Craig Comrie, CEO of Profmed
For many South Africans, reviewing their medical aid has become an annual exercise in making the numbers work. As another year approaches, the question is often the same: how much more will I be paying, and can I still afford my cover?
The Council for Medical Schemes (CMS) has recommended a 3.8% starting point for 2027 increases but also indicates that that price point is subject to other influences such as utilization changes. That’s a useful reference because healthcare costs are driven by far more than inflation. Until we deal with those utilisation and other pressures which drive above inflationary increases, affordability will remain a challenge.
Inflation is only part of the story
Many assume medical aid increases should track the Consumer Price Index (CPI). Inflation pushes up healthcare prices, but it isn’t the only driver. Utilisation is a major contributor> Utilisation simply means how often members use healthcare services.
Take a scheme that pays for 100 hospital procedures in 2026 and expects to fund 103 in 2027. Its costs have increased 3% before inflation has even been considered. Now assume, purely for illustration, that those procedures become 5% more expensive in 2027. Simplistically that’s an overall increase of 8%. Schemes aren’t just paying more for healthcare; they’re paying for more of it.
Age makes this harder. Older members generally need or utilise more healthcare, while high unemployment and low medical scheme uptake among younger people mean the risk pool is ageing . Annual contribution increases cannot solve a problem that stems from an ageing membership and reforms to improve overall age of the medical schemes risk pool, have remained outstanding for years.
Reforms that never arrived
Part of today’s pressure comes from reforms outstanding for more than twenty years. Community rating was a significant step: schemes can no longer set contributions according to age or health status. But it was meant to form part of a wider package covering Prescribed Minimum Benefits (PMBs), low-cost benefit options and mandatory membership.
The idea was a more balanced risk pool, with younger, healthier members helping carry the cost of an ageing membership. Mandatory membership could potentially reduce overall medical scheme rates by as much as 30%. The Competition Commission’s Health Market Inquiry raised these same issues a decade ago, yet no reforms have materialised.
Another panel is reviewing PMB’s, yet there have been many review panels in the past, yet 2 decades later no changes have been implemented. Schemes are past the need for guidance; what we need is implementation of the outstanding legislation. Rather than waiting for a flawed reform like the NHI , we should implement the outstanding reforms recommended by the Health Market Inquiry that could make a difference to affordability now.
The cheapest option can cost you the most
When money is tight, a cheaper option looks sensible. But a lower monthly contribution doesn’t necessarily mean lower healthcare costs. People often focus on what they can afford today and give less thought to what they’ll need their scheme to pay for tomorrow.
Cheaper options can come with fewer benefits, higher co-payments and tighter limits. Schemes regularly fund individual cases running into millions of rands, some exceeding R10 million. In some cases, members discover too late that their cover falls short, leaving them to find money for expenses that could have serious financial consequences.
This is also why medical scheme cover and health insurance aren’t the same thing. Health Insurers may pay out for specific events, but shouldn’t be treated as a replacement for comprehensive medical scheme cover. They usually carry extensive exclusions and are able to risk rate individuals based on age and healthcare risks thereby attracting younger unsuspecting under-covered healthcare consumers.
The better question isn’t simply whether you can afford your monthly contribution. It’s whether you can afford what happens if your cover isn’t enough.
Before you change your cover
If you’re reviewing your medical aid for 2027, start with an honest assessment of your health risks. Consider your age, medical history, existing conditions and family circumstances. Would your current benefits hold up if you or a dependant needed unexpected hospitalisation or specialist treatment?
Read the detail of your option. Understand your hospital benefits, limits, co-payments and potential out-of-pocket expenses. Those answers are easier to get now than in a hospital waiting room.
Best place is to speak to a broker who can assess your healthcare risk and your levels of affordability. There may be good reasons to move to a more comprehensive or lower option, particularly if your circumstances have changed. Just make that decision after assessing your risk, rather than looking at price alone.
Prevention belongs in the affordability conversation
Managing costs isn’t only about choosing the right benefits. It’s also about how we use healthcare. Schemes must negotiate responsibly with providers, but price negotiation only goes so far when demand and the resulting utilisation keeps climbing.
Regular screenings, check-ups, early intervention and healthier habits help members identify risks before they become serious, expensive conditions. At Profmed, as at other schemes, encouraging preventative care is part of helping members manage their long-term health.
This isn’t about discouraging people from seeking treatment. There’s a difference between using less healthcare because you’re looking after yourself and skipping care because you’re worried about the bill. We should be encouraging the first.
When more members take part in preventative care, they benefit personally, while schemes can better manage avoidable utilisation and maintain sustainable benefits.
Looking past the 2027 percentage
As the review period approaches, I encourage South Africans to look beyond the percentage on their contribution notice. Affordability matters, but it cannot be separated from health risks and treatment costs.
For members, that means understanding what you’re paying for, reviewing your benefits and carefully investing in your health by accessing appropriate preventative care benefits.
For schemes and policymakers, it means recognising that annual guidance cannot replace the long-term reforms needed to address the real drivers of cost. The conversation ahead of 2027 isn’t only about what medical aid will cost. It’s about whether people can still access the care they need, when they need it.
Looking after your health is the best place to start. It may save you money, and it may save your life.
Ed’s note: Watch EBnet’s podcast series Health Hack SA, where we unpack how medical aids work.
ENDS
