Chilean health insurance system: a source of inequity and selective social insecurity

Abstract

More than 20 years after its radical marketoriented reform, the Chilean health care system shows serious equity and fairness problems. Private insurance companies have used ex-ante as well as ex-post risk selection to avoid the affiliation of poorer and older enrolees presenting higher risks. The coexistence of a solidarity-driven public sector and a for-profit private sector operating with risk-adjusted premiums has led to a twotier health insurance system. Unpredictable, often existentially threatening co-payments have become an serious problem for the users of the Chilean health care system, and coverage-lacks have become a major menace for patients. Private insurers supplement "Cream Skimming" and risk selection with contracts calling for significant out-of-pocket payments for health services. This article develops and applies a methodology to measure and compare systematically the impact of user charges for varying levels and complexity of treatment in the public and private health care sector. Co-payments in the private sub-sector show enormous variation, are hyper-regressive and discriminate not only against the ill, but also against the members of the lower socio-economic classes once they have passed the high access barriers. As cost-sharing affects the financial coverage and thus the accessibility of health care, it has become an important mechanism of quality skimping and active disenrolment. Private health insurance companies are relatively well prepared to cover costs for a wide array of traditional health problems; they fail, however, to respond for the costs of other leading diseases in Chile. The private system seems to be poorly prepared to face the challenges of the epidemiological transition in emerging countries.

Religion and Spirituality in Coping with Breast Cancer: Perspectives of Chilean Women

“…For some, religion was one of the few resources available to them. Public counseling services are sparse and largely inaccessible in Chile, and most people cannot afford private services (12). In contrast, religion presented an unlimited resource freely available to all these patients, if they had the requisite willingness and affirmation.…”

Regulating self‐selection into private health insurance in Chile and the United States

“…With the advent of democracy in Chile, policy makers acknowledged that the fragmented health insurance market and the lack of adequate regulations undermined solidarity across health insurance funds and promoted the regressive financing of health insurance (Mesa‐Lago, ). New policies were implemented to reduce self‐selection and improve the functioning of the private health insurance market through reduced health plan heterogeneity, dissemination of information about the performance of private health plans and the definition of essential health benefits (Jost, ; Sapelli and Vial ; Holst, Laaser and Hohmann, ; Sapelli, ).…”

“…The experience of Chile and its mixed market‐based model has often been criticized in the health policy literature as one that enhanced social inequalities, increased administrative costs and mostly benefited the wealthier and healthier sectors of the population (Holst, Laaser and Hohmann, ; Homedes and Ugalde ; Paraje and Vasquez ; Vasquez, Paraje and Estay ). Unrestricted self‐selection into public or private health insurance has translated into market segmentation and increased administrative costs (Holst, Laaser and Hohmann, ; Mesa‐Lago, ; Sapelli, ). Chile achieved nearly universal health insurance coverage using a public–private mix; however, inequities have increased as well (Unger et al .…”

Retrenchment Reconsidered: Continuity and Change in the Post‐authoritarian Institutions of Chilean Social Policy

“…Given the high administrative and operational fees associated with the private sector, only the upper‐middle and upper classes of Chile have been able to afford to enrol in ISAPREs. In 1990, only 16 per cent of Chileans had purchased private insurance, and 86 per cent of these purchasers had incomes over $40,000 per year (Holst et al. 2004).…”