The decline of the health system that led to the end of the EPS Sura

The only thing there is consensus about the Colombian health system is its deep crisis. A crisis that is confirmed with the request presented this Tuesday by the Sura Health Promotion Entity (EPS) to stop operating. What was for years the EPS with the best indicators among the dozens of public and private entities in charge of recruiting and ensuring the health of Colombians, voluntarily resigns from continuing to work. That is a decision that is explained not only by the deficit faced by the company, but by more general problems, of the entire system.

When President Gustavo Petro chose the reform of the health system as his great political banner, at the beginning of 2023, to the point of sacrificing for it his majority coalition in Congress and his cabinet with social democratic and liberal figures, the health system was to face one of its toughest tests, with the pandemic of 2020. At that time, resource needs skyrocketed while the economy fell. For this reason, the Government of Iván Duque allowed the EPS to spend part of their reserves in the hardest months of the health crisis. After the collapse last April of the Petro reform, which essentially sought to eliminate them and had agreed to reduce them to a minimum, the ghost of that exceptional expense came to haunt them, as it became an argument for the Government to criticize them and, Eventually, the Health Superintendency intervened in several of them and marked the beginning of the end of the health system that Colombia has had for three decades.

EPS Sura’s decision leaves more than 5 million members on tenterhooks. It adds to the 2.2 million EPS Compensar, which has been waiting for a month for a response on its decision to liquidate. They join at least 24.5 million more, from the intervened companies Savia Salud, Asmet Salud, Emssanar, Famisanar, SOS, Nueva EPS and EPS Sanitas. The system is in an explicit crisis, and it is not clear what the path is to get out of the crisis, since the Government focused on building the failed reform and has not revealed a plan to act without this legal change. This Executive strategy keeps the EPS alive, although the majority have the Government in their administration. It does not give them certainty about their future or that of the contracts with the providers. It also adds to several structural factors that have not been addressed until now. These are the main three:

1. The structural problem of labor informality

The current health system, which was born with the famous Law 100 of 1993, essentially establishes that the State pays with its resources for a public scheme for Colombians and that those who provide the services can be public or private. Between that large payer and those providers are the EPS, public or private entities that enroll people and receive money per year from the State for each of them. Thus, the State does not pay everything they ask for and the economic risk lies with the EPS, which must then negotiate well with the laboratories, clinics or doctors. They do well when patients request few services (because they are healthy, prefer to pay out of pocket, do not know their rights or the EPS deny them) and poorly when the opposite occurs (because they are sick populations, clinics and hospitals invent procedures or they raise their prices, or the money paid to them by the State is miscalculated).

A good part of the system is financed with resources from workers and their employers, who contribute 12% of their salary to the fund managed by the State. For this reason, it initially had two categories, the contributory regime, which included those who contributed to the system, and the subsidized regime, for the poorest population without income, who had fewer benefits. The system was very successful in expanding coverage, since Colombians covered by social health security went from 22% (the rest attended public hospitals with the hope of being treated, without further support or follow-up) to practically 100%. %. However, health contributors are much fewer: around 8 million Colombians, less than 20% of the total, contribute to social security, according to the information provided by the Integrated Social Protection System of the Ministry of Health with a cut-off of 24 of May. This means that the State must take more resources from other funds, such as the general budget, so that the system can insure all people, or pay less to the EPS: contributions went from being more than 50% of the resources in 2010 , to around 40% in 2023. The financial squeeze was clear.

2. The demand for health has no bottom

The Colombian system has been expanding what it covers to people in several ways. On the one hand, between 2009 and 2012 the Governments of Álvaro Uribe and Juan Manuel Santos unified the benefits of the contributory and subsidized regimes, as they reinforced discrimination against impoverished people. On the other hand, the definition of what was covered was eroded. The so-called Mandatory Health Plan (POS) grew slowly, but judges were granting more goods and services through guardianship actions. In addition, a path was created so that the EPS that were obliged to provide these services could then ask the State for that money, as if it were beyond their risk; The so-called recoveries skyrocketed starting in 2001, governments were lax in these payments and the entire system was put at risk. Although the Santos Government managed to tackle this threat, by setting more requirements for collections and controlling drug prices, at the same time it agreed to increase the services and products covered by the system (now called PBS) in exchange for increasing what the State pays. .

With Gustavo Petro, however, this logic of increasing resources was stopped. One of the repeated complaints of Sura and other EPSs has been that the money that the State pays them annually per member, the capitation payment unit or UPC, increased very little. Already in August 2023 Sura, the intervened Sanitas and the also exiting Compensar sent a letter to the Minister of Health, Guillermo Alfonso Jaramillo, in which they warned about the matter. “The value of the UPC is insufficient to cover the Health benefits plan,” the letter reads. “It is estimated that the value of the UPC in 2022 was insufficient by 8%, compared to the increase in the value of the services covered by the PBS.” The Government has denied that this is true, and its 12.01% adjustment to the UPC for 2024, below inflation of 13.34% for 2023, was criticized. “It will deepen in a critical and acute manner by the year 2024, with undoubtedly a deterioration in the care for users but, above all, in the sustainability and viability of the health system,” Ana María Vesga, director of the health union, said in January. the EPS. “Everything that the health system covers in Colombia is wonderful, but we cannot pay for it,” former Health Minister Augusto Galán recently summarized in an interview with this newspaper.

3. The EPS have been in the crosshairs for bankruptcies and corruption

The current crisis has a history, including cases of corruption. The most notorious was that of the EPS Saludcoop, which according to the Comptroller General’s Office diverted 1.3 billion pesos in 2011 from health to other purposes. The Santos Government intervened in 2011 and liquidated it in 2015. Since its 4 million members could not be left without insurance, the State transferred them to the small Cafesalud, which did not have the capacity to manage such a large group of people. So much so that by 2019 the Government ordered it to be liquidated. Medimás was also liquidated in 2020, with almost 1.5 million members; the state-owned Caprecom between 2015 and 2016, when it had 2.2 million members; or the historic EPS of the Social Security Institute, in 2007, with more than 3 million members.

This history of scandals and repeated bankruptcies has led to repeated discussion about the organization of the system and the function of the EPS. The debate was especially strong in the first Government of Juan Manuel Santos. At that time, the Executive, with Alejandro Gaviria as Minister of Health, presented to Congress a bill that rethought the system, created a single national affiliate and took away several of its functions. The left-wing opposition, led among others by the then congresswoman and now Minister of Labor Gloria Inés Ramírez, brought forward its own proposal, which eliminated the EPS from the ground. Ultimately, none of them passed and the adjustments were minor.

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