Former President Álvaro Uribe, one of the most knowledgeable men in health care since he was rapporteur on Law 100 when he was a congressman, spoke out this Friday, February 17, against the health care reform proposed by Gustavo Petro’s government.
While the President recognizes some important points, He asserted that the reform “will wither away the private sector”, “restrict the right to free choice” and could provoke political clientelism. In addition, according to the former President, the EPS is “finished”.
Uribe also attacks the Cuban health system: “The paradise they show the visitors is the opposite of what the Cubans register. The state monopoly started well and today it is total chaos.”
These are Uribe’s reflections:
1. In the first reading of the bill, articulated and reasoned, an ideological scenario is observed that will wither the private sector, including health foundations, and impose a dangerous state monopoly, backed by myriad groups with very likely political homogeneity.
2. There is a confrontation between the current mixed system, which critics call the market, and the state monopoly, which glorifies it as social.
3. The current system is mixed: the state regulates, that is, it legislates, it also monitors, but it is not the only operator. The benefit can be provided by state, mixed, private corporations, cooperatives, foundations, family compensation funds, etc.
4. The current system is constitutionally governed by the principles of solidarity, universality and efficiency.
5. The gain attributed to good EPS is much less than the cost of public inefficiency. Good EPS, which spends most on administration, does not exceed 4.5% and returns on equity have been minimal or negative.
6. There is also no room for a division between rich and poor, since the solidarity of the system means that everyone has the same benefits, the same care and access to the same hospitals, public, private or foundations, despite different contributions.
7. The real divide is between well-endowed and deficit regions, particularly in rural areas. There are also shortcomings in the social determinants such as nutrition, housing, education, public services, etc. that the project points out.
8. The division of results between well run companies and those with corruption and/or politics is clear. In addition, care in health centers and hospitals, especially public ones, is in a desolate state.
9. According to the project, affiliation would be through registration in a primary care center which, regardless of its public or mixed character, would be embedded in a state monopoly system.
10. There would be one center for every 25,000 people. No fewer than 2,000 new centers would be needed, costing about 10 billion pesos, an amount apparently earmarked for physical labor and omitting equipment.
11. The right to choose freely is limited, which also cannot be understood absolutely, because there are regions that do not have enough infrastructure to choose from and good service, a variety of insurers is also not convenient.
12. The 2023 budget has an item of 1.5 billion for the improvement of base centers in rural areas. The sum would grow at a real annual rate of 1.1% for 10 years. This effort is necessary.
13. The amount of the contributions will not vary.
14. Co-payments and moderator fees are prohibited. Article 26(1). He keeps them for what is not “vital”. The current system limits them to the contributory system and to an earnings-based system, which is fairer.
15. The primary care center defines the partner’s need to be referred to a more complex service. According to Article 87, this decision appears very complex and is governed by four concepts.
16. One of the major complaints in Colombia, expressed by a good portion of the 90,000 guardians each year, is the delay in patient referrals. With the proposed bureaucratic framework, this problem could increase.
17. Delays are a global problem. In Canada, it went from 3.7 weeks in 1993 to 11.1 weeks in 2021. In Colombia, it depends on subject areas and unavailability of specialists. The average values for this waiting period range from 8 weeks in obstetrics to 13.7 weeks in gynaecology.
18. The current system of guardianship, health inspectorate and multiple institutions offers citizens more opportunities to assert claims. The possibility of claiming a state monopoly becomes a political privilege.
19. With regard to the supply of medicinal products, Article 125 of the project only states that this is to be done by authorized distributors. Here another concern arises that any pharmacy or dispensary must be dependent on a government monopoly, with risks of bottlenecks and distribution logistics.
21. The prevention programs would be located in the primary care centres. They would be supported by 11,700 regional teams and 5,000 health promoters. The fear of an explosion of political clientelism is justified. On average there would be more than 3 visits per year per person. Consultations worth 200 million per year would be more transparent and of better quality by strengthening the current system with greater integration with hospitals, compensation funds, community and departmental organisations. In addition, with an increase in telemedicine, which includes the project, and a rigorous motivation and monitoring of the national bodies. There is consensus that prevention needs to be improved, although the country has made progress, as evidenced by increases in life expectancy and vaccination coverage.
22. Although the reduction of maternal and child morbidity and mortality needs to be accelerated, it must be recognized that the unsatisfactory average is mainly due to differences in infrastructure between regions and even in large cities.
23. Tariffs are unique and set by the national government. The same article 47 expresses that the system is modulated with the tariffs not only in the results but also in the range of services. There is no norm obliging the differentiation criterion based on the characteristics of regions with its perverse effects on quality and on increasing citizens’ own spending.
24. The one-time fee puts you in a straitjacket that can demotivate even the best hospitals. Rather, the reference interest rate offers leeway for providers and insurers to analyze costs and qualities. In a country with price controls on some drugs, controlled freedom on others, and the ability to extend those powers to procedures, the flat rate set by the government becomes a pernicious excess of government control.
25. In the regional funds there will be a director who will be an officer of ADRES – official administrator of the funds – who will approve the contracts and payments. The state is changing from monitoring, which works without a monopoly, to being the only one who hires and pays. Although today there are delays in payments and balances that hospitals have not been able to catch up with, the state monopoly can exacerbate the problem to the extent that the accelerated expenditure of resources, the subsequent exhaustion, is added to the political intrigue that replaces the democratic claim , viable with the mixed System. Within the framework of a large number of actors, the claim arises, but in the face of the monopoly state, fear and silence prevail.
26. The project proposes a series of bureaucratic institutions, most of them made up of collectives, with the risk of dangerous selection based on political criteria that do not affect administration and cause excessive costs and duplication. In addition to the 11,700 territorial teams and the 5,000 health promoters, there are other creations: on page 133 of the project, Rationale, you can read the list of 9 entities that would be created, 8 of which would be collective; 6 of the 9 would be at the territorial level, in clear duplication with district, departmental and municipal health facilities. A simple reorganization would suffice for the current institutions to fulfill these tasks. To this must be added the decentralization of Adres, which, as stated on page 141 of the project’s explanatory memorandum, would have 7 regional directors for recruitment and payment and 33 departmental audit offices.
27. If the project is approved, the mixed insurance system will be transformed into a system of state and political mediation. In fact, the project ignores the nature of EPS insurers and stems from the disqualification that saw them as mere intermediaries. Insurance responsibilities such as affiliation, collection, servicing, health and financial risk management, auditing, sanctioning and approving accounts, assessment and payment of economic benefits all remain with the state or are under its absolute control.
28. The EPS could be primary care centers, hospitals using the new terminology, or government contractors. In the end they are over.
29. There were EPSs with serious corruption and political problems, with abuses by their owners and delays in payments. The previous government put a lot of effort into cleaning it up.
30. Difficulties of the EPS arising from instances of slowness in ADRES in transferring resources, over-billing and glossing over by insurers and providers should be noted. Also the inadequacy of the per capita fee and the non-payment of special services in exceptional times – maximum budgets -. And the negative impact on hospitals caused by liabilities with no equity support and no payment in liquidated EPS must be recognized.
31. Public EPS and cooperatives have failed, with notable exceptions such as Mutual Ser and CooSalud. It is grievous that corruption and maladministration in some compensation funds that should be exemplary have done as much damage as many of them are, for example in the supply of medicines.
32. Many failed EPS have their roots in the public, national and regional sectors. This reality proves that the current system was truly mixed, with the state as regulator and watchdog, but without monopolies of operation.
33. The ideal of a transparent state is approached with the democratic context and the possibility of criticism generated by private participation, not by political collectives absorbed by the state.
34. Good EPS is a very important heritage for the whole country that should not be abolished. The low profitability of these assets should draw the attention of the government and Congress to ensure, with the consistency of high-quality EPS, that these assets, many of which are private, continue to serve the country. Let’s keep in mind that very often these assets absorb healthcare losses, with the consequent savings for the state.
35. The health database of all connected citizens would be converted into a state census.
36. The value defined by the regional health insurance funds of serving every citizen in medium or high complexity would replace the per capita fee that the EPS receives today. They have to assume solvency, build up reserves and vouch for their investment. These guarantees disappear in the state monopoly.
37. Good EPS represent the patient who would be at the mercy of a state-only system with unavoidable risks of political intrigue and corruption.
38. We insist on the proposal that the EPS must obtain the highest quality accreditation.
39. Many public hospitals have lived from crisis to crisis due to politics, corruption and delays in collecting their portfolios. With the project’s proposal to tie its missionary human resources to a permanent contract, politicking may decrease, which would prevent the mobility of temporary workers in line with policy direction. It will be necessary to take into account peaks in demand and not to exclude the possibility that the workers’ organization will carry out outsourcing or even missionary tasks through a union contract or similar.
40. Hospitals in remote regions or with dispersed populations receive official budgets without having to match bills for services rendered, which would be very damaging if this exceptional practice were generalized because it would encourage waste.
41. Colombia has excellent hospital foundations, many of which are exemplary on labor issues. The experience of running away from government payments sets a bad precedent for this government monopoly project that could see them wither away in a step-by-step scenario. It should be noted that many of these foundations are examples in labor matters.
42. The project can make the state the sole employer of health care.
43. Article 61 of the project orders direct transfer without exception, which is an old hospital wish.
44. Article 98 proposes a period of 30 days from the approval of invoices to pay 80% of their value. What seems very good can be degraded over time given the context of the items, which can lead to resource depletion and customization through the reduction of the performance plan.
45. Let’s not forget that citizens’ own spending exceeded 55% before law 100 and now 16%, a trend that could reverse if the new system deteriorates over time.
46. A good way against corruption and disorder was the possibility of entrusting the management of public hospitals with outstanding private foundations (non-profit). Unfortunately, Article 148 of the draft law excludes this possibility.
47. There is no doubt that the economic benefits related to invalidity and invalidity due to general illness and maternity or paternity are managed and recognized by the public monopoly. Despite the fact that, according to Article 101 of the project, the competence to define the topic lies with the Ministry of Health, the consistency with the remaining articles supports our conclusion.
48. The special regulations and in particular the National Fund for Social Benefits for Teachers are excluded from the new regulation. Despite the fact that I was spokesman for the law that created the Teachers’ Fund in 1987, 1988 and 1989, there have been serious allegations of its use by grassroots teachers who complain about cases of corruption and politics. I do not exclude myself from the responsibility that I have in some ways as a former President of the United States for the shortcomings in the services provided to military personnel, retirees and families. This regime, which would remain in force, requires major improvement in several regions.
49. Article 51 of the project requires tourist and temporary residents medical insurance with an effective guarantee of recovery. The phenomenon of displaced immigrants from countries like Venezuela cannot be ignored.
50. The improvements needed by Colombia’s health system, which are largely described in the motivation for this government project, could be thwarted by the state monopoly enshrining its Articles.
51. Permission for a state monopoly is difficult to reverse. Law 100 allowed adjustments, state monopolies have a rigidity that excludes them.
52. Cuba, a dictatorship hailed by its friends and treated favorably by western democracies. In the health sector, there are important commonalities between critics and defenders of the system. We must remember that between 1960 and today, Cuba has doubled its population and Colombia has tripled it. Cuba has no population dispersion, Colombia a lot. There are serious disagreements about the development of life expectancy and other indicators. Some applaud and others criticize the pre-Castroist system. There is consensus about the important achievements in the early years of the revolution. Regarding the present, both the new 300,000 migrants who have arrived in the United States and people studying this issue agree that there is a deep crisis, marked by the deterioration of infrastructure, a 32% decline in infrastructure between 2008 and 2021 says Professor Mesa Lago, Emeritus of the University of Pittsburgh. Added to this is the decay of the remaining infrastructure, the lack of equipment and medicines that the regime accuses the US of, the deterioration in quality and the circulation of medical and support staff. Out of 10 people who need services of medium and high complexity, they reach only 2. Social determinants such as public services reduce hours and quality. Foreign doctors who went to orthopedic specialties left frustrated because they have to make the prostheses using the bones of the corpses of people who died in adulthood. The paradise they show visitors is the opposite of what Cubans register. The state monopoly started well and today it’s total chaos.