Table 1. Population based on healthcare coverage (2020) CADIEM SECTORIAL REPORT #15 on HEALTHCARE S...

Chart 1. Cost of Healthcare subsystems in Argentina, 2015.

It happens to many of us in our daily routine clinical practice. We are trapped between the patient and his medical insurance having to discuss so many different parameters.

The health professional supports a medical indication backed by the references and experience that should improve the patient’s quality or prognosis of life. On the other hand, medical insurance companies deal with the costs associated with this or that medical act while trying to solve the patient’s suffering with the least possible cost. Two different points of view that are not necessarily compatible.

How can these different criteria

work together?

The patient is, then, caught between two different opinions while the end of his suffering keeps getting further and further away from him considering the time elapsed between the indication and the administration of therapy, thus increasing the risks associated with the therapy and affecting disease progression.

The legislation governing health is the law used by the state to lead its citizens to eventually set the limits of what will be allowed between the two.

In its sections 14, 33, 41, 42, 43, and 75 the Argentine National Constitution1 discusses the benefits of social security adding that its nature should be comprehensive and inalienable. The same thing goes for the comprehensive protection of the family, family property, and access to a dignified home.1

The Universal Declaration of Human Rights was enacted back in 1948 by the Society of Nations.2 In our constitution its status is higher compared to our own legislation. It includes the rights and liberties that all human beings can aspire to inalienably and on equal conditions.

Section 25 guarantees that each individual and his family shall have “Healthcare and proper clothing, home, medical care, and all the necessary social services.”

“The state shall observe the right to healthcare. Failure to comply will allow citizens to file a writ of protection”. The right to healthcare does not oblige the state whatsoever to heal or achieve total wellbeing “but facilitate access to the resources needed to achieve it”.

Back in 2019, the National Health Service Superintendence and Prepaid Medical Companies—the governing body—published a Regulatory Compilation3 to arrange the Argentine rules governing healthcare by compiling a total of 2300 rules and regulations of individual or general scope regarding healthcare.

Regarding the National Healthcare System there are two laws—23.660 4 and 23.6615—about Social Works plus 17 other decrees.

Obviously, this goes on and on until the aforementioned number of 2300 rules and regulations, and most of the times that a law is mentioned it is the one that deals with the creation of social works.

Psychologist Martin De Lellis, Head Professor of Public Psychology and Mental Health, in his report entitled Healthcare Reform and Healthcare Coverage: Notes from a perspective of rights6 speaks about the origin of a solidarity-based system built upon the creation of Community Hospitals.

“You could see this in community institutions arranged mostly based on ethnic criteria associated with the country of origin. Therefore, a somehow culture of mutual protection was created that eventually gave rise to the appearance of numerous health centers like the British Hospital, the Italian Hospital, the Spanish Hospital, etc. in the main cities of the country”.

During the first presidency of General Juan D. Perón (1946-1952) and under the Ministry of Health run by Dr. Ramon Carrillo, MD a total of 500 new health centers and hospitals were built. This is the flash point when the State of Argentina becomes the official healthcare provider for all its citizens.

The decade of 1970s saw a growth in healthcare and technology and under the government of General Juan C. Ongania all workers are instructed to join social works according to Law 18.610/707 revoked and complemented by Law 22.269/808 enacted by President General Jorge R. Videla. The objective of this law was to guarantee the provision of healthcare resources with the best possible level of medical healthcare and maximum use of resources.

The universal healthcare system is supported by the national, provincial or municipal government, and the resources needed to support it are funded through taxes.

Then, the state is given supremacy over the provision of healthcare, and then replaced by a group of companies according to the article “Social works and other social security and healthcare related institutions in Argentina. Origin and current situation of a highly unequal system” published by Óscar Cetrángolo, and Ariela Goldschmit back in July 2018.9 They describe the system including 292 Social Works, and 196 Prepaid Medical Companies created by the Law 26 682.10

“Social Works provide coverage 28.1 million people, that is 56% of the population. A total of 5% of these Social Works cover 50% of all members, a situation that we see back again in resource allocation where 5% of Social Works cover 48% of all resources available. The same thing happens with Prepaid Medicine where companies cover 6.3 million members, which is 14% of the population. The first two (1.0%) concentrate 50% of medical coverage.

In the SECTORIAL REPORT #15 ON HEALTHCARE SERVICES published back in August 2020, the Argentine Chamber of Institutions for Medical Diagnosis (CADIEM)11 tells us that 100% of the population has the right to be covered by the public sector, Also, for 36% of the overall population, this is the only health insurance they have. These rates are on the rise. A total of 64% of the population is also covered by the Social Security (National Social Works, Provincial Social Works, PAMI, and Social Works with their own legislation). A total of 14% of the overall population has private insurance (Prepaid Medical Companies, Mutual Insurance Companies, etc.) Most beneficiaries of Social Works also pay prepaid medicine, the direct members of these represent nearly 35% of the total.

It is estimated that nearly 5% of the population has 2 and, in some cases, 3 different medical insurances.

As it can be seen, the state delegates its obligation to provide healthcare services to healthcare providers. That is so because the official health structure cannot cover the population needs in its entirety. Patients who seek medical help through their SW or PMC decompress the public healthcare system so 36% of the population can be taken care of according to the medical literature available. However, currently, it should reach 50% of the population for whom the public healthcare system is the only medical insurance available.

The companies get paid voluntarily (prepay) or through discounts on the people’s wages (social works). These sums of money are used to pay for the healthcare coverage provided. Afterwards, these companies hire medical centers or health professionals that get paid per consultation, module, or depending on the contribution made per person. We need to think that in our routine clinical practice we use machines and equipment. Also, that interventions and procedures are performed by a thinking human being—the treating doctor—that assesses and puts into context the results provided by these machines and equipment by manipulating tools to perform procedures successfully.

Therefore, the cost of a routine medical act varies (medical fees, costs, less common terms of payment) since the disappearance the National Nomenclator. Module is the overall value of medical acts where fees and costs are divided with different criteria depending on the hospital, healthcare provider, contribution made per person, and overall value of a monthly number of medical services rendered based on annual statistics where less healthcare equals more gains. The healthcare provided can be paid off through 3 different ways:

What rights do members have?

Access and accessibility to the system.

Access is the conditions and means through which service distribution occurs. Accessibility is the opportunity citizens have of receiving the healthcare services required without any hindrances or obstacles.

Therefore, we need to study the laws already mentioned—that happen to be very similar between one another—that dedicate 11% (5/45) of their sections to the rights of members themselves. How come Social Works belong to members. SW shall dedicate primarily 80% of their overall resources to healthcare compared to only 8% of their overall resources that shall be dedicated to administrative costs. Regarding the Decree 492/199512 of the Mandatory Medical Program (MMP) just by looking at the year of creation it is obvious it has become obsolete regarding member rights, meaning it should be changed creating an emergency MMP no to improve but to reduce the amount of medical acts with which patients are protected (Decree 486/2002).13 The current intolerable levels of poverty, the crisis that affects the entire healthcare system, the deep productive paralysis with its corresponding financial disorder, and the existing political crisis are well known by all. This situation extends to provincial states that have become the essentials providers when it comes to preserving life and curing diseases for as long as this situation of emergency stands.” This situation is maintained to this date since this emergency has become worse.

What happens with members?

Protection of the weakest, “Favor Debilis”, Finnis, John. 1980: Natural Law and Natural Rights14 states that “it is a principle of law that the weak shall be protected from their weakness.” And as all principles of law, it has become a source of right in the novel Civil and Commercial Code of the Argentine Republic.15 It it was passed back on October 2014 and became effective in August 1, 2015.

As Oscar Cetrángolo and Ariela Goldschmit say in their article “Social works and other social security and healthcare related institutions in Argentina. Origin and current situation of a highly unequal system” 9 “In the Argentine case, social security was early organized around different institutions that kept certain traits of inequality right from the start. The public sector provides healthcare to all the people living in Argentina regardless of whether they have social or private insurance on the side, and regardless of their nationality or place of residence”.

In her article: A Decade of healthcare reform in Argentina, author Susana Belmartino16 Professor and Researcher at Universidad Nacional de Rosario, Argentina, and Member of the Research Council at Universidad Nacional de Rosario, Argentina, says: “care provided under MMP for all national social works is formulated as a pack of guaranteed services, but without any conditions or guarantees of access to the services provided, which may end up becoming just a set of good intentions or formal coverage, and not an explicit or effective system of healthcare coverage for the Argentine pople.” France invests 9.3%, United States 13.9%, and Argentina 10% of their GDPs in the provision of healthcare. Still, in our country, results are not looking any good.

Let’s just seen an example of a SW of 1 600 000 members by estimating the wage of members in $80 000.

Employer pays 4.5%: $3600.

Employee pays 3%: $2400.

Pay for coverage per two family members 1% x 2 = $1600.

A typical 3-memebr family pays $7600 per 1 600 000 members.

Overall, monthly, $12 160 000 000.

Annual: $145 920 000 000.

Also, we should mention that in section 24, Law 23.6615 creates a solidary fund, the so-called Redistribution Only System (ROS). This system provides financial support to healthcare providers to fund both cheap and expensive medical acts, as well as prolonged care provisions. Everything under the watchful eyes of the National Health Service Superintendence, a regulatory and auditing body of the Argentine National Health System that, back in 2019, transferred over 5 million pesos to SWs. The remaining 45% of these funds went directly to the first 10 SWs.

Journalist Hernán Cappiello published an article on Diario La Nación back on October 28, 2021. He referred to the judiciary in the following terms: “The court had decided to audit the healthcare provider after finding irregularities. The funds managed by the social work can be counted by the millions. “The SW has fixed-term deposits for over 34 000 million pesos and others for as much as 4 million dollars. And, in this year alone, SW has received funds for as much as 13 000 million pesos” according to the official legal documents from the Judiciary Information Center (CIJ)”. The example provided is totally consistent with it.

What the law says is what goes in Argentina. However, should we remain silent witnesses of this decay? Should we take matters into our own hands through scientific societies and organizations?

I say we should spread the word and explain all these problems in such a way that members/patients become aware of the rights they are entitled to. Also, we wish to propose the authorities the creation of a multisector organization to establish the rights of members/patients based on scientific knowledge by assessing the level of success of the therapies provided and the cost-effectiveness ratio involved.

1. Constitucion Nacional de la Republica Argentina.

2. La Declaración Universal de los Derechos Humanos. Secretaria de Derechos Humanos y Pluralismo Cultural. Ministerio de Justicia y Derechos Humanos.

3. Superintendencia de Servicios de Salud. Digesto Normativo 2019. Sistema Nacional del Seguro de Salud y Entidades de Medicina Prepaga. Secretaria de Salud. Ministerio de Salud y Desarrollo Social. Presidencia de la Nación.

4. Ley 23.660. Ministerio de Justicia de la Nación. Obras Sociales, Nuevo Régimen. 29 de diciembre de 1988.

5. Ley 23.661. Ministerio de Justicia de la Nación. Obras Sociales. Sistema Nacional de Seguro de Salud ANSSAL. 5 enero 1989.

6. Reforma Sanitaria y Seguros de Salud: Apuntes desde una perspectiva de derechos. Facultad de Psicología Universidad de Buenos Aires. Página Web Universidad de Psicología. Martín de Lellis

7. Decreto-Ley 18.610/70. Poder Ejecutivo Nacional. Obras Sociales Norma de Funcionamiento y Creación del Instituto Nacional de Obras Sociales. Creación del registro Nacional de Obras Sociales.

8. Ley 22.269/80. Congreso de la Nación Obras Sociales Nuevo Régimen. Sustituye el Régimen de la ley 18.610, que regula la estructura y funcionamiento.

9. Oscar Cetrángolo y Ariela Goldschmit. Las obras sociales y otras instituciones de la seguridad social para la salud en Argentina. Origen y situación actual de un sistema altamente desigual. Fundación Centro de Estudios para el Cambio Estructural. 19 de julio 2018.

10. Ley 26.682 Ministerio de Justicia de la Nación. Medicina Prepaga, Marco regulatorio. 04 mayo de 2011.

11. Reforma Sanitaria y Seguros de Salud: apuntes desde una perspectiva de derechos, Informe Sectorial #15 Servicios de Salud agosto 2020, de la Cámara Argentina de Instituciones de Diagnóstico Médico, CADIME. Elaborado por: Área Técnica de CA.DI.ME. y el Centro de Investigación de la Fundación Desarrollo Productivo Tecnológico (DPT).

12. Decreto 492/1995 de la creación del Programa Medico Obligatorio (PMO). 24 setiembre de 1995.

13. Decreto 486/2002. Ministerio de Salud Pública, Resolución 201/2002, Apruébase el Programa Médico Obligatorio de Emergencia PMOE integrado por el conjunto de prestaciones básicas esenciales garantizadas por los Agentes del Seguro de Salud comprendidos en el artículo Nº 1 de la Ley Nº 23.660 Bs. As. 9/4/2002.

14. Finnis John, Ley natural y Derechos Naturales, traducción castellana de Cristóbal Orrego Sánchez de Natural Law and Natural Rights 1980; Abelerdo Perrot: Buenos Aires 2000.

15. Ministerio de Justicia de la Nación. Código Civil y Comercial de la Nación. 08 octubre 2014.

16. Susana Belmartino. Una Década de Reforma de la Atención Médica en Argentina. Revista Salud Colectiva. Vol 1; Nº 2; 2005.

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