I had the privilege of spending my last real summer break doing antibiotic resistance research and a mini-rotation at a hospital in Bogotá, the capital city of Colombia. This was actually my second stay in Colombia – I had spent 10 weeks studying Spanish there before my first year of medical school and fell in love with the culture, the food, and most of all, the amazingly kind and welcoming people. Despite this prior visit, I knew practically nothing about the country’s health care system when I arrived for a second time this May.
The professors at Case Western Reserve University, my medical school, tell us that a good bioethical analysis always starts with good facts. Given that I was researching antibiotic resistance through a bioethics lens, I needed to gain a good understanding of the country’s health care system in order to perform a meaningful analysis of the ethical dilemmas involved with treating the problem of antibiotic resistance. So I started by diving headlong into the literature and talking with any health professional willing to share their insights. What I quickly discovered is that the major Colombian health insurance reform that occurred over 20 years ago looks a whole lot like our Patient Protection and Affordable Care Act, aka Obamacare. I realized immediately that, because of this parallel, learning more about the climate of Colombia’s current health care system could provide insight into what might be in store in the U.S. after near-universal health insurance coverage has been around for a while.
Before Colombia’s 1993 health law reform, less than a quarter of the population enjoyed health insurance coverage. Thanks to the reform, over 97 percent of Colombian’s now have health insurance. Without question, this impressive increase in health insurance coverage translates well to an increase in access, one of the fundamental components of the so-called “iron triangle of health care” along with cost and quality. With any luck, perhaps Obamacare could similarly facilitate coverage of the 40 million people in the United States (which is about the size of Colombia’s population). But my question is this: has Colombia’s near-universal health insurance coverage conferred the same kind of widespread benefits that have been observed in countries with government-owned, single-payer health care systems?
Despite the fact that practically all the patients I saw had some kind of health insurance, there was nevertheless an evident lack of access to appropriate health care. For example, I routinely saw patients having trouble getting an appropriate antibiotic to treat resistant bacteria (which is extremely prevalent in Colombia) or an oxygen tank to provide relief for a patient with COPD (also widespread due to cooking with firewood in poorly ventilated kitchens). This issue didn’t stem from the hospital itself, which had a well-stocked formulary and a modest but sufficient inventory of diagnostic tools. Ironically, the observed impediments to access seemed to come from the health insurance companies themselves. Everyone I asked about this problem gave me the same response: insurance companies have gone to great lengths to limit the provision of health services in order to minimize spending on each patient, which in turn maximizes profit generated by the fixed amount of money that the government gives to insurers for each beneficiary they have. Reports in the literature provide support for the anecdotes that I heard from patients and health care providers alike – Colombian health insurance companies engage in corrupt practices to intentionally obstruct their own patients’ access to health care.
While it’s impossible to predict whether the U.S. health care system will take a similar route, the trajectory of health insurance reform in Colombia provides at least one important lesson: the existence of profit motives within health care has significant potential to motivate unethical private-sector behavior that ultimately results in a reduction of the ability for people to access reasonably-priced, high-quality care. While Obamacare has been successful in getting more people insured in the United States, I wonder what it does to minimize the potential for profit-motivated health industry entities to obstruct access to care. In my opinion, the gravity of this concern is sufficient justification for a government-run health program that would, by its very nature, eliminate this possibility.
Max Feinstein is a medical student at the Case Western Reserve University School of Medicine.