What caused the deficit
Despite the surplus, the government and BPJS Kesehatan are still wary that a deficit might be incurred once more. Several factors might cause such a deficit. First, premium contributions set by the government are not in accordance with the actuarial calculation by the National Social Security Council (DJSN).
When JKN commenced, DJSN recommended a premium of Rp27,000 per person per month for PBI but the Susilo Bambang Yudhoyono administration decided to go with Rp19,225. Likewise, when a premium increase was decided in 2016, DJSN recommended Rp36,000, but the first Jokowi administration set it at Rp23,000.
Research by the Social and Economic Research Institution at the University of Indonesia Economy and Business Faculty (LPEM FEB UI) published on August 15, 2017, found that the JKN premium was underpriced. The actuarial calculation for Class III was Rp36,000, Class II Rp62,000, higher than the government-set price of Rp25,500 and Rp51,000, respectively.
Another factor was the still low participation rate in the early days. At the start of the program, only 133,423,653 participants (52 percent of total population) were registered. In 2016 this increased to 171,939,254 (66.2 percent of total population). The average contribution per capita per month rose from Rp25,433 in 2014 to Rp32,669 in 2016.
Secondly, there are still many participants who are in arrears. As of December 31, 2020, contribution arrears from independent workers amounted to Rp15.32 trillion, which when combined with other cohorts amounted to Rp16.63 trillion. The number of participants in arrears increased from 23,114,123 in 2020 to 48,591,973 in 2022.
Thirdly, weak regulation enforcement means that there are still many wage earners (PPU) at state/region-owned as well as privately-held enterprises who have yet to register with the JKN program, even it has been made mandatory since January 1, 2015. As of the end of 2020, only 16,786,051 workers in this cohort (37,775,609 if counted together with the spouses and children) were registered.
According to Statistics Indonesia (BPS), there were 51.78 million formal workers in 2020 (39.5 percent of the 131 million workforce). This means that many are yet to be registered. If participation can be increased, potential revenue from this cohort can soar from currently Rp33.71 trillion to Rp 80 trillion.
Labor inspectors must improve the quality of their supervision, especially for companies that have yet to register all their workers. They must work closely with the National Police (Polri), the Attorney General’s Office (AGO) and BPJS Kesehatan supervisors.
Fourthly, there are still frauds committed by wayward hospital personnel. According to the Health Ministry, there are at least 12 types of fraud in relation to JKN. The most common one is discharging patients early from hospitals and telling them to return for treatment a few days later. Of course, this will cause the cost of Indonesia Case Based Groups (INA-CBG) to double or triple. Forcing C-section surgery, as mentioned earlier, is another modus operandi.
Fifthly, doctors in FKTP, especially community health centers (Puskesmas), have yet to be able to diagnose 144 types of illness (of a total of 736) as per Health Minister Regulation 5/2014. This accordingly increased the referral rate from Puskesmas to hospitals to 14.8 percent in 2020. The higher the referral rate, the greater the INA-CBG costs for outpatient and inpatient care at hospitals.
Sixthly, disease prevention and health promotion efforts are still weak, as indicated by the rising prevalence of catastrophic illnesses whose treatment is funded by JKN. Health screening should be improved and community health care facilities should be more proactive in carrying out preventive and promotive efforts.
A JKN deficit will surely have an impact on the quality of health care services delivered to participants. Delays in payment of claims will put more financial burden on the hospitals, which needs the funds for operating costs such as buying medicines and medical devices, as well as paying the wages of health workers and other staff. And if this is allowed to continue, it can potentially lead to a deficit of trust toward the JKN program.