“The current context means that, for the first time in many years, the possibility of incorporating the mutualist population into public healthcare is both a viable and reasonable option.” The Ministry of Health has prepared a report to analyze the impact that the incorporation of the million Muface users who have opted for private care would have on the health system if coverage is not finally awarded and concludes that the situation may even become an opportunity. , although the department directed by Mónica García does not close the door to any exit.
The proposal that private insurers gave to Health in the competition to renew the Muface concert in 2025 and 2026 has caused the ministry to consider, perhaps for the first time realistically, ending the system that currently allows public officials to choose each year between private or public coverage. The report, to which this newspaper has had access, studies for 17 pages what would happen if Muface were extinguished or profoundly modified, it accuses private insurers of the “more than evident” practice of referring patients who are not economically profitable for them to the public system and Finally, it concludes that “the SNS (National Health System) should have the capacity to provide this service with adequate management of the transition process,” although it does not support any specific solution.
The negotiation is being led by the Ministry of Public Function, which on Friday explained that it is studying the possibility of mutual members choosing the type of health coverage they want “forever” and not annually, so that it would be “easier to plan the sources of income of the system and its sustainability,” as explained by sources from the department headed by Óscar López.
Meanwhile, according to the detailed analysis carried out by Health of Muface users who have chosen private healthcare (those who would have to join the public system), the autonomous communities of Andalusia, Castilla y León and Extremadura, together with the autonomous cities of Ceuta and Melilla would be the most affected both by the number of general mutual members and by the proportion of people over 65 years of age, the patients who generate the most health expenses.
As you can see in the following table, they are the only regions that would add more than 3% of new users to the system (or almost, in the case of Andalusia). The Balearic Islands, Catalonia, Euskadi and Navarra would be the ones that would notice it the least in numerical terms.
An insufficient increase?
On October 8, private insurers decided not to present offers for the renewal of the Muface concert, which expires on January 31, 2025. Despite the fact that the Government increased the offer by 17% compared to the current one to a total amount of more of 1,337 million euros for 2025 and 1,345 million for 2026, with a total biannual increase of 304 million euros, neither Adeslas, Asisa or DKV, the three companies that currently provide the service, decided to participate, claiming that the increase is “insufficient ” even if it were 25%. The companies say that young mutualists (those who give profits to private insurers) increasingly choose public health care while the older ones, economically less profitable, stay in the private one.
The data provided by the Health report validates these statements: the average age of the mutual member has risen 3.7 years in a decade and if the distribution of citizens by age groups in the public health system and among Muface users is compared with private insurance, it is observed that in the SNS those over 65 are 20.39% of the total, while in Muface they are 31.9%. But the ministry analyzes this difference as another problem for the future: “It suggests that if the current model of service provision continues, the capita increases that would have to occur in the future would be of a significant amount, as there is no distribution age (and, probably, consumption of health resources) that allows the sustainability of the system in the medium and long term.”
Translated: since there are no young people joining the private system – excluding babies and those over 90, the least Muface has are twenty- and thirty-somethings – paying for this concert will be increasingly expensive.
Faced with this rupture – for which the parties blame each other –, Health speculates with the two options it has. The first is to increase the economic offer to convince private insurers. But, the ministry contextualizes, it is probably an “insufficient” solution (insurers demand an increase of more than 40% compared to current financing conditions); unsustainable (because it does not address the long-term dynamics of aging of the Muface mutualist subpopulation); and inequitable for assuming percentage increases that would be unthinkable in the field of direct public provision.” And he concludes that in reality it could be considered that this is “postponing a decision that will have to be made sooner or later.”
Health denounces “the more than evident existence of risk selection practices by private insurers.” That is, they refer patients who are economically unprofitable to the public system.
But this possibility poses a problem, the report continues. “It should be noted that the more than evident existence of risk selection practices by the private insurers that provide health care to Muface mutual members is a phenomenon that supposes an assumption by the SNS of the risks and costs that should take on private health insurers.”
Given that the “risk selection” referred to by Health is, in summary, the technicality with which private insurers “avoid coverage of those that, because they could cause frequent or high-value losses, would cause an economic imbalance in the results of the company, according to your own definitionHealth is accusing companies of referring the most expensive patients to the public system. “It represents a problem from which it is impossible to escape when it comes to analyzing this matter.”
The alternative to increasing the offer is to execute a nine-month extension in the agreement provided for in the law and during that period prepare the entry of those million mutual members with private insurance into the public system. In this case – for which a method is even proposed: “A gradual incorporation stratified by the letter of the beginning of the first surname, age and insurance provider of services could be proposed” – the system would have to take into account factors such as the identification of immersed patients. in therapeutic processes that require continuity (oncology, for example), which would be the last to change networks, or develop a transition plan to guarantee continuity in highly complex chronic treatments and other elements, describes Health.
2% more
The report evaluates in detail the impact of adding one million new users to the system. As a whole, the SNS would receive 2.1% of new users: 2% in the group between 0 and 14 years old, 1.3% from 15 to 34, 2% from 35 to 64 and 3.3% 65 years and older. But the reality is very different depending on each autonomous community. Health has divided the autonomies into three groups based on the number of mutual members they have, by age group.
Those that come out the worst, according to this analysis, are Andalusia, Castilla y León, Extremadura, Ceuta and Melilla. All of them have an increase that is greater than half a percentage point compared to the average, and in all cases the percentage of private mutual benefit population over 65 years of age compared to the total of those over 65 years of age is even higher. Andalusia is the community that stands out the most in this aspect, with a theoretical increase of 4.6% in this group, except for Ceuta and Melilla, which exceed 9%.
In the middle, Aragón, Asturias, the Canary Islands, Cantabria, Castilla-La Mancha, Galicia, Madrid, Murcia and La Rioja are slightly above or below the average. In this group, Health highlights the case of Madrid, which despite presenting standard figures in general, increases slightly among those over 65 years of age, who would increase by 4.5%.
Finally, in the Balearic Islands, Catalonia, Euskadi and Navarra the mutualist population does not exceed 1.2% of the general population “for different reasons”, figures that represent “a figure similar to the annual increase in the population that can face a autonomous community”. Health points out in this case the anomaly of Euskadi, which despite presenting a high rate of mutual members with private healthcare over 65 years of age (35.65%) would barely suffer an impact of 1.63% among the group.
The report does not point towards any course of action, although it does explain that it would be “viable” and “reasonable” to incorporate those million people into the public system. Or, put another way, extinguish Muface, at least as it works now. “This occurs due to the conjunction of two elements, one purely cyclical and the other structural,” the ministry argues. “The first is the lack of participation of private insurers in the conditions offered by the Government of Spain. The structural reason (…) shows an aging of the base population of Muface with the absence of counterbalancing elements that serve to adjust the capita to lower and controlled amounts for the coming years. The Muface model is currently not sustainable, not even with a significant increase in the capita, because no insurance system works if it does not have a pool of risks that allows counterweights to be exercised between those who demand the service the most and those who make less intense use.”
And he concludes: “If the financing currently allocated to the health care of Muface mutual members who go to the private insurer were transferred to public health in the process of internalizing the provision of said care, the SNS should have the capacity to provide that service with the appropriate management of the transition process.”
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