Bambang Pamungkas
Jakarta, CNBC Indonesia – The "Health Insurance Ecosystem Forum 2026," hosted by CNBC Indonesia, served as a pivotal platform for key stakeholders – regulators, industry associations, and insurance professionals – to collectively address the pressing challenges and chart a course for the accelerated growth and transformation of Indonesia’s health insurance sector. Held against a backdrop of escalating medical inflation and a burgeoning demand for robust healthcare solutions, the forum underscored the urgent need for a comprehensive overhaul of the existing framework, with a particular focus on the implications and opportunities presented by the recently enacted OJK Regulation No. 36 of 2025 (POJK 36/2025). The discussions aimed to foster collaborative strategies for regulatory adaptation, effective cost containment, and innovative service delivery models to build a more resilient and accessible health insurance landscape.
The Imperative for Reform: Tackling Soaring Medical Inflation and Over-utilization
The forum commenced with a sobering assessment of the global and domestic challenges facing the health insurance industry. Ogi Prastomiyono, Chief Executive of Insurance, Guarantee, and Pension Fund Supervision and Member of the Board of Commissioners of the Financial Services Authority (OJK), highlighted the alarming surge in medical inflation as a critical global concern, with Indonesia experiencing its own significant escalation. Prastomiyono revealed that medical inflation in Indonesia reached an estimated 13.6% in 2025 and is projected to climb further to 14.4% in 2026. This trajectory has inevitably led to a substantial increase in overall healthcare costs, placing immense pressure on both patients and insurance providers.
A primary contributor to this escalating cost burden, as articulated by OJK, is the pervasive issue of "over-utilization" in healthcare services. This refers to the phenomenon where patients or providers engage in unnecessary medical tests, procedures, or prolonged hospital stays, often driven by a lack of clear protocols, misaligned incentives, or a desire for comprehensive (sometimes excessive) diagnostic certainty. Such practices not only inflate costs but also strain the financial viability of insurance companies, many of which are reporting claims ratios exceeding 100%. A claims ratio above 100% signifies that insurers are paying out more in claims than they are collecting in premiums, an unsustainable model that threatens the long-term health of the industry. This trend is not unique to Indonesia; globally, healthcare systems grapple with balancing access, quality, and affordability, often battling against the rising tide of chronic diseases, the introduction of expensive new medical technologies, and an aging population. Indonesia, with its vast archipelago and diverse socioeconomic landscape, faces additional complexities in standardizing healthcare delivery and ensuring equitable access while managing costs.
POJK 36/2025: A Landmark Regulation for Ecosystem Strengthening
In response to these critical challenges, the OJK has introduced POJK 36/2025, a landmark regulation designed to strengthen the entire health insurance ecosystem in Indonesia. Prastomiyono underscored that this regulation was meticulously crafted through extensive consultations with a broad spectrum of stakeholders, including insurance companies, participants/patients, hospitals, BPJS Kesehatan (the national health insurance agency), and relevant entities, notably involving input from Commission XI of the House of Representatives (DPR RI). This collaborative approach aimed to ensure the regulation effectively balances the interests of all parties while fostering a more robust and sustainable healthcare and health insurance ecosystem for the nation.
One of the most significant policy changes embedded within POJK 36/2025 is the introduction of a re-sharing or co-payment scheme. This mechanism allows insurance providers to offer policies where policyholders bear a portion of their total claim costs. Specifically, the regulation stipulates that policyholders may be responsible for 10% of the total claim, with a maximum co-payment of IDR 300,000 for outpatient services and IDR 3 million for inpatient care. The rationale behind this co-payment structure is multifaceted. Firstly, it aims to instill a greater sense of financial responsibility among policyholders, potentially reducing the incidence of moral hazard and discouraging unnecessary healthcare utilization. By having a direct financial stake, patients are expected to make more informed decisions about their medical needs and be more discerning about the services they consume. Secondly, for insurers, this mechanism provides a vital tool for risk management and cost control, helping to mitigate the impact of soaring claims and improving their financial sustainability. This allows insurers to offer more competitive premiums in the long run, making health insurance more accessible to a wider segment of the population.
The introduction of co-payment aligns with similar models implemented in many developed and developing nations globally, where a balance between individual responsibility and collective risk-sharing is deemed essential for the sustainability of health insurance systems. It marks a significant shift in Indonesia’s private health insurance landscape, moving towards a more shared financial burden model.
Bridging the Coverage Gap: OJK’s Ambitious Target for 2029
The OJK’s initial observations following the implementation of POJK 36/2025 indicate positive trends. There has been a recorded increase in the number of health insurance policies issued and premiums collected, suggesting a growing awareness among the public regarding the importance of mitigating health risks. This uptick is crucial, as the current penetration of private health insurance in Indonesia remains relatively low. OJK data presented at the forum revealed that public expenditure on health insurance currently stands at approximately 5%, or IDR 35 trillion per year, significantly dwarfed by the total public healthcare costs, which amount to a staggering IDR 640 trillion annually. This vast gap highlights a substantial protection deficit, leaving a large portion of the population vulnerable to catastrophic health expenditures.
Recognizing this critical disparity, the OJK has set an ambitious target: to increase the proportion of the population covered by private health insurance from the current 5% to 20% by 2029. Achieving this goal requires a concerted and multi-pronged approach, necessitating robust collaboration across various government agencies and industry players. To this end, the OJK is actively working in synergy with the Ministry of Health, the National Agency of Drug and Food Control (BPOM), and BPJS Kesehatan. This collaborative framework aims to streamline processes, improve data sharing, and launch public awareness campaigns to educate citizens about the benefits and necessity of health insurance. The Ministry of Health’s involvement is crucial for aligning private insurance schemes with national health policies and public health initiatives, while BPOM ensures the safety and efficacy of medical products, indirectly influencing cost and trust. BPJS Kesehatan, as the administrator of the universal health coverage program (JKN), plays a vital role in ensuring that private insurance complements rather than competes with public provisions, potentially covering services or preferences not fully addressed by JKN. The combined effort seeks to create a more efficient and integrated health financing system that can effectively cater to the diverse needs of the Indonesian populace.
Industry Reactions and Implementation Challenges
The introduction of POJK 36/2025 and the OJK’s ambitious targets have naturally elicited varied reactions from within the industry. Insurance providers generally welcome the regulatory clarity and the potential for improved financial stability that the co-payment scheme offers. Many see it as an opportunity to design more sustainable products, manage risk more effectively, and ultimately foster long-term growth. However, insurers also acknowledge the immediate challenges, particularly in terms of public education and acceptance. Communicating the benefits of co-payment – such as potentially lower premiums and the sustainability of coverage – while managing initial resistance from consumers accustomed to full coverage, will be crucial. Innovation in product design, leveraging technology (insurtech) for seamless claims processing, and enhancing customer service will be vital for successful implementation.
Healthcare providers, including hospitals and clinics, also stand to be significantly impacted. While the regulation aims to reduce over-utilization, hospitals might need to adapt their administrative processes to accommodate the co-payment structure. There is a potential for reduced administrative burden from unnecessary procedures, allowing healthcare professionals to focus more on evidence-based care. However, ensuring transparency in billing and clear communication with patients regarding their co-payment obligations will be paramount to avoid disputes and maintain patient trust. The regulation also implicitly encourages a stronger partnership between insurers and healthcare providers to establish clear treatment protocols and cost-effective care pathways.
For policyholders, the co-payment scheme introduces a new layer of financial responsibility. While this might initially seem like an added burden, it is framed as a measure to ensure the long-term affordability and availability of health insurance. The OJK’s emphasis on balancing the interests of all stakeholders, including participants, suggests that the regulation is designed to provide sustainable access to quality healthcare. Public education campaigns will be essential to explain how co-payment contributes to a healthier insurance ecosystem, potentially leading to more stable premiums and preventing the collapse of insurance programs due to unsustainable claims. Consumer advocacy groups will likely monitor the implementation to ensure fairness and transparency.
Broader Implications for Indonesia’s Healthcare Landscape
The OJK’s initiative, spearheaded by POJK 36/2025 and the targets set for 2029, carries profound implications for Indonesia’s broader healthcare landscape. From an economic perspective, a more robust and widely adopted health insurance system can significantly reduce the out-of-pocket healthcare burden on households, thereby enhancing financial stability and reducing poverty caused by medical expenses. It can also free up government resources that would otherwise be allocated to direct healthcare subsidies, allowing for investment in other critical public services or infrastructure.
Moreover, the push for increased private health insurance penetration complements the existing universal health coverage provided by BPJS Kesehatan. While BPJS Kesehatan ensures basic access to healthcare for all citizens, private insurance can offer additional benefits, greater choice in providers, and enhanced services, catering to a diverse range of preferences and income levels. This tiered approach, if managed effectively, can lead to a more comprehensive and responsive healthcare system overall. The collaboration between OJK, the Ministry of Health, BPOM, and BPJS Kesehatan signifies a strategic intent to integrate public and private efforts towards a common goal of national health security.
The emphasis on cost control and addressing over-utilization also has the potential to drive greater efficiency and accountability within the healthcare sector. By aligning incentives and encouraging more responsible consumption of services, the regulation could foster a culture of prudence among both providers and patients, ultimately leading to better resource allocation and improved healthcare outcomes. The long-term vision is a dynamic health insurance market that is not only financially sound but also deeply integrated into a high-quality, accessible, and sustainable national healthcare system. The success of these reforms hinges on continuous dialogue, adaptive implementation, and a shared commitment from all stakeholders to navigate the complexities and realize the full potential of a transformed health insurance ecosystem in Indonesia.
The "Health Insurance Ecosystem Forum 2026" thus marked a significant juncture in Indonesia’s journey towards a more resilient and equitable healthcare financing future. The discussions, led by prominent figures like Ogi Prastomiyono, highlighted not just the challenges but also the strategic pathways and collaborative spirit essential for achieving the ambitious goals set for the nation’s health insurance sector. The outcomes of POJK 36/2025 will be closely monitored as Indonesia strives to ensure better health security for its rapidly growing population.
