Chilean Health Insurance System: History
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1 ClermondFerrand, 2 nd December 2004 Dr. med. Dr. PH Jens Holst Chilean Health Insurance System: History " # $ $"$ $ & ' ( $ ( * ( + *, ( * ' '. ( * ' ( *
2 Chilean Health Insurance System: Reform Health sector reform of 98: Decentralisation: Division of the SNS in 27 regional Health Services ( SNSS Communities become responsible for basic health care Setting up of FONASA (National Health Fund as public health insurance Admission of private funds for mandatory social health insurance: ISAPREs Health Welfare Institutes Chilean Health Insurance System: Reform Sociopolitical background: Military dictatorship of Augusto Pinochet General austerity policy regarding social expenditure Continuous cut of public spending on healthcare Worldwide predominance of liberal economic ideas (Milton Friedman Characteristics of the Chilean health reform: Lack of regulation and control of private health insurance No participation, topdownstructure Lacking transparency, insufficient consumer information
3 Chilean Health Insurance System: Reform Goal: Competition between public and private health insurers (principle of solidarity versus principle of equivalence Health insurance remains mandatory, minimum contribution 7 of taxable earnings Dependent and nondependent workers and employees have at least theoretically the option of choice between public and private health insurance The public insurer (FONASA underlies the contractual obligation to accept all citizens; affiliation to a private insurance company (ISAPRE requires an active step and is voluntary Chilean Health System: Insurance competition ISAPRE Can refuse applicants Individual, riskrelated health plans Plans renewed every 2 or 24 months Has to accept all applicants Collective, riskindependent health plans Unlimited duration of contracts FONASA
4 Chilean Health System: Insurance competition ISAPRE Contribution calculated for each group according to expected expenditure Principle of equivalence between contribution and risk contribution and coverage FONASA Contributions according to wage income only (up to upper ceiling Principle of solidarity contribution according to wage coverage according to need 0 Chilean Health System: Insurance competition Contributors of FONASA and ISAPRE by income Number of contrinutors "2$2 3$ Monthly income (in 000 Pesos 750 unknown
5 Chilean Health System: Insurance competition "2$26 3$ & "# Chilean Health System: Insurance competition Public opinion: Priorities in health financing :& 6 * :& 6 * 9 * 2 * $ * * * * * * * * $, $ ; $
6 Health sector reform Chile: Results 8 ( * "2$26 =$6 * =$6 58 ( 8 + * * & 3$245 3., ( # ' & 8 ( 4 6,?. & Chilean Health System: Comparison Copays Main criteria for B. A $ & 2 2 = 2 "
7 Chilean Health System: Comparison Copays $ & ' 5 3= C 2 ' The sample: Family structure: Family type : Male enrolee 25, wife 24, son 3 years Family type 2: Male enrolee 40, wife 39, son 5, daughter 4 years Family type 3: Male enrolee 55, wife 54 years. Income groups: Monthly wage of 400, 700, 00 and 600
8 ' Private Insurance Companies: Market share Rest of open Isapres 37 Cruz Blanca 6 Banmédica 9 Vida Tres 6 Consalud 22 Chilean Health System: 2 2 = 2 "(# 0 0 "#
9 Chilean Health System: 2 2 = 2 "(# 0 "(# ' ' ( 9 6, 6 * ( ' ( 8 ( $ D 3 ' 3 ' ( 3 &
10 Health sector reform in Chile: Results * * A A A0 A0 A0 A A A A A A : " Health sector reform in Chile: Results * A * A A0 A0 A0 A A A A A A? 2E9 57 6
11 Health sector reform in Chile: Results :7 7 2 "? 2E9 $ 57 Health sector reform in Chile: Results 0 Copayment relation Famil, :7 A0 A A 7 2 "? 2E9 $ 57
12 Health sector reform in Chile: Results 0 :7 7 2 "? 2E9 $ 57 Health sector reform in Chile: Results $245A "2$2 6
13 Chilean Health System: Insurance competition Basic elements of health insurance competition in Chile:. Mandatory health insurance for all citizens 2. Social fairness of financing exogenous (wage related definition of contributions 3. Health insurance competition excludes the poor 4. Private health insurance companies determine their target groups 5. Competition focussing on good risks and high income groups Chilean Health System: Insurance competition Basic elements of costsharing in Chile:. Social cushioning of copayments in public sector only: waivers and exemptions in place 2. Application of the principle of equivalence on the side of expenditure: a. Variable coverage of health costs b. Partly high, generally unpredictable copayments c. The lower the contribution, the higher the cost sharing d. Insufficient consideration of epidemiologic needs
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