruling, adding that the government was in the process of drafting a new regulation to make it legal. He also gave an assurance that the agency would return overpaid fees by deducting them from the next payment period.

The government recently unveiled a Rp 405.1 trillion stimulus package to tackle the COVID-19 outbreak and its immediate effects on the country’s economy.

Of that amount, Finance Minister Sri Mulyani said Rp 75 trillion had been earmarked for healthcare spending, including additional capital injections to assist BPJS Kesehatan’s finances following the Supreme Court ruling.

“We hope BPJS Kesehatan will be able to pay all the outstanding bills to the hospitals,” she said recently.