Cablegate: Uribe's Health Care Scheme Under Fire
RR RUEHAO RUEHRS
DE RUEHBO #0335/01 0551708
ZNR UUUUU ZZH
R 241708Z FEB 10
FM AMEMBASSY BOGOTA
TO RUEHC/SECSTATE WASHDC 3027
INFO WESTERN HEMISPHERIC AFFAIRS DIPL POSTS
RHEHAAA/NATIONAL SECURITY COUNCIL WASHINGTON DC
UNCLAS SECTION 01 OF 03 BOGOTA 000335
E.O. 12958: N/A
TAGS: PGOV SOCI ECON CO
SUBJECT: URIBE'S HEALTH CARE SCHEME UNDER FIRE
REF: 08 BOGOTA 3352; BOGOTA 163
1. (SBU) SUMMARY. President Uribe declared a "Social Emergency"
just before the New Year, giving the executive branch the power to
issue health care reforms by decree. The decrees -- implemented
without Congressional approval -- aim to prevent the financial
collapse of the health care system, which faces an estimated $3
billion shortfall. The measures also seek to improve medical
attention for 51% of the population that receives subsidized health
care. Widespread public opposition has focused on the GOC's lack
of consultation with stakeholders, restrictions on prescribed
treatments, and penalties against doctors who fail to adhere to the
new program. Within several weeks, the Constitutional Court is
expected to rule on whether the new taxes and reform measures are
legal. END SUMMARY.
GOC ADDRESSES RISING COSTS, HEALTH CARE INEQUALITIES
2. (SBU) Colombia faces the dual challenge of widening access to
health care and improving the quality for its poorest citizens.
The GOC enacted two parallel health system programs in 1993 to
ensure universal access to health care: the subsidized program,
which covers the unemployed and the informal sector, and the
contributory program, under which the salaried or self-employed
contribute 12% of their salary. Under this progressive design,
contributors help underwrite the subsidized system. As a result,
health care coverage expanded from 20% of all Colombians in 1992 to
94% in 2009 (ref A). While the 1993 reforms resulted in very high
levels of "coverage" in terms of numbers of Colombians having
health insurance, "access" -- in terms of actual services -- has
lagged considerably, especially in rural areas.
3. (U) The health care system is threatened by two problems. The
system is almost bankrupt due to unrealistic estimates of the
number of Colombians in the contributory system. Unemployment for
2009 averaged 12% (13% in the last decade), and the informal sector
has increased in size -- from 48% to 58% of the workforce -- over
the past 10 years (ref B). Second, those under the subsidized
program (51% of the Colombian population) enjoy fewer benefits and
lower-quality care than those in the contributory system.
4. (SBU) The proposed reforms identify new funding sources to avoid
bankruptcy of the system and equalize health care coverage for
subsidized and contributory users under the basic Obligatory Health
Plan ("POS"). By July 2010 - as directed last year by the
Constitutional Court -- the POS coverage must be the same under
both the contributive and subsidized plans. The Finance and Health
Ministries calculate that this ruling will impose an additional
billion in funding costs.
GOC IMPOSES LIQUOR TAX, ABOLISHES LAWSUITS
5. (SBU) To expedite the process and avoid a laborious negotiation
with Congress, President Uribe declared a "Social Emergency" on
December 23, 2009, allowing him to impose new taxes and procedures.
Of the 16 decrees, ten (Decrees 126-135 of 2009) are considered
controversial and include major changes to the health care system.
New elements include:
-- Regulations to control health costs, including a list of
approved drugs and treatments under the POS. There are sanctions
and even jail time for doctors and health professionals who do not
abide by these regulations.
-- VAT tax of 14% imposed on national and imported beer sold in
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Colombia (the prior VAT was 3%), which will help finance the
broadening of services covered by the POS. Similar taxes will be
imposed on cigarettes, liquor and gambling.
-- Services that are not included within the POS are called
"exceptional health services" and will be reviewed by a committee
of health care providers and outside experts. Previously, patients
could initiate a judicial lawsuit ("tutela") to obtain needed
treatment for their ailment. If the committee denies coverage, the
patient can utilize pension savings to pay for medical services.
6. (U) A national level committee made up of representatives from
the Ministries of Finance, Health, Colciencias (science and
technology agency), and three outside experts will periodically
evaluate the services and medicines covered by the POS.
MEDICAL ESTABLISHMENT AND PATIENTS OUTRAGED
7. (SBU) President Uribe's government has come under heavy fire for
not consulting with stakeholders before issuing the decrees. The
new measures sparked opposition from medical professionals, labor
unions, patients, Congress, and the public. The decrees also
became a campaign issue for presidential candidates. Two senators
plan to introduce a "patient's bill of rights." A presidential
advisor told us privately that Uribe is extremely displeased with
the handling of the issue by Minister of Social Protection Diego
Palacios and fears that the health care controversy could be as
politically damaging as the DMG pyramid scheme.
8. (U) Gustavo Malagon, President of the National Academy of
Medicine, stated the decrees are a "serious attack on the medical
profession. Such an attack has never happened before in this or
any other democratic nation." The Academy claims the decrees
undermine doctors' expertise and limits their autonomy, "trapping
them in an insurance system that is eminently commercial in
nature." This criticism is echoed by the Colombian Association of
Clinics and Hospitals and other health sector actors.
9. (U) Oscar Rodriguez, Economics Professor at Universidad
Nacional, noted the reforms are not intended to improve the
health care system; the objective is to alleviate an overburdened
national budget. Rodriguez argues that the decrees will increase
poverty levels, because the poor will have to finance "exceptional"
illnesses with their limited personal savings.
10. (U) Others criticize the burden of equalizing the two health
care systems, claiming it will fall too heavily on the contributive
system. While the goal is to expand services under the POS, some
patients fear that by giving the health provider authority to grant
or deny health coverage to patients (rather than an independent
judge), objectivity will be lost and coverage will become more
11. (SBU) Executives at Profamilia, a large private provider of
reproductive health services, told us the proposed taxes on beer
and other items will probably only raise about US$1 billion in
revenue, not enough to cover the US$3 billion health deficit.
URIBE DEFENDS REFORM
12. (SBU) President Uribe has invested considerable time, notably
on radio talk shows, answering questions about the emergency
measures. He also publicly criticized embattled Health Minister
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Palacios for not being responsive to criticisms about the decrees.
Palacios claims the new measures have been "misunderstood." In
addition to official voices, a handful of respected analysts
support the reforms, including the Presidents of ANDI (National
Association of Industrialists) and ANIF (National Association of
Financial Institutions), who emphasize that the reforms help fix a
structural fiscal problem.
GOC BACKTRACKING, COURT TO RULE ON LEGALITY
13. (U) In response to the outcry, President Uribe and Minister
Palacios held a series of meetings with medical associations and
Congress to negotiate the implementation and scope of the decrees.
Already, Uribe has backtracked on some of the decrees, including
financial sanctions against physicians that prescribe unapproved
medication or procedures and the use of pensions to pay for
treatments outside POS coverage.
14. (U) Minister Palacios submitted technical justifications in
support of the decrees to the Constitutional Court on February 12
for its review. The Court is expected to take at least one month
to consider the constitutionality of the GOC measures. The
President of the Constitutional Court said the decrees could
crumble under judicial scrutiny -- particularly the ones imposing
COMMENT: A POLITICAL BLUNDER?
15. (SBU) The fallout from the "Social Emergency" decrees could not
come at a worse time for President Uribe, who is being criticized
from many sectors in an election year. The fiscal implications of
a universal health care system are a serious and legitimate
concern. While no poll numbers are yet available to gauge the
impact of the controversy, Uribe's popularity may suffer. By
unilaterally applying decrees on such a sensitive issue, Uribe has
given his opponents a theme to rally around as the country heads
into its presidential campaign.