‘May PhilHealth naman’

“May PhilHealth naman (There’s Philhealth).” In many Filipino hospitals, those three words are offered as reassurance. A doctor has advised admission, the family is frightened, and someone is already doing arithmetic in silence. How much will the room cost? Which medicines must be bought outside? Will there be a procedure?

Then someone remembers PhilHealth, and the tension briefly eases. But the next questions soon follow: “Magkano ang sagot (How much will it cover)?” “Ano ang hindi kasama (What’s not included)?” “Magkano pa ang kulang (How much more is lacking)?” We have become accustomed to a peculiar kind of insurance -- one that assures us there will be a deduction, but not necessarily that the remaining bill will be bearable. The patient may be covered and still fear the cashier almost as much as the diagnosis.

That is the real PhilHealth problem. It runs deeper than the familiar complaints — delayed claims, inadequate case rates, confusing rules and failures of governance. It is the distance between coverage and protection. Coverage means a Filipino has a record in the system. Protection means illness does not dismantle the family’s finances. In 2025, households still paid 41.2 percent of the country’s current health expenditure directly from their own pockets. That figure includes medicines, outpatient care, diagnostics, private services and other spending; it is not a measure of PhilHealth alone. But it reveals the burden families continue to carry. We have pooled some of the cost of sickness, yet much of the uncertainty remains at the bedside.

PhilHealth has not been idle. In his 2026 State of the Nation Address, President Marcos highlighted YAKAP, GAMOT, expanded benefits and zero-balance billing in the wards of Department of Health (DoH) hospitals. These are meaningful developments. They also arrive at a moment of new health leadership. Dr. Jose S. Pujalte, Jr. now heads the DoH and, by law, serves as the ex officio, nonvoting chair of the PhilHealth Board. The appointment does not change the diagnosis; it sharpens the opportunity.

The Philippines does not need a weaker national health insurer. It needs one that is adequately funded, more purposeful and more accountable. PhilHealth should not merely pay for healthcare. It should help build a better healthcare system. Benefits can be announced in a speech. The budget will reveal whether they are sustainably funded; the bedside will reveal whether they are reliably delivered. Government must fund the promise. PhilHealth must make it real.

That distinction should change the scoreboard. PhilHealth understandably reports members enrolled, claims processed and pesos reimbursed. Patients need other numbers. What share of the final bill did PhilHealth actually cover? How much did the family still have to find? How often did people borrow, sell property, postpone treatment, or leave without receiving it? How does protection differ between uncomplicated and complex cases, public and private hospitals, Metro Manila and a distant province? A deduction is an accounting event. Protection is a human outcome. We should not congratulate ourselves because an insurance card was presented or a claim was processed. We should ask a simpler question: after the patient went home, could the family still afford the life waiting outside the hospital?

As a nephrologist, I see one of our financing system’s strangest habits: it often becomes most visible when disease is least reversible. Once kidney failure requires dialysis, the system has a defined benefit. Years earlier, the same patient may have needed a blood-pressure check, an affordable medicine, a creatinine test and someone responsible for noticing that the results were getting worse. The SONA’s promise to expand testing and medicines for kidney disease is therefore welcome. But a test does not prevent anything by itself. Prevention requires someone to order it for the right patient, interpret the result, act on it and make sure the patient returns. We remain willing to pay repeatedly for the flood while underinvesting in the drainage. Sometimes the most valuable benefit PhilHealth can purchase is the admission that never had to happen.

Payment must also recognize that illness does not come in standard sizes. Payment categories are necessary because every insurance system needs rules. But every category is a simplification, and no patient is average. Two patients assigned to the same payment category may require very different lengths of stay, medicines, procedures, nursing care and professional expertise. When reimbursement falls far below what appropriate care actually costs, the difference does not disappear. It is absorbed by the hospital, shifted elsewhere, or passed to the family.

The answer is not a separate rate for every conceivable patient; that would replace simplicity with chaos. It is a payment system that becomes more sensitive to how sick the patient is and how complex the care becomes, while rewarding appropriate care, honest documentation and good outcomes. Otherwise, we may improve the labels without fixing the incentives.

Even generous benefits remain theoretical when care cannot be reached. The President’s call for more clinics to participate in YAKAP is necessary, but adding names to an accredited list is only the beginning. A Filipino may be entitled to a consultation, medicine, operation, or cancer treatment and still live hours away from a functioning provider. Travel, lodging, lost work and the income sacrificed by a companion rarely appear on the hospital bill, but they often determine whether treatment happens. PhilHealth should help build -- and sustain -- networks of care where they are still missing.

Just as membership is not protection, accreditation is not access. A clinic may appear on a list yet be unable to complete the digital steps or connect the patient to the pharmacy. The answer is not to abandon documentation, accountability, or fraud controls. It is to make them workable for the clinics expected to deliver the benefit, so patients are not turned into couriers between disconnected systems. Trust is built when benefits are understandable, services are reachable, providers can participate, payments are dependable and results are visible.

“May PhilHealth naman” should one day be enough to reassure a family — not because every service will be free, but because the remaining burden will be fair, predictable and survivable. The success of PhilHealth should not be measured by how many Filipinos possess a membership number, how many claims it processes, or how many billions it reimburses. It should be measured by how rarely a diagnosis is followed by borrowing, begging, selling, or walking away from necessary care.

Universal healthcare will not be achieved when every Filipino has a PhilHealth number. It will be achieved when “May PhilHealth naman” finally becomes a complete sentence.