Everything you need to know about... Health financial crisis

Why now?

According to the OECD's Health at a Glance 2025 report, published in mid-November, Poland last year reached a historic level of health spending: 8.1 percent overall, including public spending of just over 6 percent of GDP. Real GDP, not the one in the revenue law, which relates spending to GDP two years ago. Money has been flowing into the system in recent years in a swift stream, so why did the crisis erupt when this year - nominally - it's bigger after all?

There is no mystery in this, and there should be no surprise. It wouldn't have been if, in mid-2024, decision-makers - the government, the Ministry of Health, members of the Health Committee - had taken seriously the first expert report on the financial gap in the budget of the National Health Fund that will emerge in a few years. It is worth recalling that the size of this gap in the years 2025-2028 they estimated, in the extreme case, at almost a quarter of a trillion zlotys (it is known that this scenario is unlikely to materialize, because one of the counted costs was a civic bill to amend the law on minimum wages, which will certainly not be passed in "civic" form). The reasons for the gap have been, that is, the ever-widening spread of the scissors between the system's revenues and its costs, have also been thoroughly pointed out. The primary generator of the gap is the law on minimum wages for health care workers, which is not bad - it is inadequate for the increase in health expenditures provided for by the revenue law. But there are other reasons, such as the removal of limits from a large part of health services, which makes or such a construction of the program of free medicines for seniors and children and adolescents, which promotes the explosion of costs (making budget planning difficult). These are not decisions that have been made in the last two years.

What is the scale of the problem?

PLN 14 billion gap this year, PLN 23 billion gap next year. This is a declaration from the beginning of October, and there is no indication - at least for this year - that it was misguided. For a little more than two months, this year's gap has been reduced somewhat, as the state budget transferred additional funds already in October, bond money from the NPRM came in November, and there was also a small injection of money from the Health Ministry's budget, but it is clear that there is still a shortfall of about PLN 9-10 billion. Missing, but to what? To close the NFZ budget, i.e., to settle all 2025 liabilities from the current financial plan. And the NFZ and the Ministry of Health are already officially admitting that the benefits provided in 2025 in the fourth quarter will be paid at least in part from next year's financial plan - probably a minimum of PLN 4 billion will be rolled over.

Another, virtually unknown before, problem has emerged this year - a shortfall on the revenue side. After three quarters, there is a shortfall of about PLN 3.4 billion in health premiums. The reason is overly optimistic macroeconomic assumptions. For many years it has been a tradition to amend the financial plan in connection with a larger-than-planned premium runoff and to divide, in the last quarter, the financial "top". This year there is nothing to share, and the financial plan cannot be amended either... because there is none.

The plan is not there and will not be?

For the first time in its history, the National Health Fund has operated on the basis of a provisional budget for an entire year - the Finance Ministry has refused to accept the financial plan for 2025 and is refusing to accept the plan for next year. In correspondence with the Ministry of Health and the National Health Fund, the Finance Ministry indicates that it is impossible to accept a plan that is incalculable, because it is known in advance that costs will be significantly higher (only it is not known how significantly) than revenues - and the plan will have to be amended during the year, which means the need to "organize" additional funds from the state budget.

The National Health Service responds, not unreasonably, that countries as matter becomes them - matter, that is, planning data. For it was politicians, not the payer, who made the decisions that are now generating multi-billion-dollar burdens for the payer's budget, and it was politicians who ignored the warnings of experts - even after the second report on the financing gap was published, which the Health Committee very briefly looked at, the prevailing view was that money is "always" in short supply and "always" the state budget makes up the shortfall.

More than 6 percent of GDP...will it be less?

While the OECD report should please, it doesn't - for a simple reason: it's not hard to see that this just over 6 percent of GDP in public spending is a problem for politicians. Because the jump from about 4.7 percent to more than 6 percent. - in just two years - has been generated solely by unleashing costs and attempts to finance them, by patching holes in the payer's coffers: it's forced (or "hollowed out," as NFZ Vice President Jakub Szulc said during one of the recent discussions on systemic challenges) injections from the state budget or transfers of funds from Part 46 to the NFZ budget by the Minister of Health on the Ministry of Finance. These are, to put it another way, multibillion-dollar sums that politicians did not plan for health, but had to spend anyway. At the same time, when a proposal is put on the table to add funds to the NFZ budget in advance to prevent the payer's budget from unraveling (last year, MPs from Together submitted an amendment for an additional 20 billion zlotys, this year, with the budget just under way, for an additional 23 billion zlotys), it is rejected in advance. This can be read as a message: we are ready for 5.5 percent of GDP and not a penny more.

At the same time, there is evidence in the same report that the money spent has not been "wasted," "burned through," or simply - spent solely on staff salaries. With that said, the latter statement is at odds with common sense, since the OECD has been saying for years that one of the most important, if not the most important, challenge for aging societies is securing medical staff, including by improving working conditions, which includes the area of salaries. Especially in Poland, where salaries have been very low for decades. But the shortening of queues for elective surgeries (cataracts, endoprostheses) and the fact that Poland is indicated as one of the countries that have made the greatest progress in the last few years should give food for thought.

What about the savings?

Queues in cataract surgeries have been shortened very effectively, almost to zero - and perhaps that's why, just in this case, the MZ's proposed reinstatement of limits will not be felt so much. However, Jolanta Sobierańska-Grenda's savings plan to the Finance Ministry, disclosed by the media this week, is stirring up huge political and social emotions - certainly the topic will not soon die down, especially as Thursday and Friday will be dominated by health debates: in the Sejm (government current information), at the government summit ("Safe Patient") and at the summit at the Presidential Palace.

The Health Ministry and the government explain that this plan contains "proposals, not decisions." However, many things have already happened: NFZ and AOTMiT are working on the retarification of services, the deputy health minister announces the decision to end the "Good Meal" pilot and implement the nutrition standard nationwide, but says nothing about financing, and since the MZ has put the end of the pilot in the table with savings (PLN 900 million), and no additional costs (increase in valuations) appear in it, one can presume that this standard will be implemented by hospitals under current valuations.

There are more question marks: the government side, despite the lack of consensus with the social partners, is to present a draft amendment to the law on minimum wages. Doubts as to whether it can be passed in such a "forceful" formula are not unfounded. Despite the promises made publicly, the issue of medical contracts still seems to be open: the MZ tells doctors that they will remain, the social partners make it clear that the matter is still up for discussion.

It is hardly surprising that before the marathon discussions, a lack of confidence that they will bring solutions to the problems any closer is prevalent. There are fears that they will only exacerbate these problems.