For many South Africans, medical aid and medical insurance have become the single biggest expense in their monthly household budgets. Bigger than rates and taxes. Far bigger than electricity. More than petrol, and often considerably more than all their other insurance premiums combined.

The costs have simply grown out of all proportion.

And then, just to rub salt into the wound, you see the fat-cat CEOs of some of these medical companies earning R20 million or more a year, bragging on social media and in business publications about how well their companies are performing. One wonders whether they have any idea what their customers are going through. It’s enough to make you sick. Although, given what medical treatment costs these days, perhaps that’s not a good idea.

There are reasons why medical costs have climbed so dramatically in South Africa. One of the biggest is the deterioration of the public healthcare system over the past 30 years. Public hospitals have deteriorated, some facilities have closed, and the infrastructure investment needed to keep pace with a growing population has simply not happened on anything like the scale required.

The consequences are felt by everyone, not just those who depend on public hospitals.

When the public healthcare system struggles to cope, more people who can afford it turn to private healthcare. The demand for private hospital beds, specialists, doctors and other medical services increases. And so do the costs. Those costs are ultimately passed on to medical aid members and insurance policyholders.

But spare a thought for those who cannot afford medical aid at all.

Visit a public hospital and you will quickly understand the problem. The queues are enormous, the facilities are overcrowded and the pressure on medical staff is immense.

Imagine being an 80-year-old woman who has broken her arm and having to sit for hours waiting to be seen. Or a child who has broken an ankle playing football on the beach. Or someone who has suffered a stroke and needs urgent attention.

There are reports of people waiting five or six hours, sometimes longer, before receiving attention. In an overstretched emergency department, patients may be triaged according to how seriously ill they appear to be. If your vital signs are stable, you may find yourself waiting while more critical cases are dealt with.

But imagine the anxiety of sitting there, not knowing when somebody will attend to you.

That is the reality facing many South Africans who have no alternative.

And it raises another question. What happens to those of us who are still managing to pay medical aid premiums today but are increasingly wondering how much longer we can afford to do so?

Take what you are paying now and project those increases over the next five, ten, fifteen or twenty years. The figures are frightening. What will medical aid cost by then? Will you still be able to afford it? And if you can’t, what exactly are your options?

There is a rather grim irony here. You might spend your working life paying medical aid contributions, only to reach retirement age when you need healthcare most and discover that the premiums have become unaffordable.

You might not even be around to worry about the problem twenty years from now. Not because you have lived a particularly long and happy life, but because you couldn’t afford the healthcare needed to keep you going.

The government has been talking about National Health Insurance for years. But there is very little public confidence that it will solve the problem. Many South Africans simply don’t trust the government to manage such an enormous undertaking. They fear that what is presented as a solution to the country’s healthcare crisis could become another enormous bureaucratic structure, with political appointments, questionable procurement and opportunities for well-connected individuals to enrich themselves.

There are also those who argue that our public hospitals could function perfectly well if only more money were allocated to them. Perhaps. But throwing more money at a system where accountability is weak, procurement is questionable and funds don’t always reach the facilities that need them is hardly a solution.

The question is not simply how much money we spend on healthcare. It is how much of that money actually reaches the people who need it.

So what are South Africans doing?

Essentially, there are three groups.

First, there are those who can afford pretty much anything. They have the money to pay for comprehensive medical aid, private specialists and whatever treatment they need. For them, the escalating cost of healthcare is an inconvenience rather than a financial crisis.

Then there is a growing group of people trying to find a compromise. They are looking at hybrid arrangements, using private medical cover to protect themselves against major and expensive medical events such as cancer, heart attacks, strokes and other serious illnesses, while relying on public healthcare facilities for more routine treatment.

Some are also looking at entry-level hospital plans, rather than comprehensive medical aid, to protect themselves against the potentially devastating cost of private hospitalisation.

Finally, there are millions of South Africans who have no choice. They rely entirely on the public healthcare system, whether they like it or not.

For households under financial pressure, a more practical approach may be to use public clinics and affordable nurse-led healthcare facilities for routine medical needs, while retaining some form of hospital cover if the budget allows.

It isn’t an ideal solution. Far from it. And anyone considering this route needs to understand exactly what their policy covers, particularly when it comes to chronic conditions, specialist treatment, emergencies and serious illnesses. A hospital plan is not necessarily a substitute for comprehensive medical aid, and medical insurance policies can have very different exclusions and limitations.

But the reality is that people are having to make these choices because they simply cannot afford to keep paying ever-increasing premiums.

We have reached a point where staying healthy is becoming a luxury.

This is a damning indictment of the state of healthcare in South Africa.

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