The Social Medicine Portal

Lessons from Colombia: The Failure of Private Insurance to assure Health for All

The weekend of May 16th-17th brought Dr. Mauricio Torres, Andean Coordinator for ALAMES (the Latin American Social Medicine Association) to New York City.  Dr. Torres is part of Colombia’s Movimiento Nacional por la Salud (National Movement for Health) and we found a few minutes to discuss the current state of health activism  in Colombia.  Recent developments in Colombia are not without relevance to the current US debate over the role of private insurance in assuring health coverage for all Americans.

Colombia was one of many countries in Latin American which adopted neo-liberal health reforms in the 1990′s and privatized much of the health care system. In Colombia’s case this took the form of a 1993 law known as Law 100.   Law 100 established a health insurance market with the goal of increasing efficiency through competition.  Law 100, however, was built on a two tier insurance system.  Individuals who were employed in the formal sector or had incomes two times the minimum wage were required to enroll in the Plan Obligatorio de Salud (POS), a compulsory health insurance system.  The rest of the population was placed in a State-subsidized Plan Obligatorio de Salud Subsidiado (POSS). Benefits in the subsidized plan were half those of the employee plan, but promises were made that benefits in the two programs would be equalized by 2001. These promises have yet to be kept.

The Colombian system has been criticized for a number of reasons.  First, according to data from 2007, only 88% of the population is actually covered by this “universal” system.  And, as might be expected, it is vulnerable populations who are most likely not to have insurance. Secondly, health insurers in Colombia (like everywhere) have learned that there is more money to be made by denying services than by providing them.  So the mere fact of having insurance does not necessarily equate with access to care.  This problem, of course, is not unknown in the US and was the subject of Michael Moore’s movie, SiCKO.  Thirdly, by organizing the health care system around profit-based personal medical services, public health was neglected; the organic bond between clinical services and public health was broken.  Finally, and perhaps most significantly, Plan 100 was criticized for making health care a commodity and not a right.

The failings of the Colombian system have led people to seek redress in the court system. This is done by requesting tutelas (court-ordered protection or  supervision) to enforce their particular claims to treatment.  These claims are based on the premise that insurance company denial of treatment is a violation of their right to health.   As discussed in a recent article published in PLOS (see reference below) there were approximately 90,000 petitions to the Colombian courts for such tutelas in 2008.  The courts generally supported these petitions in cases:

(i) when there is an inextricable relationship with “fundamental rights,” including the right to life, such that if the right to health were not protected immediately it would result in the violation of these latter rights; (ii) when the case involves a person or group of people in especially vulnerable circumstances, such as children, pregnant women, or the elderly; and (iii) when the health good or service at issue is included in the POS/POSS, which the Court has taken to define a minimum core content of the right to health.

In July of 2008 Colombia’s Constitutional Court issued a landmark decision (T-760/2008) declaring the the current system had failed to guarantee the right of Colombians to health and ordering a series of remedial actions by the State. These actions were to be carried on a specific timetable that would fulfil the 1993 promise of equity between the two plans by 2010.

The decision was widely commented in Colombia. Was it really such a good idea for the Constitutional Court to be setting health policy (or telling the government exactly how and when it should go about implementing the existing policies)?  Was the decision, with its limited vision of a right to health expressed through health insurance, really a progressive one?  Would the decision actually be implemented?  If implemented, would it be enforced?

It remains to be seen whether or not the Colombian government will, in fact, carry out the Court’s orders, although it has formally accepted them.

In the meantime Colombia’s health insurance industry suffered a major public relations blow in April when the National Superintendent for Industry and Commerce cited 15 health companies for anti-competitive practices.  The Superintendent accused the companies of illegally fixing prices, conspiring to limit access to services, and falsifying or hiding information.

Commenting on this case in the Colombian edition of Le Monde Diplomatique, Carlos Ivan Pacheco S. noted wryly:

“It is, to say the least, surprising that the investigation was carried out by the Superintendent of Industry and Commerce and that the charge was anti-competitive practices.  This clearly shows the way in which Capital has come to dominate the health field.  The Superintendent of Health and the Ministry of Social Protection were notable for their absence in this case, thus  leaving the initiative to the  Superintendent of Industry and Commerce, which had recently investigated cement  and banking industries for similar practices.  And so the right to health now falls into the same category as cement production and banking.” [Our translation]

This story should sound familiar to us New Yorkers. In January our Attorney General Andrew Cuomo reached an agreement with the insurance giant United Health Care.  Quoting Attorney General Cuomo: “For the past ten years, American patients have suffered from unfair reimbursements for critical medical services due to a conflict-ridden system that has been owned, operated, and manipulated by the health insurance industry.”

The philosopher David Hume reminds us that:  “From causes which appear similar we expect similar effects.” We might, therefore, reasonably ask: Do we really expect a for-profit health insurance market to provide high-quality, equitable health for all?

Further Reading

A full copy of the 411 page Constitutional Court’s decision can be found at this link.

The Colombian Supreme Court’s decision is discussed in an article written by Alicia Ely Yamin and Oscar Parra-Vera entitled How Do Courts Set Health Policy? The Case of the Colombian Constitutional Court and published in February 2009 in PLOS.  Those who read Spanish may want to look at Carlos Ivan Pacheco’s complete article in the Colombian edition of Le Monde Diplomatique entitled El derecho fundamental de la salud para los colombianos. This article adopts a critical view of the Court’s decision.  A critical analysis of the Colombian Law 100 is provided in Colombia and Cuba, contrasting models in Latin America’s health sector reform written by Pol De Vos, Wim De Ceukelaire and Patrick Van der Stuyft and published in Tropical Medicine and International Health in 2006.

Dr. Torres has agreed to share with the Portal’s readers a recent presentation reviewing the Colombian Health Situation in a time of crisis and pandemic illness.

posted by Matt Anderson, MD