The inescapable evolution of the Chilean health system
Pier Paolo Tropeano
Experience in APS and Access
Chile is in one of the most relevant discussions in terms of public health in the last decade, where the main objective is to carry out a structural reform that allows progress towards a more equitable and supportive health system.
The Chilean health system has undergone important transformations in recent decades, which have a neoliberal turn towards the privatization of insurance and the health market since the reforms of the 1980s. Among the main changes are the creation of the National Health Fund, the National System of Health Services, the Health Insurance Institutions (ISAPRES) and the process of municipalization of primary care.1
These reforms improved, on the one hand, the separation of the functions of financing and provision of health services, and on the other, the decentralization processes of the national network. However, the current structure of the health system tends to produce and encourage inequities and inefficiencies in the management of the sector, which have been raised by citizens and governments in recent years.2
One of the main dimensions that has been questioned in the media has been the financing and collection of the current system, which lies in the fact that health contributions can be directed alternately towards two health insurance systems, which work in parallel and with different incentives. . In the first place, contributors can choose between being part of the public health insurance (FONASA) or the private health insurance offered by the ISAPRES. If the payment of the mandatory contribution (which corresponds to 7% of the gross salary) goes to FONASA, the contributor and their dependents are assigned to the public health system. In case of choosing to channel the payment to the ISAPRE system, the contributor becomes part of the private health system.
This type of system constitutes, according to experts, an anomalous situation in the international context, mainly because the latter do not act as private insurance, but as private institutions that collect and administer an insurance that is social, being able to legally manage and benefit from the health contribution of the affiliated chileans3. This is due to the fact that in the current constitution (in force after the exit plebiscite of September 4, 2022) it mentions the "freedom of choice" of health systems, where a segment of the population with higher income and lower health risk could take their mandatory social security contribution to subsidize the payment of private insurance premiums. However, it is interesting to note that the ISAPRES have discriminated against people's income and health risks, generating a large number of “health plans”, which is typical of private insurance, but not social welfare insurance.
This mixed health system has strengths and weaknesses in the forms of insurance and provision of health services used. In particular, the private system is affected by the usual problems of individual insurance (risk selection, short-term coverage, high administration and sales expenses, lack of transparency of plans and benefits), while the deficiencies of the public system are They concentrate on the problems of attention to users commonly reported by bureaucratic organization schemes financed on the basis of supply. Additionally, the conjunction of both systems separates the population into segmented groups according to socioeconomic and health risk variables.4
Today, thanks to our constitutional discussion process (which climaxed on September 4, 2022, when citizens rejected the new Magna Carta proposal), the health dimension is even more highly evaluated by experts and society, however , is not a discussion that governments have not addressed in the past. Various reforms since the birth of the ISAPRES have been carried out to try to reduce the inequity that exists in the system. A clear example occurred in 2000, when former President Ricardo Lagos created the AUGE Plan (today called GES, Explicit Health Guarantees4) to face health problems prevalent in the population, guaranteeing its comprehensive approach. On the other hand, in the administration of former President Sebastián Piñera, the Ricarte Soto Law was created, which addresses the issue of financing treatments and medical devices for high-cost diseases and the National Cancer Law (creating guidelines for its comprehensive approach).
It is for this reason that the health reform constitutes one of the three structural changes in the government program of President Gabriel Boric. Based on her government plan, the Minister of Health María Begoña Yarza published her legislative proposal for this semester in the following areas:
- Creation of the Universal Health Fund (FUN): Sole administrator of resources through the universalization of FONASA coverage to all people residing in the country. In other words, the transfer of ISAPRE affiliates (close to 3.5 million) and their 7% contributions to the national fund.
- Elimination of ISAPRES and transformation into complementary insurance: Creation of insurers that receive an additional percentage of contribution from members to complement public guarantees. Therefore, they do not constitute substitute entities of the FUN.
- Creation of a National Health Service, with an integrated public-private network. This forces private providers to adhere to the guidelines and tariffs of the national system.
These edges have materialized in initiatives already implemented by the government. One of them corresponds to the elimination of the co-payments of the FONASA beneficiaries belonging to brackets C and D, whose taxable income constituted the highest value of the 4 brackets (A, B, C and D). In other words, all FONASA affiliates will have free access to all their care in the public health system (AUGE/GES and No AUGE/GES) in addition to those who are part of sections A and B.
This announcement translates into an automatic benefit for 5,388,907 people belonging to the indicated sections. With this, the more than 15 million users who are in FONASA will have free access to the Institutional Care Modality (Public Health Network).5
Although the measure is a solution to the out-of-pocket expenses of FONASA patients, according to the Institute of Public Policies in Health (IPSUSS) it does not constitute a solution to the essential problems that are experienced in the public system: low capacity to respond to demand of specialists, long waiting lists for explicit guarantees and a large percentage of FONASA beneficiaries who, since they are not attended, must approach private health providers through the Free Choice Modality (MLE).6
Finally, the elimination of the co-payment in the public system, a proposal for an independent ETESA institutional framework, and the intervention in the tariffs for benefits in private providers are symptoms of the imminent reform that Chileans will experience in the face of a more equitable health system.
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1. OECD Public Health Reviews: Chile Towards a Healthier Future, Assessment and Recommendations, OECD (2019). Retrieved online on May 19, 2022 at: https://www.oecd.org/health/health-systems/Revisi%C3%B3n-OCDE-de-Salud-P%C3%BAblica-Chile-Evaluaci%C3%B3n-y-recomendaciones.pdf
2. Subsidiary state, segmentation and inequality in the Chilean health system. Goyenechea Hidalgo (2019). Medical-social notebooks. 59. 7-12.
3. The Chilean Health System: A pending task. Alejandro Goic (2015). Medical Journal of Chile; 143; 774-786
4. Political Constitution of Chile [Const]. Art. 19 numeral 9. September 17, 2005
5. Consolidation of norms approved for the constitutional proposal by the plenary session of the convention. Retrieved online on May 19, 2022 at: https://www.chileconvencion.cl/wp-content/uploads/2022/05/PROPUESTA-DE-BORRADOR-CONSTITUCIONAL-14.05.22.pdf