The contributory scheme is designed to cover salaried workers earning one or more minimum salaries and independent workers with an income equivalent to one or more minimum salaries with an Obligatory Health Plan (POS). This is made up of benefits covering primary and highly complex heath care for the contributor and his family. The plan has five million affiliates and seven and a half million beneficiaries. It has shown a tendency to grow during the past year.
The basis of the contribution paid is income: 12% of the salaries, one-third paid by the affiliate and two thirds paid by the employer. There is a co-payment assessed on services, an average of 5% and a maximum of 10%.
A total of four public insurance entities, known as Health Promotion Entities (EPS), share 15% of the total population of insured, while 22 private companies cover 85%. The percentage of affiliates is 80% for public service providers and 20% for private service providers. In general the system provides 30% of the services in its own facilities and fees for provision are fixed.
The system as a whole is financially solvent, with mechanisms of solidarity between schemes and mechanisms of compensation between EPS, although there are problems of evasion by non-affiliation, evasion and delay of contributions. Another significant problem is the contracting of the Social Insurance Institute (ISS) and the public EPS with the public and private sector, which results in payment delays that are pushing the private and public Health Providing Institutions to the verge of bankruptcy.
In the contributory scheme the prescription of medicines must correspond to a comprehensive list that includes in-hospital medicines.
As in the case of other countries included in this study, the Argentine Health System is presented in general terms first and then its scheme of decentralized social insurance is described. The Health System is completely fragmented, with four types of institutions: National Benefit Societies, Provincial Benefit Societies, other Benefit Societies and Prepaid Medicines.
National Benefit Societies (OSN) and Provincial Benefit Societies (OSP) were created in 1970, and are private in nature. They have work-connected criteria of affiliation and a single benefits plan. The OSN cover twelve million affiliates with basic obligatory service provisions, and the OSP cover four and a half million with highly complex cases, both with a tendency to grow. Contributions are based on income. Three percent is paid by the employee and 5% by the employer in the case of the OSN. In the case of the OSP the employee and the employer each pay 4%.
There is a co-payment, which varies depending upon the Benefit Society (OS) or private company chosen, and it is generally a fixed part of the value of the consultation. It is utilized to contain demand and the maximum legal ceiling is 20% of the cost to the entity. Non-hospital medicines for which the affiliate is responsible have co-financing, the amount of which depends on the financial agency, the average being 60% of the final cost. Medicines dispensed in hospitals are covered by the financial agency involved.
There are 293 private insurance agencies in the OSN and 23 mixed private/ provincial enterprises in the OSP that provide between 4 and 5% of the services in their own facilities at the rates they set.
Other Benefit Societies "OBRAS SOCIALES"
In all, there is a total of nine other Benefit Societies that altogether enroll approximately 1.2 million persons, a number tending to increase. The insured personnel are members of the Army, the Air Force, the Navy, University personnel, the Federal Police, the Judicial and Legislative Branches.
The membership criteria is work-connected. The single benefit plan covers the first, second and third levels. Affiliate and employer each contribute 4%. Co-payment criteria are the same as the OSN and OSP.
These Benefit Societies provide 30% of their services in their own facilities free of charge.
All the health insurance systems include medicines with a comprehensive list that includes in-hospital medicines. Co-financing (between 40 and 60%) of all prescription-only drugs is included in the insurance system. OTC medicines are not covered, but 100% of medicines used in hospitals are covered. In practice, all prescriptions are written using brand names and the pharmacist cannot substitute a generic drug. Medicines and trademarks associated with alternative therapies are not recognized.
When the insurer and the provider are different, the service provider buys the medicines used in hospitals but there are no procedures for bulk purchases. Except for drugs consumed in hospital, delivered by the service provider, medicines are delivered to the patient by the insurer when the insurer and the provider are different. In the latter case medicines are delivered by contracting with a third party and a discount is negotiated between the parties.
The drug supplied is always delivered, in all the systems, and there is always a co-payment by the consumer.