I’ll be in Bogota this week, speaking to the Colombian Health Economics Association about the ethics of resource allocation and rationing. I’ve been reading about the Colombian health system. It’s a fascinating story.
Prior to 1993 Colombia had health insurance for less than a quarter of the population. This sparked passage of Ley 100 (Law 100), which created a new system, modeled on the principles of managed competition. Ley 100 created two separate insurance programs. The Contributory Regime is for the formal sector and self employed workers, and is financed by employer and employee contributions. The Subsidized Regime is for the poor and is publicly financed. Consumers choose from a set of health plans which act as purchasers for enrollees.
Ley 100 specified that the benefit package, which was more extensive for the Contributory Regime and more limited for the Subsidized Regime, would become equal by 2000, resulting in a single universal system. However, although insurance has increased from close to 20% to 74%, the benefit package for the poor remained much more limited.
If Colombian citizens believe that an intervention that is not covered by their benefit package is “medically necessary,” they can sue the health plan or public provider based on the constitutional right to health. These claims (called “tutela”) have quadrupled between 1999 and 2005.
Courts focus on individuals and their rights. One result of the tutela system is that therapies costing more than 100,000 in USD get covered for individuals at the same time that the Subsidized Regime leaves out elements of basic care for the poor.
Since the 1993 implementation of Ley 100, the Constitutional Court has been tracking health-related tutelas. In the past year it ruled that the pattern of claims demonstrates repeated violation of the right to health. The ruling stressed health as a fundamental right with the physician as the competent authority to establish which services are required. The court recognized that the right to health is not unlimited, but required that the limits be “reasonable,” with priority given to children, pregnant women, elderly and handicapped persons and special attention to the rights of the neediest.
To an outsider (me) it appears that Colombia is experiencing a face-off between a market approach to health care, reflected in its managed competition system, and a human rights approach. As the U.S. health system sees every day, markets don’t create fair access. Only the state can ensure reasonable coverage for all.
In Colombia the Constitutional Court has spoken for equity and universality. But the court system can’t be expected to allocate resources in a field changing as rapidly as medicine, especially if individual physicians, with all that we know about practice variation, are empowered to decide “medical necessity.”
The face-off between the Constitutional Court and the Ministry of Social Protection has an almost mythic structure. The Court speaks the language of rights. The Ministry speaks the language of market competition. This tension is at play in the U.S. as well, but in a much less explicit manner. The opportunity to learn more about Colombia and to speak to the Health Economics Association is a privilege, for which I thank Professor Diana Pinto of Universidad Javeriana in advance!