National Health Insurance IC Presentation

Island Council Meeting February 9th 2009

Commissioner Maria Buncamper-Molanus


Agenda # 8 Topic: (AZV-Project) National Health Insurance Project


On September 11, 2007 the Executive Council Of St. Maarten approved, in

principal, the review of the present health insurance system, considering

the concept of a national health insurance system for Country St. Maarten.

Research was done and discussions were held including members of the Island

Council. You may recall the document at the basis of this discussion being

that which was prepared by BMC titled "Met the welvaart stijgen de kosten".


It is clear that the way forward and goals to be achieved in country SXM

should be that of universal health care to guarantee access to health care

services for all residents.


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Being realistic about the size of the informal economy, the consideration

for the establishment of an emergency fund for uninsured undocumented



The documents related to the research and discussions are:


1. The discussion paper "Alternative Contribution Systems";

2. the proposed basic package for the National Health Insurance Country St.


3. The "Terms of Reference" i.c.w. the bidding process for the future

exploitation organization for the N.H.I.;

4. The Project organization planning in terms of time needed to introduce

the N.H.I.;

5. The proposal by "Keesen Actuarissen" for the preparation of a scenario

model to determine the appropriate premium structure and level.


All these documents have been submitted to the members of the Island



Mr. Chairman, allow me now to continue with providing the council with a

synopsis of each of these documents:



Based on the discussion regarding the paper "Alternative Contribution

System", it became obvious that the choice for a premium or contribution

system could not be solely based on an evaluation of several alternatives.

The current and future level of health care, the basic healthcare package,

the increasing cost and the aging are all factors that must be considered.



As a result of the consultation rounds with several stakeholders a preferred

package was identified. This package would be based on that which is

currently available in the Netherlands including the AVBZ care. This would

be the basis for our N.H.I system.



Ref. 3:

The objective of the T.O.R. is to guide the selection process of the future

local, regional and international insurer, as the professional exploitation

organization of the National Health Insurance. With this T.O.R. the bidding

process can be organized.

The T.O.R. is still in draft form because several issues still have to

receive a final decision before we can proceed. These issues are:

– The legal structure of the organization (Public or Private),

– the premium (will it be income based or a nominal amount, or a


– as well as the final decision on the basic health insurance package has

to be made.



In the T.O.R. a project organization is proposed consisting of the


– Stuur groep: responsible for achieving the objective which is the

implementation of the NHI its members: Project Manager Constitutional

Affairs and several directors.

– Project management

– Committee of Experts: for the development of certain aspects, such as the

premium structure, communication and legislation.

– And an advisory committee: These are the stakeholders in the field who

can advice Government about the implementation (with the ins en outs).



January 1st 2010 has been targeted for the implementation of the N.H.I.. It

is for this reason that we must intensify the preparation for the

implementation of the N.H.I.. In line with this a duo-project management

team is proposed. Two experienced senior policy advisors have been selected

from within the Government organization, namely Drs. M. Koopman and Drs. R.



Finally, the company Keesen Actuarissen gave a demonstration of interactive

scenario models of national health insurances. Mr. Laurence H.M. Keesen, an

actuary established on Curacao, proposes that a scenario model be designed

specifically for St. Maarten. This scenario model will provide valuable

insight into the questions related to how we should pay for the national

health insurance for the people of St. Maarten. Here again the question on

whether this should be based on:

1. a nominal amount or on the level of income of those paying into the

national health insurance.

2. taking into consideration the short and long term aspects;

3. demographic factors such as aging;

4. immigration;

5. economic growth;

6. and inflation.


The model consists of several parameters which can vary. Examples of the

variables are:

a. Economic growth

b. Inflation

c. Birth rate

d. Emigration

e. Immigration

f. Salary structures

g. Interest rates


The value of these parameters can be changed and within seconds the

consequences on the financing or cost of the NHI system can be established

immediately. It is for this reason that the scenario model is a powerful

policy tool/instrument to be used in the critical process of determining the

premium necessary to pay for the cost of the basic health insurance package.

With the Scenario model you will be able to show or demonstrate the

consequences of the choice for example of level of the premium.


This scenario model will also give us the ability to make the right

decisions now, to secure the feasibility on the long term. ……… In other

words, avoid major miscalculations that could lead to flaws in the decision

making for this major health reform.

Avoiding what has taken place in the Netherlands Antilles and in Aruba,

whereby the NHI are threatened by bankruptcy resulting in all sorts of

inconveniences, such as periodic increases in premiums, late payments to

healthcare providers, continuous reduction of the healthcare package, just

to mention a few.


The proposal made by Keesen Actuarissen for the development of the scenario

model for the N.H.I. for St. Maarten is USD 57.600.

The decision to present one proposal to the Island Council includes

considerations such as:

1. time factor;

2. no other actuary known;

3. experience / expertise (scenario model) with both health insurance and

pension plans.


The Island Council is requested to approve the NHI project; phase 1 to 3 of

the development of the scenario model for an amount of NAF 58.320,– and NAF

20.000 for travel expenses.


Should the proposal receive approval by the Island Council the following

resolution will be established:






That On September 11, 2007 the Executive Council Of St. Maarten approved, in

principal, the review of the present health insurance system considering a

national health insurance system for Country St. Maarten;


that the company Keesen Actuarisses made a proposal for the development of a

scenario-model to facilitate the critical decision process regarding the

final choice of the premium and basic package;


that the Scenario model is a powerful policy tool in order to enable the

calculation into the future of the financing of the National Health

Insurance system for Country St. Maarten.


Having read the letter of the Executive Council of January 9th 2009;





Article 1


To approve phase 1 through 3 of the development of the scenario-model,


– Phase 1: establishing the requirements of the scenario model;

– Phase 2: the collection of data;

– Phase 3: building the scenario model.


Article 2


To approve the amount of NAF 58.320,– for phase 1 through 3 and NAF

20.000,- for travel expenses.


Start: February. Phase 1is expected to be completed in 2 months. To be

followed by the fundamental decision making about NHI package, contribution

system and executing agency in IC.



Mr. Chairman, when assuming the responsibilities that come with country

status, we should aim to improve the service government provides to its

citizens. With this in mind the Island Government has embarked on developing

a National Health Insurance System for the people of St. Maarten, which will

provide improved service to its people. The debate today covers a portion

of the many activities required to realize this NHI system, certainly a very

important portion that requires our keen attention and good, founded

decision making.


Mr. Chairman with these final words I conclude my presentation and appeal to the Island Council for its support.