Reasons Why Deficit Recurring
Since the JKN program was run in 2014 for the first time until now, BPJS Kesehatan's finances have always been in deficit. The amount of claims that must be paid to cover treatment is still higher than the total premium paid by participants. The ratio of claims to receipts is always above 100 percent.
BPJS Kesehatan’s claim ratio had reached 105 percent in 2014 and rose to 108 percent in 2015. The ratio dropped to 100 percent a year later, reaching the break-even. In 2017, it rose again to 114 percent. Ideally, the claim ratio that can be tolerated is less or equal to 90 percent, so there is still a remaining 10 percent that can be used to finance operations and the formation of reserve funds.
Finance Minister Sri Mulyani said four things are causing a high claim ratio and deficit. First, the premium is still low, underpriced, or below the ideal count to cover health costs.
Citing the book 'Sustainability of JKN Program in the National Social Security System' published by the House of Representatives Commission IX, the premium determination does not refer to the results of an actuarial study. The Health Ministry, along with BPJS Kesehatan and DJSN, performed JKN premium calculations in 2015.
Based on the actuarial study, the ideal premium is at Rp 36,000 for premium assistance participants, Rp 80,000 for independent class I participants, Rp 63,000 for class II participants, and Rp 53,500 for class III participants.
However, the government did not accommodate this recommendation. The amount of premium stipulated in the Presidential Regulation No. 28/2016 is only 63 percent of the proposal for the premium assistance participants, 47.6 percent for non-wage recipient (PBPU) class III participants and 80 percent for class II participants.
Second, JKN participants who have a low level of discipline. Many PBPU participants or from the informal sector only register when they are sick and stop paying the premium after receiving health services.
Based on data from the Finance Ministry, the total premium from the PBPU participants over the past year was only Rp 8.9 trillion. However, the entire claim to be paid by BPJS Kesehatan for this participant group reached Rp 27.9 trillion.
Based on the findings of the Development Finance Comptroller (BPKP) as an internal auditor of the government, 50,475 business entities have a low level of discipline in cooperating with BPJS Kesehatan, 528,120 workers have not been registered by 8,314 business entities, and 2,348 business entities did not report salary correctly.
Third, the low level of activity in paying the premium. The PBPU participants’ level of activity was only around 54 percent, meaning 46.3 percent of independent participants are in arrears. From 2016 to 2018, the arrears of independent participants reached around Rp 15 trillion, while the level of utilization (the use of insurance) is very high, with a claim ratio reaching 313 percent.
Fourth, the tremendous burden of financing for catastrophic diseases that must be borne by BPJS Kesehatan. Such conditions require high costs in treatment, such as cancer, heart disease, and kidney failure.
The financial burden incurred by BPJS Kesehatan for claims of this disease reached 20 percent of the cost of benefits. Based on BPJS Kesehatan's data, the catastrophic disease category was costing Rp 11.07 trillion in 2014. This burden continues to increase every year to Rp 14.88 trillion in 2015 and Rp 16.94 trillion in 2016. It became Rp 18.44 trillion in 2017 and Rp 20.42 trillion in 2018.
This increase in expenses is in line with the increasing number of participants. The prediction is that the burden of financing for catastrophic diseases this year will be the same as last year, which is around Rp 20 trillion. This prediction refers to the figure at Rp 10 trillion as of June 2019.