On 17 December 2023 the Chilean people rejected the proposal for a new constitution for the second time, with 55% voting against it.12 After the results were published President Gabriel Boric announced that this signalled the end of the constitutional reform process.
The impossibility of significantly advancing the constitutional process, despite a 2020 referendum suggesting that Chileans want change,3 arouses deep frustration. There’s an urgent need for public policies that guarantee equitable access to health and education and improve conditions for retirees. Instead, a Pinochet era constitution that has proved insufficient for more than 40 years remains in place.
The Chilean health system is segmented, with public health insurance (Fonasa) financed by a mandatory social security premium and a contribution from the fiscal budget, covering people who can’t pay for healthcare; and substitute private health insurance, known as an Isapre, for those who can afford it.1
In the individual health insurance market, Isapre insurance providers charge a premium for the expected costs of each contract, administration expenses, and profits. Most people with a high health risk can’t pay for their insurance or do so with significant out-of-pocket expenses. Out-of-pocket health spending in Chile exceeds 30% of health expenditure, higher than the OECD average of 18%.4 Isapres have historically raised payments for young children, women of childbearing age, older adults, and people with chronic or pre-existing diseases. These charges are also increasing yearly.
In this way, Isapres cover a low proportion of older adults (only 6%; 94% are in Fonasa), fewer women (116 men for every 100 women), and more of the economically active population (71%, versus 63% in Fonasa).3 A recent study indicated that the people using public health insurance programmes (Fonasa) had worse health outcomes than those with private insurance (Isapre), and the use of healthcare services was concentrated in the richest households.5
As a result, Chile has a two tier health system: public solidarity health insurance that covers more than 80% of the population, without discrimination based on income or health conditions; and private insurance providers that participate in a market that’s highly segregated by health risk and income capacity. In this system the principle of “freedom of choice” is flawed, given that nearly 40% of members have difficulty changing between Isapres because of pre-existing conditions or their age.3
Opposition
The first draft of the proposed new constitution, presented to a vote in 2022, suggested a publicly funded, universal national health system focused on equity, solidarity, and interculturality. It also proposed other progressive improvements in the distribution of political and economic power, labour rights, inclusive education, gender rights, and environmental rights, among others.67 This would have required major progressive reforms to facilitate more equitable access to healthcare, reduce out-of-pocket expenditure, and tackle discrimination.
The main opposition to the rejected draft centred on the proposed shift to a universal healthcare system, which some viewed as an infringement on private property rights and a threat to the existing private insurance industry.6 This proposed system was perceived as inefficient and prone to corruption, which would limit choices for consumers and diminish the role of private healthcare providers.
After the first draft was rejected an unfavourable scenario unfolded: the constitutional proposition was spearheaded by a Constitutional Council that, from the outset of the 2019 reform process, publicly expressed its opposition to a fresh constitution and signalled its intent to impede efforts to transform the healthcare system.8 This wasn’t surprising given the ideological divide between people on the left and right of politics in Chile, with the former advocating a more universal and accessible healthcare system and the latter favouring the current private healthcare model and protecting the private insurance industry.
The second, more conservative draft that was rejected in December 2023 outlined a limited description of the state’s role as protector and guarantor of health services and a weak statement on the principles of universality, social justice, and solidarity.9 The draft mainly advocates coordination and supervision by health providers and highlights free choice for people when selecting healthcare from public or privately funded providers,8
Pooling resources
The persistent challenges faced by private insurance providers present obstacles to healthcare and its accessibility. Serving nearly a fifth of Chile’s population, Isapre providers are grappling with escalating legal and financial complexities.10 In 2010 gender and age based discrimination in insurance payments was ruled unconstitutional,11 and in 2022 the Supreme Court mandated that health plans adhere to a unified risk assessment table outlined by the Health Superintendency—a ruling that required Isapres to reimburse their members about US$1bn (£0.79bn; €0.92bn).10 In 2023 the Supreme Court rejected efforts to increase other premiums in the private health system, compelling Isapres to follow the ruling. Meanwhile, Congress is discussing a new law to protect public health and to shape the future of Isapres.12
The current system hasn’t provided freedom of choice and has failed to offer universal, equitable access to healthcare. Future proposals for constitutional reform should promote the creation of a single national health fund. This fund should incorporate the mandatory Isapre contributions, pooling all available resources in a public body responsible for allocating resources to the entire healthcare system, allowing the coexistence of public and complementary private health insurance. Thus, the health system would become more equitable for Chileans.
Unless there’s a drastic change in the political landscape or a willingness to put aside partisan interests, the future of Chile’s healthcare system looks bleak. The constitutional process has given citizens an invaluable opportunity to participate in and reflect on a new social framework. However, this same process of constitutional reform has plunged Chile into uncertainty, requiring its politicians to rethink this crisis of legitimacy and inability to reach agreements for the good of its citizens.
Footnotes
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Competing interests: None.
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Provenance: not commissioned, not externally peer reviewed.
