2023-05-20 05:20:23
12:01 AM
In record time, the Seventh Commission of the House of Representatives approved 84% of the health reform of the Government of Gustavo Petro. He did it in long days of three sessions – the last one lasting twelve continuous hours – in which he gave free rein to 117 articles that include the most sensitive points of this questioned project. It was so fast-paced that in the last stage of the discussion, an average of one article was approved every seven minutes.
It was a legislative race in which the support of the representatives of the Liberal and La U parties was fundamental, each with two votes, who had a “yes” for the articles that were approved these weeks. Among these were the most sensitive and those who, first, were full of the famous “red lines” of those two parties and the Conservative. However, in today’s sun, all that remains of those lines of all colors is the memory that a few months ago they were the cause of dispute and estrangement between the Casa de Nariño and the directors of those communities.
Words more, words less: the 117 approved articles include those that most concern medical associations, researchers, technicians, and former Health and Finance ministers. For example, the future of health promoting entities (EPS) and their conversion to Health and Life Management Entities; the future Administrator of the Resources of the General System of Social Security in Health (ADRES) and its new functions; payment of health services and health insurance; the payment of debts with public hospitals, as well as the creation of regional health funds.
Although it still lacks three long debates in Congress to become a law of the Republic, EL COLOMBIANO summarizes what has been approved so far.
The EPS, as they were known, will no longer continue
Articles 49 and 50 talk about the “transformation of Health Promotion Entities” and the “nature and functions of Health and Life Managers.” This gives a life time of two years to the EPS as they are currently known, since they must meet “the conditions of permanence that apply to them.”
In that time, insurers will have to comply with eight parameters, which include organizing Primary Health Care Centers and articulating health service providers in comprehensive integrated networks authorized by the Ministry of Health.
The rapporteur coordinator of the reform, representative Martha Alfonso (Historical Pact) made it clear that insurers will not continue to be financial intermediaries, since it is the soul of the reform: “The public administration of public resources.”
However, Harvard University health researcher, Johnattan García, said that removing this function from the EPS “lessens the State’s ability to control spending,” and warns that “the lack of control management can lead to spending in this sector skyrockets” and it is time to get those shortages from other places.
Public sector will manage health money
This part of the reform was approved in article 60, which defines the new functions of the Health Resources Administrator (ADRES), which is a dependency of the Ministry of Health. Currently, that entity functions as a health bank. That is, it collects the contributions that citizens make through their employers or as independent workers, and then transfers that money to the EPS and some health providers (IPS).
With the new functions that the ADRES will have, in addition to this function, it will be a single payer, make collections and carry out financial audits and financial risk management (a function that EPSs currently fulfill). This is in line with what the Government has proposed to be the one that manages health resources, but it raises fears as to whether it would have the capacity to fulfill these functions.
This is what the former Superintendent of Health Fabio Aristizabal puts it, as he points out that “it will not be prepared, neither in one nor in two years, to fulfill these functions. In order for it to do so, the ADRES will have to have the installed capacity that the EPS have today. She does not have the professionals or the experience or the ability to do what we need her to do.”
For his part, Andrés Vecino, a health systems researcher at Johns Hopkins University, states that “this will divide the functions instead of integrating them. It is a serious issue, because they will make the system much more inefficient. Today, the ADRES has not even been able to contract the SOAT audit system, which is 3% of the service”.
The state will pay the debts of the EPS
“They will be paid gradually, with future terms agreed with the Ministry of Finance and Public Credit,” reads article 84 of the project on the receivables that the liquidated EPS have left in public hospitals.
To begin with, future periods are a commitment that is paid with budgets for subsequent years, which in this case would be assumed by the State. Secondly, this debt could rise, as of today’s sun, to $1.7 trillion, according to the National Health Superintendence (see graph).
However, former Superintendent Aristizabal believes that a reform of this caliber is not necessary for the State to take over this debt and warns that “there will be many risks of corruption.”
And then: where are the patients?
After all, a health system is focused on meeting the health requirements of people who go to the doctor. And Colombia has managed to maintain good rates of care in the last 30 years, through health insurance that is universal, since its coverage is 98%.
In this sense, Andrés Vecino warns that the EPS knows the changes that would come if this reform is approved and put into practice, since the damage would fall on the users of the system. Because? He says, the insurers would turn to “generating the same type of insurance service that they have in Peru and Brazil, because they know that more demand for work will come.”
What does this mean? That if the objections of so many health technicians about the negative effects of this project come true, it will end in that, given the delay and difficulty of accessing services, high-income people will end up paying for private insurance (in Brazil, a 27% have it) and those with less income will be subject to more waits.
The old and familiar saying goes: “nobody knows what they have until the day they lose it”. Will this happen with the Colombian health system?
“The Government has no scruples”: Forero
House representative Andrés Forero (Democratic Center) has been a belligerent voice in Congress against health reform. In the sessions, his voice is one of the most heard. He is one of the most critical congressmen of the way in which the project has been discussed and has even revealed possible cases of corruption in the health sector.
In dialogue with EL COLOMBIANO, he spoke about the last day in which the commission of which he is a part approved 84% of the text.
Do you think that the red lines of the parties to the project were taken into account?
I consider that the Government and the speakers refused to accept the proposals of the parties of La U, Liberal and Conservative. There was only one change in the Managers, but everything else remained unchanged. Despite the change of minister, he managed to move it forward despite what the political parties requested, since the only modifications have been cosmetic. The intention to nationalize the system and end the insurance is maintained.
Why do you think health insurance is affected by what was approved?
There are several articles that affect insurance because the organization of the system changes. The relevant elements will be the primary health care centers. These would be the ones in charge of assuming many of the responsibilities that the EPS have, which in practice run out and end up being replaced by mayors and governors. In addition, care is fragmented and it is not clear how they are going to guarantee it and coordinate with the health secretariats.
Do you think ADRES will have the capacity to carry out the new functions?
The ADRES is currently the revolver of the health resources, while the ones that do the audit are the EPS. So with the disappearance of these, ADRES would have to carry out these tasks, and what would happen is that they are going to allow health spending to skyrocket due to their lack of experience in this. Today the Resource Administrator has very little responsibilities with the payments and, even so, it is doing very badly. If she can’t handle a little, she will hardly be able to handle a lot. The “black Septembers” in which health resources ran out prematurely can be repeated.
What would be, then, the payments for health services?
It is a change in health contracting, because there would be no contracts but rather it would be similar to SOAT claims, in which any company can ask ADRES for attention. With the reform, these health expenses would be 80% assumed by the Administrator and 20% would be paid after the audits. This is how we saw what happened to the “SOAT cartel”.
What do you think of the block vote on the reform articles?
It was an approval to the races and against the experts and against the doctors. It was the intention of the Government through the president of the Commission (Agmeth Escaf), who did not take off the Vice Minister of the Interior and who gave him orders. Although the discussion of discussing article by article had been raised, that did not happen and the articles were rather approved in large blocks. This way of debating this project is unfortunate because they voted for it without being able to study it in depth.
How do you think the reform will go in plenary?
After what happened yesterday, we saw that the traditional parties did not enforce their red lines because they denied all the proposals of the parties, which is further from what Dilián Francisca Toro proposed and was more similar to what Carolina Corcho proposed. In plenary I know that several of the Green Alliance do not fully agree with this, as well as some liberals. I think it will be a very close vote, but we have already seen that the Government has no scruples to achieve the majorities it needs. And in addition to the processing vices that it has, it is inconvenient.
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