The middle class will have to pay more tax and will not be able to use medical aid schemes to fund most private healthcare procedures - if and when national health insurance is introduced by the government. Health Minister Aaron Motsoaledi released the NHI policy document for public comment on Friday.He has been promising its "imminent" release for the past three years.The white paper says that the NHI would consist of a single, state-run fund that paid for all health services for all South Africans. Payments to the fund would be compulsory.The fund would pay the state and private sectors for services but it is not clear who would be allowed to use private hospitals and who would use state hospitals.Medical aids will be allowed to provide "complementary cover" for services not covered by NHI."With the implementation [of NHI] the role of medical schemes in the health system must change," according to the white paper.Brian Ruff, CEO of healthcare management company PPO Serve, said: "[The NHI white paper] proposes the end of private comprehensive medical aid cover."Chemotherapy, a heart bypass operation or any major health procedures will be purchased by the NHI fund."Medical aids will be for top-up care or for minor, elective procedures, and for what the NHI doesn't cover. But what exactly the NHI won't cover is not defined."The government document predicts that there will be fewer medical aid schemes than the current 83.Government medical aid schemes such as the SA Municipal Workers' scheme, the police medical aid scheme and the Government Employees' Medical Scheme, will reallocate the monthly premiums they take from workers into the NHI fund.This could mean that the middle class will be forced to use state facilities and services.The document states that, when NHI is "fully operational", the tax credits that medical aid users earn each month will be revoked and redirected to the NHI fund.It suggests that households will spend less on medical scheme contributions and more on a "general tax allocation" towards the NHI fund.The document calls for a "complete reform" of the health system in both the way services are provided and how doctors and hospitals are paid.It states that health must not be treated "as a commodity, but as a social good".It slams the fact that the 16% of the population using private healthcare spends the same amount each year as the government spends on 84% of the population dependent on state healthcare.It states that doctors are overrepresented in the private sector.It blames the private sector for "high salaries" and suggests forcing doctors to work where they are most needed.A health expert, speaking on condition of anonymity, said: "The policy paper is absurd, superficial and irrational. No aspect will survive a legal challenge."Instead of trying to improve health services in the state sector, it is attempting to change how health services are provided to people with medical aid. It is focusing on 9million people who already have good healthcare."The white paper states that:Private healthcare costs must come down;Private ambulances will be forced to help all patients, not just those who can afford private care;Hospitals must have functional laundry and security services;Management and quality of state hospitals must improve; andThe middle class will not be able to go to specialists direct but will have to a use a general practitioner first, who will refer them to a specialist if needed.Motsoaledi said it was not yet clear how the NHI would be funded.The policy document predicts that, if the economy grows by 3.5% a year, the government will be short of R71-billion in 2026 when the NHI is scheduled to be fully implemented.If growth reaches only 2% a year, the fund will be short of R108-billion from 2026.The document suggests various remedies, such as hiking VAT by 2%, deducting NHI contributions from salaries and increasing personal income tax.It envisions moving spending on private healthcare into the public sphere.Ruff said it will be interesting to see if the government "could sell this to the middle class and if it is economically viable"...