Jakarta. The government has finally admitted a fundamental problem with BPJS Kesehatan, its much-taunted social health insurance that was launched back in 2014: it has failed to collect enough premiums from its subscribers to keep it running smoothly.

Many Indonesians often skip paying their BPJS Kesehatan premiums until they actually get sick. Those who pay their premiums regularly — including company employees and poor families subsidized by the governments — do so at a level far lower than required to sustain the system.

This happened because the government was at first reluctant to put too much burden on ordinary Indonesians to keep the system alive. Conversely, it was also a strategy to rein in the amount of subsidy for the poor.  

But the insurance has proved to be popular among Indonesians and unpaid medical bills have been piling up over the years.

To cut a long story short, BPJS Kesehatan has been in the red since its inception.

The insurance is projected to accumulate Rp 28 trillion ($2 billion) in deficit this year, Rp 9 trillion of which carried over from last year.

And just like in previous years, BPJS Kesehatan's deficit is likely to bite back the government when the bailout requests come.

The government has now agreed that the insurance premium should be set at a more realistic level next year, which could be between 50 percent and 83 percent higher than the current premium. 

Finance Minister Sri Mulyani Indrawati said the government intends to set aside Rp 48.8 trillion for healthcare in the 2020 state budget, a much larger provision than this year's Rp 26.7 trillion to take into account the increased subsidy for the poor so they can afford their health insurance. 

But having increased the health budget, Sri Mulyani said the government now demands that BPJS Kesehatan improve its management and also calls on local governments to play a bigger role in ensuring the system works as it is supposed to.

"[We] need to pay more attention to purchasing strategy for the payment system, the synergy between the insurance providers and on keeping the operational expenses under control. [We] also need to strengthen the contribution from regional governments," Sri Mulyani said.

BPJS Kesehatan president director Fachmi Idris, in response to Sri Mulyani's comments, has said that the insurance is committed to fulfilling the government's demands. 

Positive Impact

Achmad Ansori, the commissioner of the National Social Security Council (DJSN), said the premium increase will have a positive impact on BPJS Kesehatan and also improve hospitals' cash flows.

BPJS Kesehatan is often forced to pay back hospitals four to six months in arrears on average, disrupting the flow of basic supplies.

Some private hospitals would even ask patients to buy their prescriptions outside of their establishments so they don't have to cover the costs. 

Doctors, nurses and other hospital staff sometimes even have to receive their paychecks late. 

Ansori suggested the government should increase the premium for all BPJS Kesehatan members to cut back on its deficit.

The DJSN recommended that subsidized customers of BPJS Kesehatan – those who come from poor families – should now pay the same premium as the insurance's third-tier members of Rp 42,000 per month, a 65 percent increase from the current Rp 25,500 per month.

Second-tier members, still according to the DJSN, should pay a premium of Rp 80,000 per month (Rp 51,000 previously) and first-tier members should pay Rp 120,000 per month (Rp 80,000 previously).

The premium for individual members and company staff should remain unchanged at five percent of their salary, but the maximum wage limit from which the premium is deducted should be increased to Rp 12 million (Rp 8 million previously).

Reactions

Fajar Himbawan, 23 years old, an unsubsidized member of BPJS Kesehatan, said he was opposed to the monthly premium increase.

"At the moment, I'm paying a monthly premium of Rp 102,000 for four family members. If the premium is increased, I will have to pay Rp 168,000 per month. That's quite a hike," he said.

Iyan, 34 years old, a BPJS Kesehatan customer from East Jakarta, said the case for the premium increase is not compelling. 

"It's still very difficult for BPJS Kesehatan members to access services at the hospitals. When my mother needed skin cancer surgery at RSCM [the state-run Cipto Mangunkusumo Hospital in Central Jakarta], she was forced to wait four weeks," Iyan said.

"When she was finally admitted to the hospital, we were given third-class facilities instead of the first-class facilities that we'd paid for," he said.

Ansori from the DJSN said people might be reluctant to accept the premium increase now, but if by doing so services at hospitals could be improved, they might well change their mind.

He said the DJSN will work with hospital associations to ensure every patient receive proper and faster services.

"Once people can see for themselves the improvement in services, they would gladly accept the premium increase. People will think that their contribution can directly improve the services they're getting. But those improvements have to happen soon," he said.

Professor Hasbullah Thabrany, a health policy expert, said the premium increase is necessary to ensure the national health insurance system remain sustainable. He said the public should not expect quality services if they are unwilling to pay higher premiums.

"The number one concern is finding out the right amount of premium to cover for the hospitals' expenses," Hasbullah said.