NHI drives health workers and retirees to consider immigration: Andrew Rissik, Sable International

President Cyril Ramaphosa enacted the NHI law during the election campaign, representing the biggest shake-up in South Africa’s healthcare system since the dawn of democracy. Critics have warned that the scheme is hugely expensive and could fuel corruption, with opposition parties describing it as a “death warrant” for healthcare in South Africa. Group International Director of Sable International, Andrew Rissik, told Biznews in an interview that the policy has raised concerns among healthcare workers and those considering retirement, leading many to explore international options for alternative healthcare systems. He noted that South African private healthcare is relatively expensive compared to that of countries like Portugal and Malta, where supplemented private insurance is more affordable. Rissik also discusses the turbulent years of the investment migration industry, with several European countries clamping down on golden visas, but says there are still options for those looking for a plan B, including the US EB-5 visa, “which is still going strong,” and countries like Portugal and Greece, which offer “attractive residency and retirement visas.” – Linda van Tilburg

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Extended transcript of the interview 

Linda van Tilburg (00:00.)

I have immigration specialist Andrew Rissik, the Group International Director of Sable International. With me, we’re going to talk about the National Health Insurance bill and what effect that has on immigration, and also a couple of other immigration issues including golden visas for Europe and the US EB-5 visa. 

Hi Andy, Thank you for joining us.

Andy Rissik (00:31.735)

Hi Linda, thanks very much. Always good to be on your show and chatting with the tribe as Alex always refers to them.

Linda van Tilburg (00:40.191)

Can we start with the National Health Insurance bill that President Cyril Ramaphosa recently signed? Does that have an effect on the people knocking on your door?

Andy Rissik (00:53.111)

The government has been speaking about the NHI for a long time and it’s like everything politicians start alluding to something and then it’s a long process and it softens people up. But I think the reality of South Africa and what we’ve learned over the past three decades is that what we think is unthinkable often becomes reality because these guys are on a mission. It is very much part of their policy and it’s now in law.

There’s obviously the debate as to whether it’s been signed in just before the election. I had an interesting drive back from Hermanus two days ago listening to the president being interviewed by, I think it was KFM or Cape Talk and he was saying that this wouldn’t change anybody’s will to get up and go and vote. But who knows? But yes, we’ve had a lot of phone calls. 

We’ve had phone calls from the health worker fraternity who are obviously concerned because that has to do with their future and how they get remunerated and what their careers look like. But, for people who are probably starting to think about what retirement looks like, where healthcare becomes a really important consideration, we’ve had a few interesting conversations with clients inquiring about what the healthcare options are in other parts of the world.

Linda van Tilburg (02:15.422)

Are there better healthcare options in other parts of the world that are not going to cost you the earth?

Andy Rissik (02:22.039)

Yes, I think healthcare is becoming such a global issue now and I think we saw it with the COVID pandemic and the World Health Organisation and Big Pharma that healthcare is a massive industry. But, apart from that, the reality is every single one of us is going to at some stage need healthcare.  I think I just want to start by saying that healthcare is very expensive in South Africa.

So, in a way, the government does have a point because to make good medical services accessible to the broader population of South Africa is almost impossible because, in global terms, our healthcare is very expensive. If you compare the premiums that people like us would be paying in South Africa versus people in the UK (for private medical I’m talking about), and places like Portugal and Malta, it really is very high. 

So again, it just comes down to that economic conversation of how many people are contributing and how many people are benefiting from the system. I think that’s where the concern comes with the NHI. In Portugal, for instance, if you are resident in Portugal, or even a country like Malta, where we can help a client get access to go and live there either through investment or another type of visa, your private healthcare is more of a top-up to really good government healthcare. 

If you’re a legal resident, in most European countries, you have a right as a resident to have access to government health services. Portugal particularly and Malta are renowned for having really good medical care. But if you want a top-up, you take out private cover, much like in the UK, and it’s very affordable. So, for between €500 and €1,000 a year, you can take out comprehensive medical cover that complements what the government would give you. That’s a pretty good comparison. In South Africa, that’s probably what you’re paying per month.

Linda van Tilburg (04:26.654)

Are people immigrating because of their healthcare options? Is that a driving factor?

Andy Rissik (04:35.383)

I don’t think it’s a driving factor yet because I think it’s too new. What you’re reading in the press is that a lot of people are saying this is going to be tied up in litigation for the next eight to ten years. But I think what’s happening is we’re just delaying the inevitable. What we’ve seen consistently over the last 30 years is a lot of wealthy people moving their wealth out of the country. They’re hedging. They still want to live here.

What you don’t really want happening is for all your medical practitioners to start leaving or feeling dark about their future. But, if that trend does start to pick up, and it’s already happening, I mean, we’re seeing medical people leaving. Who’s going to be servicing you if you’re a retiree in South Africa, where you’ve decided you’re going to retire and live in a nice security estate and have private medical care? Those are the concerns. 

What we’re seeing more and more recently is people asking: If I move to this country, what does the medical look like? I think this is a work in progress and I think we’re gonna see a trend.

Linda van Tilburg (05:45.662)

Well, we talked about healthcare workers thinking I don’t have freedom of choice anymore with the new laws’. Have you had a lot of doctors who want to move elsewhere because of this?

Andy Rissik (06:00.887)

Yes, over the years, it’s more anecdotal than necessarily seeing a trend. But I had a conversation a couple of years ago with a guy who heads up one of the big medical companies here, private medical companies, and they were actually looking at creating a plan B incentive as part of the package for their medical professionals so that they didn’t feel the need to leave South Africa and go and look for a plan outside of SA.

So, it was more to say, if you come and work for us, we can help facilitate a golden visa to say, for instance, Portugal, create a plan B for yourself and your family, but you don’t need to leave the country because that’s the whole idea of a plan B. After all, medical people are exactly like all of us, we’re just concerned about what the future looks like.  I think uncertainty is something that we’ve lived with forever in South Africa, but the future does start to look more and more uncertain.

I think your average medical doctor is a person who’s invested an enormous amount of time in their career and they want certainty. So, I think it would be good if we could offer that to them. But if not, they will definitely go abroad and go and look for other opportunities. The one thing that makes it quite difficult is that if you’re a doctor here and you move to say, Portugal, you have to go through a conversion. You can’t just go and start practising. So, that is a bit of a barrier to their exit from SA.

Linda van Tilburg (07:33.566)

And even in the UK, you have to write extra exams. So what about the golden visa? A lot of doors have closed. What options are there now?

Andy Rissik (07:43.863)

Yes, that is what we refer to as the investment migration industry. So, that’s where one can get either residency or citizenship through investment. It’s been a very, very turbulent couple of years. I think we saw in February 2022, that the British government closed down the Tier 1 Investor Visa. So, that’s where you could buy the right to permanent residence by investing £2 million into government bonds.

Then, a year later, we saw the Irish investor program closing down. That was very popular with clients of ours, and that could have been either a plan A or a plan B. So, that was a very nice opportunity. Then recently, in the last couple of weeks, we’ve seen the Australian government shut down their investor programme.

So, those are three English-speaking countries that have basically closed the door to anybody accessing residency through investment. So, the only real option that we see now in the investor space to go to an Anglo-Saxon or English-speaking country is the US via the EB-5 investor programme, which is actually the oldest one in the world and still seems to be going strong.

Linda van Tilburg (09:04.126)

Well, let’s go just through that one. What do you need for that and what do they offer?

Andy Rissik (09:07.671)

That’s the princely sum of $800,000. Just to give you some context. 30 years ago when the EB-5 was first launched, this was the first investor program in the world, and it was US $500,000. About three or four years ago, they changed the threshold to bring it more in line from an inflation perspective. 

They’ll probably start indexing it every couple of years so we don’t get lagged behind again. But for US $800,000, you can invest through a regional centre into government-approved job creation schemes and then what happens is within a year or two… it’s probably taking two to two and a half years until you get your green card. But then you and your family can actually physically immigrate to the US and it gives you all the rights that a normal US citizen has. The only thing is that you can’t vote.

So, let’s say you invest through a regional centre in California, you can go and live in New York, or you can go and live anywhere. You can work, you can run a business, you can basically, get access to all the local rates for education if you’ve got children at either school or university. So, there are lots of benefits, but it’s a full-on relocation, you have to leave South Africa and move to the US.

Linda van Tilburg (10:31.23)

So what are the options for non-English speaking countries? Earlier, you mentioned Malta. 

Andy Rissik (10:37.783)

So In Malta, English is one of their first languages because the other one is Maltese, but English is an official language in Malta. But then in non-English countries, you’ve still got Portugal, which is still popular. It’s not as popular as it was because the real estate investment category has disappeared as you probably know.

But, there is an option if you invest in funds that you can still get residency in Portugal. That’s always a good one because that can be used as a plan A or a plan B. After all, it’s the only European route to actually getting citizenship without having to leave your destination country. So, that’s still a big benefit for Portugal. It does take a long time though from inception to getting your citizenship, you probably talking about eight years.

But, the good thing is that you don’t need to relocate. So, if South Africa is where you’re making your money and this is your home and where your kids are being educated, that’s still a really good option. Greece is another great option, but that residency never leads to citizenship and is underpinned by real estate investment and that’s fairly popular at the moment.

Linda van Tilburg (11:55.454)

I’ve also seen that a lot of countries are starting to offer nomad visas and retirement visas where you can come and live there. I don’t know if it leads to citizenship, but there seem to be other options.

Andy Rissik (12:06.999)

There are definitely other options. The Nomad Visa, I think they’re not quite as popular right now as they were probably two years ago. And, anecdotally and my experience in Portugal is that many people went to Portugal on Nomad Visas and they were working for big American corporations. A lot of them have actually been retrenched because we’ve seen a sort of tightening in the IT sector. It’s not as buoyant as it was probably a year or two ago, just shortly after COVID-19. And I think that

the whole work-from-home and the remote working trend, whilst it’s very much part of our lives going forward, I don’t think it’s as popular as everybody thought it would be. The Nomad visas don’t lead to citizenship and are very specific to attract younger talent into a country and to give them a place to come and sort of almost locate just to work remotely. 

Retirement visas are very interesting and the one very compelling retirement visa is Portugal, because that gives you the right to go and live in Portugal permanently. There’s no capital investment required and one can then become a citizen after naturalisation after five years

Linda van Tilburg (13:26.014)

What do you need for the Portuguese retirement visa? Would you need to earn a certain amount of money or have an investment or pension?

Andy Rissik (13:37.239)

Yes, you need to prove that you’ve got a passive income of at least €1000 a month. So, it’s not that difficult to do, but we have a very interesting product where we’ve created a sort of a retirement package where you invest in a property and then part of it is we’ll handle all the immigration, the tax immigration from South Africa,  the inward immigration into Portugal,

as well as any tax structuring that you require. Then we’re also building out some exciting products around medical insurance and life insurance in Portugal as well because we’ve noticed over the last four or five years, that it’s become a very, very popular destination for South Africans where their kids and now grandkids are possibly living in Europe or the UK with no intention to return home. So a good place to consider.

Linda van Tilburg (14:32.446)

And Greece? 

Andy Rissik (14:33.975)

Greece has a good retirement option. The only difference is that it doesn’t lead to citizenship. So you’re very welcome to go down to Greece and retire and live a lovely life, but you will always be on a permanent resident basis rather than as a national.

Linda van Tilburg (15:43.358)

Is there a wait-and-see attitude right now for people who might have considered it, but first want to see who’s in government? Is the ANC going to be in government and they form a coalition with a left-wing party that might also again lead to an exodus?

Andy Rissik (16:04.983)

We’ve seen a definite wait-and-see across all of our clientele leading up to this election. I was in Mpumalanga two weeks ago and the mood up there is interesting because it’s changed so much since 1994 that the people there just get on with their lives. They’re all hustling and the ANC has been running that place for ages.

The place where I see the biggest anxiety is in the Western Cape because it’s almost like the inevitable is just being delayed in the Western Cape and everyone’s just hoping that the DA will hang into power. 

It’s not just a national election. This is a provincial election as well. So, I think there is a lot of fear and anxiety, should I say. I think that once we see two, or three weeks who’s in charge at the provincial and national level, I think it will be very telling.  I think we’ll start seeing people making decisions again.

Linda van Tilburg (17:10.91)

Andrew Risk from Sable International, thanks so much.

Andy Rissik (17:14.455)

Linda, thank you.

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