Private-insurance debate moves to Chile
CMAJ 1997;157:1502
© 1997 Lake Sagaris
Here's a twist. As Canadians continue to debate whether to develop a parallel private health care system to take pressure off the public system, Chile is moving to take money away from the private sector to boost its overcrowded public sector. In that country, government plans to eliminate a subsidy worth about US$50 million to private health insurers have sparked fierce criticism from opposition parties and the companies themselves, but government supporters in Congress still hope the measures will pass.
During this year's state-of-the-nation speech, Chilean President Eduardo Frei announced he would eliminate the subsidy, which allows workers access to private insurance programs. The Chilean health care system, like Canada's, is modelled after Britain's National Health Service. Widely available public health insurance pays for care in public hospitals and a network of primary care clinics. However, the military government that ruled from 1973 to 1990 cut spending on the public system and at the same time created private health insurers, which now cover the wealthiest 25% of Chile's 14 million people.
Because the economy grew steadily over the past decade, health problems have shifted away from the traditional ones that dog underdeveloped nations toward the pathologies North Americans are familiar with: stress-related addictions and depression, cancer, AIDS, ulcers and back and cardiac problems.
But economic growth has not brought benefits to everyone. According to the World Bank, the UN's Economic Commission and other authorities, Chile has the worst income distribution on the continent after Brazil, and poverty remains a pressing problem for almost 1 in 4 Chileans.
The country's private clinics often offer state-of-the-art technology and catering worthy of a 5-star hotel, but many of those who, in theory, are covered by private insurance use public services when they're ill because of the high costs of private treatment.
The military's health care model has left both public hospitals and the national insurance plan, FONASA, badly underfinanced. Today's public-health budget, which is supposed to cover the needs of 75% of Chileans, equals about US$1.9 billion annually, while private insurance companies have budgets totalling about US$1.8 billion annually. The cutbacks combined with rising costs to eat away at the system, and no one is quite sure where to find the financing to improve it.
Alex Figueroa, the health minister, says the government's bid to recover the subsidy would provide money to cut through lengthy waiting lists for surgery and to upgrade facilities and improve service in the public system. Opposition leaders say that if the subsidy is cut up to a million people could be forced out of the private system and back into the public system, causing it to collapse. Proponents deny this, saying the number will not exceed 113 000. If the bill passes the government will gradually eliminate the subsidy, starting in 1998. -- © Lake Sagaris
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