Healthcare deficit: A Fundamental right unhealthily managed by Jokowi’s government

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Independent-Observer HEALTHCARE DEFICIT

IO, Jakarta – The existence of the Social Security Organizing Agency (Badan Pengelola Jaminan Sosial – “BPJS”) Health service has proved to be a great boon for Indonesians. The weak and chronically ill, those who suffer major diseases (especially the millions of low-income citizens), de­pend on Health BPJS for their surviv­al. Health is everyone’s constitutional rights, and there must be no discrim­ination in health services. The people have a right to affordable medical care, and the State must be present and ful­fill the people’s needs through Govern­ment action.

Unfortunately, since it was fist established 5 years ago, Healthcare (BPJS) continuously suffered deficits. It has been like a chronic disease in itself: first, a deficit of Rp 3.3 trillion in its initial year. In 2014, the deficit continued to increase to Rp 5.7 trillion in 2015. It later became Rp 9.7 trillion in 2016 and Rp 9.75 trillion in 2017. Deficit for this year is projected at Rp 16.5 trillion. This amount was later corrected to a “mere” Rp 10.98 trillion, according to the calculations of the In­donesia’s National Government Inter­nal Auditor (Badan Pengawas Keuan­gan dan Pembangunan – “BPKP”).

Note that before 2014, there were four health security providers: Em­ployees Social Security System (Ja­minan Sosial Tenaga Kerja – “Jam­sostek”), Retirement Savings and Insurance (Tabungan dan Asuransi Pensiun – “Taspen”), Indonesian Armed Forces’ Social Insurance (Asu­ransi Sosial Angkatan Bersenjata Re­publik Indonesia – “Asabi”) and Health Insurance (Asuransi Kesehatan – “Askes”). However, on 1 January 2014, these four health security providers were merged and transformed into a single public legal entity called “Health BPJS”. Established according to the provisions of Law Number 24 of 2011, BPJS has the purpose of running the national health security program in accordance with the mandate of Law Number 40 of 2004 covering the Na­tional Social Security System (Sistem Jaminan Sosial Nasional – “SJSN”).

The number of Health BPJS par­ticipants as of mid-September 2018 was more than 203 million. About half, or 92.4 million people to be more specific, are “Fee Aid Beneficiaries” (Penerima Bantuan Iuran – “PBI”) or poor people. The fees they must pay would naturally be on the low end, a mere Rp 25,500.00 a month. And it’s not the poor people themselves who must spend their own money, but the Government that pays for them, through the State Budget or Regional Budget. Other than PBIs, people such as Civil Servants (Pegawai Negeri Sipil – “PNS”), members of the armed forces (TNI) or the police, as well as privately employed people, must pay premium with their own money.

Health BPJS is based on a principle of a balanced budget, wherein expen­diture items must be equal to income items. Unfortunately, this principle is only a concept on paper, as there is a significant gap between income and expenditures. This is why deficits bulge, year after year.

Chronic Deficits
According to Timboel Siregar, Ad­vocacy Coordinator of BPJS Watch, the Health BPJS deficit continues to rise. This has a ripple effect through other factors, especially towards pa­tients who would be getting substan­dard treatment, as proven by Regula­tions of the Director of Health Services Numbers 2, 3, and 5 of 2018. Regula­tion Number 2 concerns treatment of cataracts, Number 3 concerns healthy newborn babies, and Number 5 con­cerns medical convalescence. These regulations were issued for the pur­pose of cost efficiency of up to Rp 360 billion, but run the risk of decreasing benefits to participants. The damage was done, even though the United Indonesia Doctors’ Association (Per­satuan Doctor Indonesia Bersatu – “PDIB”) finally applied for a judicial review at the Supreme Court.

“We pushed for immediate revo­cation of this regulation in order to prevent the necessity of cutting ser­vices to others. For example, med­ical rehab sessions can be covered more than twice a week if the doctor thinks it necessary. This is because the Regulation of the Director of Health Services Number 5 of 2018 limits coverage to twice a week, and any extra session must be paid for by patients themselves. This means reduced benefits. The same thing with cataracts: according to the doc­tor, a cataract is matured and needs to be operated on. Now the visibility rate must be measured first. If the limit is not yet reached, the patients must cover costs of the operation by themselves. Furthermore, there was a decision that BPJS would no longer cover medicine for HER2 Pos­itive breast cancer per 1 April 2018. The medicine can cost up to Rp 25 million per ampoule. Ms. Yani, a suf­ferer of HER2 Positive breast cancer and Health BPJS participant, took this case to the courts. Finally, the Government covered costs for this medicine again. This regulation is ineffective – we could have resolved something like this by strict monitor­ing,” Timboel said.

Other than affecting participant services, the deficit results in de­layed payments to hospitals, which damages their cashflow stability. Hospitals started to find it difficult to buy medicine, pay for health equipment, and pay for the services of paramedics, doctors, and nurses. Timboel said that the Health BPJS deficit is caused by several things. First, the input, i.e. the fees. Partic­ipants cannot afford to fund expen­ditures. There are 4 types of expen­diture: first, the Indonesian Case Base Groups (INA-CBG’s), which is a payment package from Health BPJS to hospitals. That’s about 84% of to­tal expenditure. Second, capitaliza­tion funds, i.e. payment to first-level health facilities (fasilitas kesehatan tingkat pertama – “FKTP”) such as community health centers (pusat kesehatan masyarakat – “puskes­mas”), health clinics or family doc­tors. Third, Health BPJS operational funds, such as wages for the Board of Directors and employees, and oth­er operations such as building main­tenance, etc. Fourth, expenditures made to cover prevention promotion – relatively little.

Input is insufficient, because fees from Health BPJS participants do not increase. Presidential Regula­tion Number 111 of 2013 Article 16 (1) states that fees shall be reviewed at least once every 2 years. The poor who cannot afford to pay the fees will have their coverage paid using the PBI scheme, which is allocated to 92.4 million people. In 2014, the fee for a single PBI participant per month was Rp 19,225.00. In 2016, the amount increased to Rp 23,000.00, because 2 years had passed. In 2018, the fee should have increased to Rp 36,000.00, but it did not rise. This Rp 36,000.00 is the economic price ac­cording to actuarial experts. There is a Rp 13,000.00 difference between the economically viable fee and the actual fee. Multiplied by 92.4 million people equals Rp 16 trillion. The State Bud­get cannot afford to fund this much. Therefore, the funds from State Bud­get that Health BPJS actually receives do not cover the actual costs for health services.

Fees coming in from the people have not increased. In 2014-2015, fees for 1st Class were Rp 63,000.00 per month; in 2016 the fees in­creased to Rp 80,000.00. Fees in 2018 were not increased, because that Rp 80,000.00 was already an economic price. 2nd Class fees in 2014-2015 were Rp 42,000.00 per month, increasing in 2016-2017 to Rp 51,000.00 per month. There should have been an increase in 2018, but there was none. 3rd Class fees were Rp 25,500.00 in 2014-2015, increasing to Rp 30,000.00 in 2016. However, there were a lot of protests from the people, so that a month later President Joko­wi amended Presidential Regulations Number 19 of 2016 to Presidential Regulations Number 28 of 2016 that stated that the fees must remained at Rp 25,500.00 per month, as 3rd Class patients are deemed unable to pay up to Rp 30,000.00 per month.

Second, FKTPs fail to keep referral levels low. In 2017, the average na­tional referral from clinics, Puskesmas and family doctors to hospitals was 12.5%. However, in September 2018 this number increased to 16.3%. FKTP is paid out by Health BPJS using cap­italization funds, and only after that can Health BPJS serve participants. The increase of referrals from FKTP to hospitals shows that the previous­ly-capitalized FKTPs fail to keep refer­rals down.

This failure is caused by insuf­ficient monitoring from the Health Office and Health BPJS. Capitaliza­tion funds are not optimally deployed by Puskesmas. After all, the Audit Board of Indonesia (Badan Pemeriksa Keuangan – “BPK”) found in 2017 that capitalization funds at Rp 3.1 trillion remained idle as unused budget ex­cess (sisa lebih penggunaan angga­ran – “silpa”), which means that the funds were not used to buy health equipment or better-quality medicine. Therefore, the quality of treatment be­comes questionable, and patients once diagnosed are finally referred away.

Data from 1 January to 30 Sep­tember 2018 show that total Health BPJS coverage claimed, not including operation costs, was Rp 68.85 tril­lion. This does not include INA-CBG’s (payment packages from Health BPJS to hospitals), capitalization funds, Health BPJS operational costs, and the relatively low costs of prevention / promotion.

There are two types of INA-CBG’s: advanced level outpatient treatment at Rp 20.1 trillion and advanced level hospitalization at Rp 37.7 trillion, for a total of Rp 57.8 trillion. Capitaliza­tion funds for outpatient treatment first-level are Rp 10.17 trillion. Capi­talization funds for first-level hospital­ization are Rp 784 billion. If we total all costs, Rp 10.17 trillion plus Rp 0.78 trillion would be about Rp 10.88 trillion. Expenditures for prevention / promotion are Rp 145 billion, or only about 0.2 %. “This means that expen­ditures pile up in hospitals. That’s why Puskesmas remain calm and do not protest: they receive the capital­ization funds but they do not optimize them. Therefore, it is true that FKTPs, especially Puskesmas, do not optimize the use of these capitalization funds. Therefore, the Government must monitor the expenditure of the capi­talization funds,” Timboel said.

Third, the Board of Directors fails to properly collect backlog fees from participants per month. The partici­pants are not disciplined for not pay­ing their fees, causing a backlog orig­inating among others from Regional Governments that pay the Health BPJS fees for Regional Civil Servants and Regional Health Security (Jami­nan Kesehatan Daerah – “Jamkesda”) fees of about 25.7 million the poor. On 30 September 2018, Regional Governments still had a backlog of payments for Regional Civil Servants’ Health BPJS fees at Rp 163.85 bil­lion and for paying Jamkesda at Rp 621.66 billion. Other than the Region­al Government backlog, there is also private company backlog payments at Rp 313.98 billion per 31 September 2018. Further, Non-Salaried Work­ers (Pekerja Bukan Penerima Upah – “PBPU”), or independent participants, have a payment backlog pf Rp 1.99 trillion, which is the biggest amount. Therefore, total backlog is per 31 Sep­tember 2018 Rp 3.09 trillion.

“The Board of Directors’ perfor­mance is also appraised by the in­crease in the number of participants. Health BPJS is social insurance based on the law of large numbers, i.e. the more participants, the more fees be­ing paid, and the bigger the capacity to fund health treatments. Now we have 203 million partic­ipants, with a target of having 250 million par­ticipants by 2019. This is the Board of Directors’ responsibility,” Timboel said.

The next issue is related to monitor­ing processes. Deficits occur not only because we are still unable to realize optimum income from fees, but be­cause expenditures are also suspected to be fraudulent. The Government has identified 9 types of common frauds, one of them being improper re-admis­sion. In this case, some hospitals (not all) treat patients Health BPJS for only 3 days and have the patients return a week later, while these patients should have been treated until they heal com­pletely. Therefore, they can make more than one claim during the treatment of these patients until they heal. Another example is when a privately employed person gets injured at work, but his treatment is funded Health BPJS in­stead of Employment BPJS. This kind of thing drives the costs of Health BPJS up.

“Therefore, Health BPJS’ Board of Directors are still unable to increase fees nor control costs, causing a defi­cit of Rp 16.5 trillion as of the end of December 2018. This is comprised of Rp 12.1 trillion deficit during 2018 alone, plus Rp 4.4 trillion in 2017. If the Government and Health BPJS fail to resolve this, the 2018 deficit will be carried over to 2019. A lot of things contribute to the deficit, for exam­ple Board of Directors fail to monitor timely payment of fees from Regional Governments. Health BPJS needs to monitor private hospitals, the Ministry of Health must monitor central hospi­tals, and Regional Health Offices must monitor regional hospitals. In short, fees must be monitored,” Timboel said.

Health BPJS, Attorney General, and labor monitoring should be assigned to monitor private companies in order to ensure that their employees are part of the Health BPJS scheme and that they do not accumulate a backlog of fee payments. However, in fact there are about 1.1 million Employment BPJS participants not enrolled in Health BPJS. Everybody needs to work on this issue. The Ministry of Home Affairs has not managed to monitor Regional Gov­ernments, as many Regional Civil Ser­vants have a large amount of indebted Health BPJS fees. Jamkesda, which is managed by Regional Governments, also has a high level of backlog pay­ments. Even though the Government has paid out Rp 4.9 trillion for Health BPJS from the State Budget, it has not resolved deficit issues due to the great amount.

In 2014 deficits were Rp 3.3 tril­lion. In 2015, the Government paid out aids in the form of State Investments (penyertaan modal negara – “PMN”) at Rp 5 trillion. After the investment, there is still a deficit of Rp 5.7 trillion, which necessitated another round of PMN aid at Rp 6.8 trillion in 2016. More deficits in 2016 cause another round of aid at Rp 3.6 trillion in 2017. Deficits continue in 2017 at a small­er amount (Rp 4.4 trillion), which is carried over into 2018. As we predict another deficit in 2018, the Govern­ment provided another Rp 4.9 trillion in support.

“Therefore, deficits occur every year, and additional Government coverage also occurs every year. Why is it noisi­er and more dramatic this year? That’s because the deficit has accumulated greatly over the years, causing Health BPJS to fail to pay huge outstanding debts to hospitals, causing the hospi­tals to scream in protest. The President heard this and reprimanded BPJS, and found out that per 17 September 2018 there is a Rp 7.05 trillion payment backlog from Health BPJS to hospi­tals. The Government finally paid out Rp 4.9 trillion in aid. Yet not all hospi­tal bills are paid out. Therefore, BPJS Watch pushes for Stage 2 Bailout from State Budget funds to ensure that the 2018 deficit is completed and all hos­pitals get paid in full,” he said.

Meanwhile, Dr. Kuntjoro A. P., M. Kes, General Chairman of Indonesia’s Hospital Association (Perhimpunan Ru­mah Sakit Seluruh Indonesia – “PER­SI”), said that Health BPJS deficit stretched all the way from the start: first, participants’ fee payments are far from reaching the amount calculated at the time. This means that the pre­mium fees must be adjusted, prefera­bly once every two years. Second, the benefits covered are reduced, even though many people need coverage. Third, the Government must keep on covering deficits.

“To resolve this, the Government must create an actuarial team to en­sure clarity in risk identification and management. Hospitals themselves have their hands full of trying to pro­vide service, improve, and adjust to adverse situations over years,” Dr. Kuntjoro said. “The most important thing is the fact that many PBPUs have payment backlogs. Only 54% pay their fees routinely. If we can get everyone to pay in full, the deficit could be at least mitigated.”

Drg. Eddy Sumarwanto, Vice Sec­retary General of PERSI, states that Health BPJS deficit is predictable, because existing Health BPJS funds are insufficient to cover all needs and claims according to the tariff set by the Indonesian Case Base Groups (INA-CBG’s). “We have several options for mitigating Health BPJS’ negative cashflow. If the Government is will­ing to be open about it, there is good reason to increase premium fees. Then there must be an obligation for middle-class people to pay for their health costs. There must be strict lim­its of the amount covered by BPJS for them. More than that, they must pay their own health costs. For example, if there is a Rp 40 million subsidy for heart operations and the patient uses up Rp 70 million, the middle-class pa­tients must pay the remaining costs. The poor, the PBI beneficiaries, must be free from all payments,” he said.

As for the backlog payment of BPJS participants, it is true that it is too difficult if Health BPJS enforces payments all by itself. There should be a connected system that involves other parties, so that they would sup­port each other in the collection and administration of payments. “Health BPJS does not have the power to sanction participants who accumu­late backlog in payments,” kata Drg. Edi said.

Putih Sari, a member of Commis­sion IX of the People’s Representative Council (Dewan Perwakilan Rakyat – “DPR”) from Great Indonesia Move­ment (Gerakan Indonesia Raya – “Gerindra”) Party, said that Health BPJS deficit is a complex yet antici­pated problem. Actuarial calculations show that premium fees are insuffi­cient and far from being ideal. “Ideal­ly, premium fees should increase reg­ularly. However, this is also a political issue as the Government still has not dared to increase premium fees until now. This is something urgent that needs to be decided soon,” she said.

As for backlog premium payments, Putih said that the collection of fees has always been troublesome, espe­cially from PBPU participants. It is difficult to enforce discipline in pay­ment of fees, because there are no actually strong, binding rules.

Social Security Expert Chazali Situmorang said that deficit occurs because of two factors. First, the amount of the fees does not cover health service costs. “I would calcu­late that in order to ensure the con­tinuation of this program, everyone must pay an average Rp 52,000.00 a month. As for PBI, whose cur ­rent fee is Rp 23,000.00, they really should be paying Rp 36,000.00. “The current amount of Rp 23,000.00 is not enough cover. There is a Rp 13,000.00 gap. With the number of PBI beneficiaries being 92.4 million, the gap would be Rp 14.4 trillion,” he said.

Secondly, we need to verify hos­pital bills, because many claims are made that are not in accordance with the actual treatment provided. For example, the participants are not op­erated on, but reports said that they were. This means that there is a pay­ment inflation. “There is this element. Therefore, if we really want to resolve deficit issues, we must resolve the two issues simultaneously: increase fees and discipline claims,” Chazali said.

As for participants with payment backlogs, Chazali said that most are independent participants, i.e. infor­mal workers. But penalty regulations are now in place. “When the person gets sick and uses BPJS claim, s/he will be fined according to the amount s/he owes. S/he will still be treated, but only after s/he settles the back­log payments. It’s not easy to catch a hold of independent participants, be­cause they often do not have a fixed address,” he said.

The President’s Dilemma
According to Presidential Regu­lation, premium fees must rise once every 2 years. However, there is no increase this year. Many believe that this is because the President is in a dilemma due to the fact that this year is a political year, so the President must make all decisions extra-care­fully. “The President must evaluate everything carefully. Such as the oth­er day, the Government subsidized Rp 4.9 trillion for Health BPJS. It’s a bit slow, but that’s just being care­ful,” Dr. Kuntjoro said. “The President states that the issue should not have reached all the way to him after all; that’s his way of stating that everyone must contribute to the solution.”

Drg. Eddy Sumarwanto believes that the Government’s pride and im­age-building prevents it from asking people to pay more. “The political stake is just too high, so they prefer to keep the status quo and not in­crease premium fees. With this cur­rent condition of Health BPJS deficit, in a political year, the Government’s pride would definitely prevent it from increasing the people’s burdens further, as this would damage their electability. If the people riot about it, the Government would find a way to issue more funds for sure,” he said.

According to Chazali, the Pres­ident would definitely object to in­creasing fees in the political year. “Because people would cook it up for sure, making it a political issue, but we must resolve this. I suggest that for these 2 budget years, 2018 and 2019, there must be coverage funds from the Government. They can take out this fund from the State Budget or from whatever source, it’s up to the Government. For example, Government might get extra fund­ing from cigarette taxes. However, the Government currently has not reached 100%, that would pay for only about 50% of the deficit,” he said.

Because the 2019 State Budget Plans are officially set, Chazali sug­gests that the Government prepare Rp 15 trillion to cover deficits un­til 2019. “We cover the deficit until 2019. In 2020, we either have a new President or keep this president for a second period. Then we would offer to increase fees,” he said.

Timboel admitted that the Gov­ernment is in a dilemma because it fears to cause a brouhaha in a po­litical year by increasing fees. “For example, the people protested loud­ly when the Government attempted to increase 3rd Class fees in 2016, forcing it to cut the fees back to Rp 25,500.00 per person per month. The Government is concerned that if they attempted it this year, their electability would be damaged. So, they opted to bail out. Actually, I think it would be best to convert the Rp 4.9 trillion bailout as “additional fees for PBI beneficiaries” at about Rp 4.000.00 per person, making the increase small enough to be ac­ceptable. If they have increased PBI coverage from the start, the people might not be as troublesome as they are now. Deficits can also be resolved if the Health BPJS Board of Directors works harder to resolve backlog is­sues. They might take to the law, increase participation, monitoring to make sure that expenditures are controlled. This would help guar­antee Health BPJS cashflow, which would allow them to pay hospitals, and hospitals in turn maintain their cash flow so that they can pay for doctors, medicine, paramedics wag­es and health equipment,” he said.

Regarding the President’s state­ment that the Health BPJS issue ac­tually did not need to get as far up as to him, Timboel believes that is because the President’s staff would not be honest and tell the truth to the President because they are afraid to be thought of as incompetent. “Some­thing that makes the President’s image worsen was when he signed Presidential Regulation Number 19 of 2016, which declared that 3rd Class BPJS fees increase to Rp 30,000.00 per person per month. The people protested it so violently that a month later, President Jokowi amended Presidential Regulation Number 19 of 2016 to Presidential Regulation Num­ber 28 of 2016, stating that fees will remain at Rp 25,500.00 per person per month. When there were prob­lems, the President’s staff should be able to respond, but since they could not respond for a long time, finally the President issued the revision, while Presidential Regulations must not be issued carelessly – there must be re­views first,” he said.

Another example was that Presi­dential Instruction Number 8 of 2017 was issued to resolve deficits by 2018. The Ministry of Social Affairs, the Ministry of Home Affairs, the Attorney General, the Coordinating Ministry for Human Development and Cultural Af­fairs, the Ministry of Labor, the Minis­try of Health, Ministry of State-owned Enterprises, as well as the governors, mayors, and regents must coordinate to help Health BPJS resolve deficits. Ironically, deficits in 2018 actually increased. “According to my opinion, that is because the Presidential In­struction Number 8 of 2017 was not executed seriously enough, causing the failure to resolve deficits by 2018. This is despite the President’s signa­ture being placed on it. If the Instruc­tion was executed properly, I believe that deficits would not even reach Rp 1 trillion per month like they are right now,” Timboel said.

Putih finds that the President’s statement that the deficit should be handled by the Minister of Health and Health BPJS by themselves makes it seem that the President is neglecting his responsibility. “No matter what, the Ministry of Health and BPJS are under the President, so when there are urgent situations, the final de­cision should be in the hands of the President,” she said.

Hospital Claims
Ideally, hospital claims must be paid 14 days after Health BPJS completed their verification. Howev­er, BPJS generally pays 2-3 months later because of insufficient funds. Dr. Kuntjoro said that not all hospi­tals can afford delayed payments, de­pending on their own financial health. “Newly-established institutions with high investment simply do not have enough finances to cover their short-term liabilities, and that is a pity,” he said. “According to me, hospitals should not even dream of getting paid anytime soon for now. They must think about getting bank loans with Health BPJS as the guarantor. That is the supply chain finance program. Some hospitals already did that in order to be able to pay their debts and operate – their financial health remains sound. The bank interest rate must be as low as possible, not higher than Health BPJS fines at 1%,” he said.

Timboel further said that payment backlog from BPJS to hospitals can be resolved using the Supply Chain Finance (SCF) involving banks. The chain is activated when hospitals are waiting for BPJS to pay their claims: hospitals can borrow from banks to tide over their cash flow. “However, many hospitals refuse to get in the program because they must pay in­terest rate to banks. The scenario must be changed: as Health BPJS is the one who is late with payment, it must borrow from banks when it suf­fers from deficits. Therefore, Health BPJS should be allowed to borrow from banks,” Timboel said.

If Health BPJS makes a late pay­ment to hospitals, according to the provisions of Presidential Regulations 19 of 2016, it must pay a fine of 1% per month to hospitals for the delay. For example, per 17 September 2018 Health BPJS has a debt of Rp 7.05 tril­lion to hospitals. Late payment for a month is fined with an additional pay­ment of Rp 70 billion, 2-month late payment means additional payment of Rp 140 billion, etc.

“With the deficit being the cause of Health BPJS’ late payment, Health BPJS should be allowed to borrow from banks with interest rate to the bank below 1% per month, let’s say about 0.7%. That’s smaller than hav­ing to pay 1% fine to hospitals. There­fore, hospitals would stop protesting because they are being paid by Health BPJS from bank loans. With the SCF, Health BPJS is guaranteed swift and full payment to hospitals. This also benefits the State Budget, because the bank would obtain more interest rate income from the payment of Health BPJS loans, and therefore the loans would become a tax object included in the State Budget. This is a positive calculation,” Timboel said.

But why is it not being done? Ap­parently, BPJS is stopped by regula­tion from doing so: Government Reg­ulation Number 87 of 2013 Article 27 states that Health BPJS is prohibited from making derivative transactions, among others borrowing from banks. With the urgent situation arising when a deficit occurs, the regulation should be revised and Health BPJS should be allowed to borrow from banks. This means that the President must act and revise the matter. The Minister of Fi­nance, Minister of Health Affairs, and Health BPJS President Director can explain the issue comprehensively to solution. In this way, hospitals will get paid, interest rates are not more than 1%, and the bank’s interest rate in­come would be a tax object that would generate returns to the State Budget. “We of the BPJS Watch suggest that the Government Regulation Number 87 years of Article 27 should be re­vised in order to allow Health BPJS to borrow from banks, as it is in urgent. We agree that this should not be al­lowed in a normal situation,” Timboel said.

Recommendations for Government
Putih observed that the People’s Representative should suggest to the Government that the fees must be increased according to available actuarial calculations. Yet again, this depends on what the Government wants with the increase of income from premium fees. After all, our current Government budget is mostly allocated for constructing infrastructure. Therefore, it is back to the issue of whether or not the Government is willing to increase fees or not.

According to Chazali, BPJS would remain in deficit until Judgment Day if this pattern continues. “We tempo­rarily have coverage from the State Budget, but again, it is temporary in nature and given due to the fact that we are now in a political year. There­fore, the fees must increase according to its economic viability rate. This will allow hospitals to operate, doctors and medical workers get paid, etc. In this way, all sectors will survive,” he said.

Timboel believes that the Govern­ment must perform a comprehensive evaluation. The deficit can be reduced if the Board of Directors works hard and coordinates properly. Backlog fees must be collected, especially from PBPU participants. Starting 1 January 2019, sanctions will be im­posed on anyone who is not yet part of the Health BPJS scheme: they can be denied this public service, or they must pay their backlog in full. The is­sue now is whether or not the Health BPJS Board of Directors is able to coordinate with other public service agencies to enforce this step. Monitor­ing from Ministry of Home Affairs and Ministry of Health must be optimized. “I see that the Hospital Monitoring Agency under the Ministry of Health is still not running properly until now; its performance should be more op­timized. Regional Governments must be monitored and imposed with sanc­tions, private companies must also be monitored with sanctions. We really should not depend on the Central Government only. Evaluations must be made both in terms of issuing regulations and implementing them, both from upstream and downstream workflow,” he said.

Health BPJS is nowadays synon­ymous with therapeutic health treat­ment. Timboel said that there should be more effort made on preventative promotion. BPJS Watch notes that Health BPJS tends to neglect pre­ventive health efforts. Add this to the already bad lifestyle of our people, which makes them tend to fall sick easily already, the people then con­tinue to misuse Health BPJS. Our people have the bad lifestyle of eating bad food in large amounts, working too hard and resting too little, plus they hate to spend money on self-care (including and especially health insurance payments). This causes us be prone to suffer from major, costly diseases such as heart issues, kidney failure, stroke.

People abuse this service because there is lack of health education. It is mostly middle-class people who use it to cover medical treatment when these lifestyle diseases which are ba­sically their own fault, robbing the poor who need healthcare more than they do and who cannot afford proper treatment on their own.

There is a way to prevent this: BPJS must also allocate more money on health education for the people, in cooperation with its network of hospitals and Puskesmas and family doctors. Health BPJS should really be treated as emergency medical funds, for illnesses that cannot be prevented by a proper lifestyle like auto-immune diseases or cancer, as it is these dis­eases that tend to drain money. There should be regulations for this much neglected, yet very important issue as well. (Dessy Aipipidely, Ekawati, Syahrullah)