Table 6 synthesizes the principal alternatives in the configuration of health insurance in accordance with the components presented.
Table 6
Components of Social Insurance Models |
MODELS |
CENTRAL QUESTIONS |
OPTIONS |
Management |
Ownership |
- Public
- Private (for profit)
- Nongovernmental (non-profit, cooperatives, unions and mutuals) |
| |
Membership |
- Open (Universal)
- Closed (focused on a specific category of persons) |
Financing |
Sources |
- Voluntary (premiums and monthly payments)
- Compulsory (contributions, taxes)
- Mixed (combination of both, co-insurance) |
| |
Forms of Payment and Providers |
- Financing of the supply (overall budget, salaries)
- Financing of the demand (through forms of payment more less agregated - from payment per provision to the individual)
- Management contracts (for results) |
Care |
Provision |
- Direct (vertical integration)
- Indirect (via contracted third parties) with free choice of provider)
- Indirect (via contracted third parties) without choice of provider
- Mixed |
| |
Payments |
- Defined freely by the market
- Regulated by the State (full, minimum, partial or in accordance with cost-effectiveness criteria for the selection) |
A broad variety of configurations can be found in the insurance systems of the countries selected for this study. Tables 7, 8 and 9 show the principle aspects, based on the categories utilized, more details of which are found in the following chapter.
Table 7:
Health Insurance Models in the Selected Countries |
COUNTRY/
DIMENSION |
COVERAGE
(in millions inhab. & %) |
AMOUNT |
OWNERSHIP |
RECRUITMENT |
ARGENTINA |
|
|
|
|
OSN |
12 |
293 |
NGO (usually unions) |
Open (after deregulation before 1993 it was closed by branch of activity) |
OSP |
4.5 |
23 |
Public |
Closed (public employees & family, although there are adherent affiliation) |
Prepaid |
2.8 |
281 |
Private |
Open - voluntary affiliation, (generally middle and upper income sectors) |
COLOMBIA |
|
|
|
|
R. Contributive |
75,30% |
26 |
4 public and 22 private |
Open (wage-earners with 1 or more minimum salaries and self-employed) |
R. Subsidized |
8,20% |
197 |
2 public, 15 private and 180 cooperatives |
Open (wage-earners with 1 or more minimum salaries and self-employed) |
Prepaid Medicines |
2% |
No data |
Private |
Open - voluntary affiliation, (generally middle and upper income sector) |
CHILE |
|
|
|
|
ISAPRES |
26.6% |
No data |
Private |
Closed (11 & 1.2 % of population); Open (24% of population) |
FONASA |
59.5% |
No data |
Public |
Open |
COSTA RICA |
|
|
|
|
CCRSS |
90.4% |
1 |
Public |
Open and Universal |
GUATEMALA |
|
|
|
|
IGSS |
15.7% |
1 |
Public |
|
Prepaid Medicines |
|
12 |
Private |
Open (open membership) |
UNITED STATES |
|
|
|
|
Medicare |
14.2% |
1 |
Public |
Open to those over 65 |
Medicaid |
10.3% |
1 |
Public |
Closed for persons of low income |
Private Insurance |
45.3% |
No data |
Private |
Open (open membership) |
HMOs |
25.2% |
651 |
Private |
Open (open membership) |
Table 8:
Health Insurance Financing Models in the Selected Countries |
COUNTRY/
DIMENSION |
VOLUNTARY QUOTA |
EMPLOYEE PAYMENT |
EMPLOYER PAYMENT |
CO-PAYMENT FOR SERVICES |
CO-PAYMENT FOR AMBULATORY MEDICINES |
ARGENTINA |
|
|
|
|
|
OSN |
No |
3% |
5% |
Up to 20% |
60% |
OSP |
No |
4% |
4% |
Non-Regulated |
60% |
Prepaid |
Yes |
No |
No |
Up to 40% |
60% |
COLOMBIA |
|
|
|
|
|
R. Contributive |
No |
4% |
8% |
Up to 10% |
There is a co-payment |
R. Subsidized |
No |
No |
No State resources |
Up to 5% |
There is a co-payment |
Prepaid Medicines |
Yes |
No |
No |
No data |
No data |
CHILE |
|
|
|
|
|
ISAPRES |
Possible to accede to better plans |
7% |
No |
Various levels (in accordance with plan and type of payment) |
Only the closed plans |
FONASA |
|
7% |
No |
Institutional: up to the income level). Free election up to 86% (in proportion to income and type of payment) |
No coverage of medicines at the ambulatory level |
COSTA RICA |
|
|
|
|
|
CCRSS |
No |
5.5% |
9.5%, 0.25% State |
No |
No, 100% coverage |
GUATEMALA |
|
|
|
|
|
IGSS |
|
4% |
10% |
No |
|
Prepaid Medicines |
Yes |
No |
No |
Yes, variable |
|
UNITED STATES |
|
|
|
|
|
Medicare |
Yes |
|
State |
Standard plan no; others yes |
No coverage |
Medicaid |
|
|
State |
No data |
50% to 75% |
Private Insurance |
Yes |
7.19% |
19.2% |
No data |
50% to 75% |
HMOs |
Yes |
7.19% |
19.2% |
No data |
50% to 75% |
Table 9:
Health Insurance Care Models in the Selected Countries |
COUNTRY/DIMENSION |
BENEFICIARY PLAN |
PAYMENTS FOR MEDICAL SERVICES |
ARGENTINA |
|
|
OSN |
Unique |
5% |
OSP |
Unique |
5% |
Prepaid |
Various |
50% |
CHILE |
|
|
ISAPRES |
About 8,000 different plans |
|
FONASA |
- Institutional Modality
- Free choice |
Group A (needy) 100%, the rest in free choice modality where 18.8% of services provided are contracted |
COLOMBIA |
|
|
R. Contributory |
Unique |
30% |
R. Subsidized |
Unique |
10% |
Prepaid Medicines |
Various |
No data |
COSTA RICA |
|
|
CCRSS |
Unique |
100% |
GUATEMALA |
|
|
IGSS |
Unique |
85% |
Prepaid Medicines |
Various |
0%
Installments not available |
UNITED STATES |
|
|
Medicare |
Standard
A
B
C (Choice Plan) |
No data |
Medicaid |
Variable |
No data |
Private Insurance |
Multiple |
0%
Installments not available |
HMOs |
Multiple |
100% |
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