Avatares de la reforma de salud de obama

AVATARES DE LA
REFORMA DE
SALUD DE OBAMA
D r. C a r l o s J a v i e r R e g a z z o n i !

July/August 2011 and the Court
Obamacare 21/07/12 10:52
ESSAY

How Health Care Can Save or Sink America
Health Reform Vote: Global Impressions - Council on Foreign Relations
The Case for Reform and Fiscal Sustainability

Peter R. Orszag
PETER R. ORSZAG is Vice Chair of Global Banking at Citigroup, an Adjunct Senior Fellow at the Council on
Foreign Relations, and a columnist for Bloomberg. He was Director of the White House's Office of Management and
Budget in 2009-10 and Director of the Congressional Budget Office in 2007-8.
Home > By Publication Type > Expert Briefs > Health Reform Vote: Global Impressions

Rising health-care costs are at the core of the United States' long-term fiscal imbalance. The Congressional Budget
Expert Brief
Office (CBO) projects that between now and 2050, Medicare, Medicaid, and other federal spending on health care
will rise from 16, 2012
Health Reform Vote: Global Impressions
July 5.5 percent of GDP to more than 12 percent. (Social Security costs, by comparison, are projected to
ESSAY
increase from five percent of GDP to six percent over the same period.) It is no exaggeration to say that the United
States' standing in the world depends on its success in constraining this health-care cost explosion;Senior Fellow forthe
Author: Laurie A. Garrett, unless it does, Global Health
Obamacare and the Court
country will eventually face a severe fiscal crisis or a crippling inability March 23, in other areas.
to invest 2010
Handing Health Policy Back to the People
The problem is not limited to the federal government. Over the past 25 years, cost increases in the national Medicare
and Medicaid programs have roughly paralleled (and actually been slightly below) cost increases infollowed the the
Barry Friedman People all over the world have the rest of political rollercoaster surrounding healthcare reform in
health-care system. These trends JacobaD. Fuchsberg Professor ofState governmentswitnessed Sunday's debate and countdown to midnight in the House of Representative
BARRY FRIEDMAN is drive wide range of problems. Law at the New York University School of Law. He is the
and millions have had to divert funds from
to health care, which is People: How Public Opinion Has Influenced the Supreme nowthe United States--featuring some 47 million Americans with no insura
we call a "health system" in often
education author of The Will of thepartly why salaries for professors at public universities are Court and 15 to 20the Meaning
Shaped
percent lower than those at comparable private universities. Meanwhile,morerisingare under-insured and face bankruptcy with catastrophic illness--stuns people overseas,
of the Constitution. the who cost of employer-sponsored
Western Europe.
health insurance has squeezed take-home pay for most U.S. workers at the same time as median wages have
stagnated and income inequality has increased. Many view passage of healthcare reform as a test of President Barack Obama's mettle, and an unfor

SI EL SISTEMA DE SALUD DE EE.UU. FUESE
UN PAÍS, SERÍA LA 7º ECONOMÍA DEL
MUNDO

LÓGICA SISTÉMICA
Un sistema donde el todo resulta de la suma de “algunas” de sus partes

SISTEMA DE SALUD
R E G L A S

Recursos!

Expresión
Monetaria Procesos!

Impacto
Gasto en Resultados!
Social
•  Humano
Salud •  Económico

Programas Medicare

SISTEMA DE SALUD
Federales
Medicaid
Chip
Veterans
Otros
Privados Seguros

Mutuales

EN EE.UU.
Bolsillo

Estados Contribuciones a Prog Federales

Seguros Estaduales

MEDICARE Y MEDICAID
Creados por el presidente Lyndon B. U.S. Department of
Johnson en 1965
Health and Human
Services
Medicare
•  Seguro de salud para retirados, con
más de 44 millones de afiliados (2008), Centers for Medicare
y que cuesta $432 mil millones o 3.2%
del GDP de EE.UU. en 2007. and Medicaid Services
Medicaid
•  Programa de protección social que
atiende a 40 millones de personas Medicare
(2007) y cuesta $330 mil millones de
dólares, es decir 2,4% del GDP de
EE.UU.
Medicaid

1.  Sub-cobertura
2.  Sub-prestación
3.  Ineficiencia
DESAFÍOS: SISTEMA DE SALUD DE USA
4.  Deslealtad comercial
5.  Gasto desbordado
6.  Innovación sustentable
7.  Financiamiento

DESAFÍOS

1.
SUB-COBERTURA
SISTEMA DE SALUD EN USA: DESAFÍOS

PERSONAS SEGÚN COBERTURA!
Tipo de cobertura
180
157
!"##$%&'()&(*&+'$%,'(-./01(

160
140
120
100
80
60 45 42 37
40
15
20
0
No Medicare Medicaid Individual Seguro por
asegurados empleador

Se estiman 45 millones de personas sin seguro de salud

LEY DEL CUIDADO INVERSO

Ley del cuidado inverso
“…la disponibilidad de en salud
cuidados médicos varía

Accesibilidad
inversamente con la
necesidad de los mismos en
la población, hecho que se
magniﬁca en operando
fuerzas de mercado…”! Necesidad

Hart JT. The inverse care law. Lancet 1971; i:405-412

and the proportion of

10

70
15

75
30
20

50
35
25

55
40

45

80
60

65
Age group (years)
reased substantially with
alf of the population had Figure 1: Number of chronic disorders by age-group
age 65 years most were
ver, in absolute terms,
90 Socioeconomic

MULTI-MORBILIDAD & STATUS
dity were younger than status 80·6
der (210 500 vs 194 966), 80 10
76·5
79·4
82·9
9
e morbidities on average 8 70·6 76·6
70 7
64·1 69·1

Patients with multimorbididty (%)
6
multimorbidity increased 5
60
the area in which patients 4 54·2 58·3
·6, in the most affluent 3
50 2 45·4
in the most deprived; 1 46·5
9; table 1). However, this 40 36·8
with caution because the 34·8
30
areas was, on average, 26·8
26·8
[IQR 21–53] in the most 20
21·2
16·8
2–58] in the most affluent 12·0
18·3

eprived areas were more 10 8·0 13·4
4·0 9·8
were those living in the 4·8
6·3
7·9
3·0
, apart from those aged 0
Young and middle-aged
4

9

4

9

4

9

34

39

4

9

4

9

4

9

4

9

4

5
≥8
0–

–1

–2

–4

–5

–6

–7

–8
5–

–1

–2

–4

–5

–6

–7
–

–
10

70
15

75
30
20

50
35
25

55
40

45

80
60

65
rived areas had rates of Age group (years)
se aged 10–15 years older
e 2 and appendix). Figure 2: Prevalence of multimorbidity by age and socioeconomic status
On socioeconomic status scale, 1=most affluent and 10=most deprived.
all patients, and 36·0%
ultimorbidity, had both a Barnett K, et al. Epidemiology of multimorbidity and implications for health care, research, and medical
education: a cross-sectional study. Lancet, May10, 2012 DOI:10.1016/S0140-6736(12)60240-2
sorder. The prevalence of disorder as the outcome (table 2), we noted a non-linear
morbidity was higher in association with age, so we included an age-squared term
bstantially higher in older in the model. The predicted probability of having a mental
(table 1). Although older health disorder increased with age up until about age

EXPANSIÓN DE LA COBERTURA

El aumento de la cobertura en salud se asocia a
reducciones de mortalidad de la población, y al
aumento de la accesibilidad.
Dos Ejemplos:
1.  Expansión del Medicaid

2.  Experimento del Seguro de Salud

¿CAMBIÓ ALGO LA EXPANSIÓN DEL
MEDICAID?
Expansión del Medicaid:
•  Jóvenes 19 – 64 años
•  Sin hijos
•  Ingresos <100% línea de pobreza

-Mortalidad Año
5 años 2000 5 años
adultos ⁄

-Percepción de
salud ⁄ •  Arizona
•  Maine •  N Hampshire
-Accesibilidad ⁄ •  New York •  Pennsylvania
•  Nevada
Sommers BD, Baicker K, Epstein AM. Mortality and access to care among adults after State
Medicaid expansions. N Engl J Med, July 25, 2012

HEALTH INSURANCE EXPERIMENT
¿Cómo impacta el tipo de seguro sobre la utilización del sistema de salud?

The Health Insurance Experiment
A Classic RAND Study Speaks to the Current
Health Care Reform DebateAtención Libre
•  Nivel de uso del médico

A
RAND RESEARCH AREAS
fter decades of evolution and
•  2.750THE ARTS

CHILD POLICY experiment, the U.S. health care
25% •  Estado de salud
Key findings:
system has yet to solve a funda-
Familias
CIVIL JUSTICE

•  Satisfacción
EDUCATION • In a large-scale, multiyear experiment,
mental challenge: delivering quality
ENERGY AND ENVIRONMENT
Co-pago participants who paid for a share of their
•  <65 años
HEALTH AND HEALTH CARE health care to all Americans at an affordable
50% •  Internaciones
health care used fewer health services
Ajus/ingreso
price. In the coming years, new solutions will
INTERNATIONAL AFFAIRS

than a comparison group given free care.
•  Incluyó niños
NATIONAL SECURITY
be explored and older ideas revisited. One
•  Calidad de atención
POPULATION AND AGING

idea that has returned to prominence is cost
95%
PUBLIC SAFETY
• Cost sharing reduced the use of both
•  6 lugares, US
SCIENCE AND TECHNOLOGY

SUBSTANCE ABUSE
sharing, which involves shifting a greater
share of health care expense and responsibil- •  Gasto de bolsillo
highly effective and less effective services
TERRORISM AND
HOMELAND SECURITY
in roughly equal proportions. Cost sharing

•  Costos de atención
TRANSPORTATION AND ity onto consumers. Recent public discussion did not significantly affect the quality of

Cooperativa HMO
INFRASTRUCTURE

WORKFORCE AND WORKPLACE
of cost sharing has often cited a landmark care received by participants.
RAND study: the Health Insurance Experi-
ment (HIE). Although it was completed over 1971 1982
• Cost sharing in general had no adverse
effects on participant health, but there
two decades ago, in 1982, the HIE remains
were exceptions: free care led to improve-
the only long-term, experimental study of cost
ments in hypertension, dental health,
sharing and its effect on service use, quality of
vision, and selected serious symptoms. These
care, and health. The purpose of this research improvements were concentrated among
brief is to summarize the HIE’s main findings
and clarify its relevance for today’sKeeler. Effects of Cost Sharing on Use of Medical Services and Health.
Emmett B. debate. the sickest and poorest patients.

Our goal is not to conclude that cost sharing is Medical Practice Management, Summer 1992, pp. 317–321
good or bad but to illuminate its effects so that
policymakers can use the information to make The HIE posed three basic questions:
This product is part of the
RAND Corporation research sound decisions. • How does cost sharing or membership in
brief series. RAND research
briefs present policy-oriented an HMO affect use of health services com-
summaries of individual
published, peer-reviewed
Learning from Experiment: pared to free care?
documents or of a body of Conducting the HIE • How does cost sharing or membership in
published work.

– 2 –

alance. Figure 1
pes of Participants with Cost Sharing Visited the Doctor Less

eri-
FrequentlyHEALTH INSURANCE EXPERIMENT
ans: 5
Annual face-to-face doctor

lved
, or 95 4
visits per capita

es that A Classic RAND Study Speaks to the Current
3
Health Care Reform Debate
rance

A
2
RAND RESEARCH AREAS

Those THE ARTS

CHILD POLICY experiment, the U.S. health care Key findings:
CIVIL JUSTICE
ge. EDUCATION

1 mentalAmericans at an affordable
challenge: delivering quality • In a large-scale, multiyear experiment,
participants who paid for a share of their
HEALTH AND HEALTH CARE health care to all
g, the INTERNATIONAL AFFAIRS

NATIONAL SECURITY

f three 0

PUBLIC SAFETY
idea that has returned to prominence is cost • Cost sharing reduced the use of both
0
sharing, which involves shifting a greater 25 highly effective50 less effective services
and 95
pend-
SUBSTANCE ABUSE

TERRORISM AND share of health care expense and responsibil- in roughly equal proportions. Cost sharing
Level of coinsurance (%) quality of
HOMELAND SECURITY

TRANSPORTATION AND ity onto consumers. Recent public discussion did not significantly affect the

1,000
INFRASTRUCTURE


977 to Los pacientes con co-pago:
SOURCE: Newhousecompleted over Insurance Experiment Group, 1993,
ment (HIE). Although it was and the • Cost sharing in general had no adverse
Tablesdecades and 1982, the HIE remains
two 3.2 ago, in 3.3.
nsur- •  Van menos al médico
NOTE: Utilizationservice use, qualityincludements in hypertension, dental health, These
sharing and its effect on numbers of both adults and children.
vision, and selected serious symptoms.
care, and health. The purpose of this research
uctible brief is to summarize the HIE’s main findings
improvements were concentrated among
the sickest and poorest patients.
and clarify its relevance for today’s debate.
Our goal is not to conclude that cost sharing is
Figure 2 good or bad but to illuminate its effects so that
ears. policymakers can use the information to make
. . . and Were Admitted to Hospitals Less Often
The HIE posed three basic questions:
nt brief series. RAND research
briefs present policy-oriented
Learning from Experiment:
an HMO affect use of health services com-
pared to free care?
for
published work.

et spend- Level of coinsurance (%)
t $1,000
SOURCE: Newhouse and the Insurance Experiment Group, 1993,
m 1977 to Tables 3.2 and 3.3.
coinsur- NOTE: Utilization numbers include both adults and children.
deductible

HEALTH INSURANCE EXPERIMENT
Figure 2
5 years. . . . and Were Admitted to Hospitals Less Often
ment
ble for .14
artici- .12
served The Health Insurance Experiment
Annual hospital
visits per capita

.10
To assess A Classic RAND Study Speaks to the Current
.08
the .06

A
ducted RAND RESEARCH AREAS
THE ARTS
.04
experiment, the U.S. health care Key findings:
rticipants CHILD POLICY

CIVIL JUSTICE
.02 mental challenge: delivering quality • In a large-scale, multiyear experiment,
nning of
EDUCATION

health care to all Americans at an affordable
0 the coming years, new solutions will
HEALTH AND HEALTH CARE
e random INTERNATIONAL AFFAIRS

NATIONAL SECURITY
price. In
0 25 50 95
ontrol for

PUBLIC SAFETY
idea that has returned to prominence is cost coinsurance (%)
Level of • Cost sharing reduced the use of both
sharing, which involves shifting a greater highly effective and less effective services
the physi- SUBSTANCE ABUSE

TERRORISM AND share of health care expense and responsibil- in roughly equal proportions. Cost sharing
HOMELAND SECURITY
SOURCE: Newhouse and the Insurance Experiment Group, 1993,
ity onto consumers. Recent public discussion did not significantly affect the quality of
n in the TRANSPORTATION AND
INFRASTRUCTURE

Tables 3.2 and 3.3. cited a landmark
of cost sharing has often care received by participants.
NOTE: Utilization numbers include bothCost sharing in general had no adverse
• adults and children.
ment (HIE). Although it was completed over
Los pacientes con co-pago:

se of • •  Se internan menos
care, and health. The purpose of this research
Participants in cost sharing plans spent less on health
brief is to summarize the HIE’s main findings
improvements were concentrated among
the sickest and poorest patients.
care; this savings came from using fewer services rather
pants good or bad but to illuminate its effects so that
than finding lower prices. Those with 25 percent coinsur-

haring RAND Corporation research
briefs present policy-oriented
ance spent 20 percent less than participants with free
sound decisions. • How does cost sharing or membership in
an HMO affect use of health services com-
and had summaries of individual
published, peer-reviewed care, and those with 95 percent coinsurance spent about
published work.

2.
SUB-PRESTACIÓN

TASA DE AMPUTACIONES, DIABÉTICOS, OECD 2007!
36 United States (2006)
26 Spain
23 Portugal
21 Belgium (2006)
21 Denmark
18 Latvia
16 Switzerland (2006)
15 Average
13 France
12 Sweden
12 New Zealand
11 Netherlands (2005)
11 Canada
11 Finland
11 Norway
11 Poland2 (2006)
11 Italy (2006)
10 Ireland
09 United Kingdom
Korea
08
07 Austria (2006)

CALIDAD DE ATENCIÓN: ADULTOS

A Classic RAND Study Speaks to the Current

•  6.712 personas 30 Condiciones

PARA CADA CONDICIÓN:

A
•  Adultos
RAND RESEARCH AREAS agudas y crónicas
•  Medición de tratamiento
THE ARTS
•  12 ciudades system has yet to solve a funda-
CHILD POLICY

CIVIL JUSTICE

USA health carementalAmericans439affindicadores de who paidrecibido
EDUCATION • In a large-scale, multiyear experiment,
challenge: delivering quality
participants for a share of their
to all at an ordable
•  Comparación con tratamiento
•  Contactoexplored and olderyears, new solutions will atención
tel.
price. In the coming
ideas calidad de

NATIONAL SECURITY than a comparison group given free care.
be revisited. One
• Cost sharing reducedrecomendado

•  Accesoidea thatwhich involvestoshifting a greater
SCIENCE AND TECHNOLOGYa has returned prominence is cost
PUBLIC SAFETY

sharing,
the use of both

andTratamientosiny
highly effective and less effective services
Historias onto health care expense public discussion
SUBSTANCE ABUSE

share of
TERRORISM AND responsibil- roughly equal proportions. Cost sharing
HOMELAND SECURITY
ity consumers. Recent
medidas care received by participants.
clínicasof cost sharing has often cited a landmark
TRANSPORTATION AND
INFRASTRUCTURE

did not significantly affect the quality of

preventivasCost sharing in 1998 no adverse
ment (HIE). Although it was completed over • general had
2000
McGlynn to summarize the HIE’s main findings
brief is EA, Asch SM, Adams J, Keesey J, Hicksand poorest patients.
the sickest
J, DeCristofaro A, Kerr EA. The Quality of Health
and clarify its relevanceCare Delivered to Adults in the United States. N Engl J Med 2003;348:2635-45.
for today’s debate.
published work.

CALIDAD DE ATENCIÓN
No recivido Proporción del tratamiento teóricamente recomendado,
Recivido efectivamente recibido por los pacientes.
The Health Insurance Experiment RAND, The First National Report
EE.UU., 12 áreas metropolitanas, 2003.
A Classic RAND Study Speaks to the Current Card on Quality of Health Care in America
100%

A
RAND RESEARCH AREAS
80%
THE ARTS

35 41 42 42
45 50
CHILD POLICY

CIVIL JUSTICE

EDUCATION
mental challenge: delivering quality
55
• In a large-scale, multiyear experiment, 55 60
60%
health care to all Americans at an affordable
90
NATIONAL SECURITY than a comparison group given free care.
40%

PUBLIC SAFETY
idea that has returned to prominence is cost • Cost sharing reduced the use of both

SUBSTANCE ABUSE
sharing, which involves shifting a greater highly effective and less effective services
share of health care expense and responsibil-
20% in roughly equal proportions. Cost sharing
TERRORISM AND
HOMELAND SECURITY

TRANSPORTATION AND ity onto consumers. Recent public discussion did not significantly affect the quality of
INFRASTRUCTURE


0% RAND study: the Health Insurance Experi-
ment (HIE). Although it was completed over • Cost sharing in general had no adverse
brief is to summarize the HIE’s main findings the sickest and poorest patients.
published work.
In the early 1970s, financing and the impact of an HMO affect appropriateness and quality

3.
INEFICIENCIA

EFICIENCIA DEL GASTO EN SALUD
Source: OECD Health Data 2011; World Bank and national sources for non-OECD
countries.
84
JPN ESP ISL
ITA AUS CHE
ISR SUE LUX
CAN FRA
NZL NOR
80 KOR AUT NLD
PRT FIN DEU
CHL DNK USA
Life Expectancy (years)

SVN GBR
IRL BEL
POL CZE GRC
76
MEX EST SVK
CHN
TUR HUN

72 BRA
IDN

RUS
68

R! = 0,69
IND
64
0 2000 4000 6000 8000
Health spending per capita (USD PPP)

Health at a Glance 2011: OECD Indicators - © OECD 2011
1. HEALTH STATUS - Life expectancy birth, 2009, and years gained since 1960 (or nearest year)
1.1.1. Life expectancy at at birth
Version 1 - Last updated: 28-Oct-2011
1.1.1. Life expectancy at birth, 2009 (or nearest year), and years gained since 1960
Life expectancy at birth, 2009 Years gained, 1960-2009

EXPECTATIVA DE VIDA GANADA, OECD
83,0 Japan 15,2
82,3 Switzerland 10,9
81,8 Italy 12,0
81,8 Spain 12,0
81,6 Australia 10,7
81,6 Israel 9,9
81,5 Iceland 8,6
81,4 Sweden 8,3
81,0 France 10,7
81,0 Norway 7,2
80,8 New Zealand 9,7
80,7 Canada 9,4
80,7 Luxembourg 11,3
80,6 Netherlands 7,1
80,4 Austria 11,7
80,4 United Kingdom 9,6
80,3 Germany 11,2
80,3 Greece 10,4 27,9
80,3 Korea
80,0 Belgium 10,2
80,0 Finland 11,0
80,0 Ireland 10,0
79,5 Portugal 15,6
79,5 OECD 11,2
79,0 Denmark 6,6
79,0 Slovenia 10,5
78,4 Chile 21,4
78,2 United States 8,3
77,3 Czech Republic 6,7
75,8 Poland 8,0
75,3 Mexico 17,8
75,0 Estonia 6,5
75,0 Slovak Republic 4,4
74,0 Hungary 6,0
73,8 Turkey 25,5
73,3 China 26,7
72,6 Brazil 18,1 30,0
71,2 Indonesia
68,7 Russian Fed. 0,0
64,1 India 21,7
51,7 South Africa 2,6

90 80 70 60 50 40 0 5 10 15 20 25 30
Years Years

COSTO-EFICIENCIA
Nivel de 250
Gasto! B
200

150

A
100

50

0
0 20 40 60 80 100
Nivel de salud!

DESEMPEÑO!
En Estados Unidos,
•  Hay menos médicos y camas que en la OECD
•  Se generan menos consultas e internaciones
•  Dos posibilidades:
•  O bien la gente se enferma menos
•  O bien la gente no recibe la asistencia necesaria
Práctica EE.UU. Promedio OECD
-Médicos 2,4/1.000 hab 3,1/1.000 hab
-Consultas médicas 4/cápita/año 7/cápita/año
-Camas de hospital agudo 2,7/1.000 hab 4/1.000 hab
-Altas/año 126/1.000 hab/año 158/1.000 hab/año
-Estadía promedio 5,5 días 6,5 días

OECD Economic Data 2009, OECD

4.
DESLEALTAD
COMERCIAL

PRÁCTICAS DE ASEGURADORAS

•  Prácticas de aseguradoras:
•  No aceptar personas con pre-existencias.
•  Suspender seguros a edades avanzadas.
•  No cubrir determinadas patologías.
•  Consecuencia:
•  Salida del sistema del más vulnerable.

5. GASTO
DESBORDADO

COMPARACIÓN: GASTO EN SALUD, 1980–2006!
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GASTO EN SALUD: INCREMENTO ANUAL Y
PARTICIPACIÓN EN EL PBI, USA, 1961-2009
20%
18%
16%
14%
12%
10%
8%
6%
4% NHE as a Share of GDP
2% Increase in National Health Expenditures
0%

Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary,
National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type
of service and source of funds, CY 1960-2009; file nhegdp2009.zip).

VARIACIÓN: GASTO EN SALUD (NHE) E ÍNDICE
DE PRECIOS AL CONSUMIDOR (CPI), 1980-2009
16%
14,2%
14%
Annual Increase in NHE per Capita
13,5%
11,7%
Annual Increase in CPI
12%
11,0% 10,6%
10% 9,2%
10,3% 8,4%
8,4% 8,0%
7,9% 7,4%
8% 7,3%
6,2% 6,1%
5,4% 5,9%
6% 5,4%
6,2% 6,3% 4,5% 4,5%
4,4% 3,8%
4% 4,8%
4,3% 4,2% 3,8%
3,2% 3,6% 3,0% 3,4% 3,4%
2% 3,0% 2,8% 2,8%
2,6% 2,3% 2,2% 2,3%
1,9% 1,6% 1,6%
0%
-0,4%
-2%

Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health
Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2009; file
nhegdp09.zip), and CPI data from Bureau of Labor Statistics at ftp://ftp.bls.gov/pub/special.requests/cpi/cpiai.txt (All Urban Consumers, All Items,
1982-1984=100, Not Seasonally Adjusted, U.S. city average).

CRECIMIENTO ANUAL PROMEDIO PER CÁPITA,
NHE Y GDP USA
,
14%
GDP Per Capita
11,8% NHE Per Capita
12%
9,6% 9,8%
10%
8,2%
8% 6,8%
5,4% 5,6% 5,8%
6% 5,3%
4,3% 3,9%
4% 2,9%
2%

0%
1970s 1980s 1990s 2000-2010 1970-2010 2011-2020

Source: Historical data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, January 2012, at
http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2010; file nhegdp10.zip).
Projections from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, July 2011, National Health
Expenditures 2010-2020, Table 1, https://www.cms.gov/NationalHealthExpendData/downloads/proj2010.pdf.

DISTRIBUTION OF NATIONAL HEALTH EXPENDITURES, BY
TYPE OF SERVICE (IN BILLIONS), 2010

Nursing Care Facilities &
Continuing Care Retirement
Communities, $143.1
(5.5%)

NHE Total Expenditures: $2,593.6
billion
Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment,
etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity,
research, and structures and equipment, etc.
Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the
Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health
Expenditures by type of service and source of funds, CY 1960-2010; file nhe2010.zip).

6.
INNOVACIÓN
SUSTENTABLE

The Lancet Commissions

INNOVACIÓN MÉDICA

24 831 21 827
Germany
139 461 106 365
USA 13 688 50 976
China
52 398 27 042
Japan

Medical device patents
Pharmaceuticals patents
Selected OECD countries 59 778 68 695 41 758 40 155
Rest of the world Selected OECD countries* Rest of the world

Figure 5: Country of origin of patent applications
OECD=Organisation for Economic Co-operation and Development. *Australia, Canada, Switzerland, Finland, France, UK, Italy, South Korea, Netherlands, and Sweden.

Howitt P, Darzi A, et al. Technologies for global health. Lancet 2012; 380: 507–35
Evidence for the importance of patents is debated. International issues of patents and lack of research into
One study159 from 2003, showed that only 17 of the tropical diseases suggest that a solution is needed to
319 medicines classiﬁed by WHO as essential for low- improve research and development for technologies for
income and middle-income countries could be patented health. Since 2003, a series of attempts have been made
in developing countries, although it has been criticised to reach a global consensus, including an independent
for selection bias because the WHO essential medicines Commission on Intellectual Property Rights, Innovation

Sobrevida a 5 años, Cáncer de mama, OECD
United States 91
Iceland 88
Canada 87
Sweden 86
Japan
Finland 86
Netherlands 85
France
Denmark 82
New Zealand 82
Norway 82
OECD (14) 81
United Kingdom 79
Ireland 76
Korea 75
Czech Republic 75
Poland 62
0 20 40 60 80 100
Age-standardised rates (%)

SOBREVIDA A 5 AÑOS DEL CÁNCER DE COLON, OECD!
Japan (1999-2004)
67
66 Iceland (2003-2008)

66 United States (2000-2005)

62 Finland (2002-2007)

61 New Zealand (2002-2007)

61 Canada (2000-2005)

60 Sweden (2003-2008)

58 Korea (2001-2006)

58 Netherlands (2001-2006)

58 Norway (2001-2006)

57 OECD

57 France (1997-2002)
Age-standardised 54 Denmark (2002-2007)
rates (%) 52 Ireland (2001-2006)
52 United Kingdom (2002-2007)
47 Czech Republic (2001-2006)
38 Poland (2002-2007)

100 80 60 40 20 0

7.
FINANCIAMIENTO

COSTO DE SALUD Y ECONOMÍA

¿Quién asume el
aumento?
100 •  EL SALARIO DEL TRABAJADOR?
o  Mayor cuota?
Costo en Salud

80
o  Co-pagos?
60 •  EL INGRESO DEL
40 EMPRESARIO?
o  Mayor cuota patronal?
20
•  EL ESTADO?
0 o  Más impuestos?
x x+1
Período

Eithoven AC, Fuchs VR. Employment-based health insurance: past,
present, and future. Health Affairs 2006; 25:1538-1547

¿Quién asume el
100

80
aumento?
Costo en Salud

60
•  EL SALARIO DEL TRABAJADOR?
o  Mayor cuota trabajador
40
o  Co-pagos
20

0
x x+1
Período


100 ¿Quién asume el
80 aumento?
Costo en Salud

60 •  EL INGRESO DEL EMPRESARIO?
40 o  Mayor cuota patronal
20

0
x x+1
Período


100 ¿Quién asume el
80 aumento?
Costo en Salud

60 •  EL ESTADO?
40 o  Más impuestos
20

0
x x+1
Período


Source: Employee Benefit Research Institute estimates from the Current Population Survey, March 1995–2008 Supplements.

COBERTURA EN SALUD Figure 3
Percentage of Adults, Ages 18–64, With Employment-Based Health
Benefits, Medicaid, and Without Health Insurance, 1994–2007
80%

69.0% 69.3% 68.2%
66.9% 67.6% 68.4% 66.7%
70% 66.9% 67.4% 65.7% 64.6% 64.3%
65.0% 64.2%

60%

Employment-Based Coverage
50%
Medicaid

Uninsured
40%

30%
19.5% 20.3%
19.8% 19.7%
17.1% 17.6% 17.2% 17.7% 17.7% 17.3% 18.9% 19.5%
17.2% 17.9%
20%

10%

8.0% 7.9% 7.9% 7.3% 8.1% 8.2% 8.0% 8.2%
7.0% 6.5% 6.4% 6.4% 6.8% 7.0%
0%
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Source: Employee Benefit Research Institute estimates from the Current Population Survey, March 1995–2008 Supplements.

EBRI Issue Brief No. 321 • September 2008 • www.ebri.org 6

GOBIERNO Y GASTO EN SALUD
Participación en el gasto personal en salud,
según fuente de financiamiento, EE.UU.
100%
90%
80%
70%
60%
50% Privado
40% Gobierno
30%
20%
10%
0%
1960 1970 1980 1990 2000 2007

VR Fuchs. Government Payment for Health Care — Causes and Consequences. N Engl J Med 2010;
363: 2181-83

GASTO EN MEDICAMENTOS, SEGÚN FINANCIADOR, USA,
1999-2009
60%
Seguro Privado
49,5% 50,2% 50,9% 50,3% 48,9% 48,9% 49,4%
50% 45,1% 44,1% 43,6%
43,4%

40%
34,6% 35,4%
29,5% 28,1% 32,1% 33,1%
30% 26,5% 26,0% 25,8% 26,0% Fondos Públicos
25,5%
25,1% 25,1%
20% 22,7% 23,6% 25,2% 22,7% 22,8% 21,9%
21,0% 21,7% 21,2%

10% De Bolsillo

0%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Notes: Percentages may not total 100% due to rounding.
Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary,
National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type
of service and source of funds, CY 1960-2009; file nhe2009.zip).

United States
Netherlands (2)
France
Germany
Denmark
Canada
Switzerland
Austria
Belgium (1)
New Zealand
Portugal (2008)
Sweden
United Kingdom
Iceland
Greece (2007)
Norway Public Private
Ireland
OECD
Spain
Italy
Slovenia
Finland
Slovak Republic
Australia (2008)
Japan (2008)
Chile
Czech Republic
Israel EE.UU. posee:
Hungary
Poland
-Menor participación pública en el
Estonia
Korea
gasto en salud.
Luxembourg (2008)
Mexico
-Pero mayor gasto total en salud
Turkey (2008)
0 2 4 6 8 10 12 14 16 18
GASTO TOTAL EN SALUD, COMO PORCENTAJE DEL PBI, 2009. OECD

DINERO PÚBLICO A LA SALUD
Producción
Gasto

Gasto Público
en
$
Salud

Precio
Impuestos

Gobierno

Gasto Salud Uso (Cantidad)

-Cuanto mayor la participación del
Gasto Público Estado en el gasto en salud, mayor
necesidad de contención de costos

GASTO EN SALUD Y DÉFICIT SOBERANO

PUNTOS ESENCIALES DE LA REFORMA
La reforma posible en una compleja trama de intereses.

REFORMA
Reforma
Cobertura
Financiamiento
Práctica

REFORMA: COBERTURA
Cobertura Reforma de los Seguros

Expansión del Aseguramiento

Expansión del Medicaid

Ampliación de cobertura al Medicare

REFORMA: COBERTURA!
REFORMA DE LOS SEGUROS
•  Prohibir pre-existencias
•  Prohibir bajas arbitrarias o por edad
COBERTURA
•  Obligatoriedad del seguro de salud: individuos y empleadores
(>50 trabajadores), efectivo en 2014
•  Multas por incumplimiento
•  Ampliación del Medicaid, si ingreso<138% de la línea de pobreza
•  Extender el seguro paterno hasta los 26 años.
MEDICARE
•  Congelamiento de precios a aseguradoras que prestan servicios al
Medicare
•  Cerrar gap de cobertura de medicamentos en el 2020 ($2,5000-$4,500)
Reuters, 16/04/10, Donna Smith, Deborah Charles

REFORMA: COBERTURA!
Principio político: cobertura para todos
Mercado
200
Dinero Federal Aseguradoras
!"##$%&'()&(*&+'$%,'(

157
150 Mayor gasto -Mayor negocio
-./01(

100
federal -Mayor exigencia de
45 42 37 cobertura
50
15
0
No Medicare Medicaid Individual Seguro por
asegurados empleador
15 M 24 M
Ampliación Mayor gasto
Mayor gasto
Subsidios y Mercados de seguros federal
federal
Obligatoriedad de empleadores y Créditos fiscales

REFORMA: FINANCIAMIENTO
Financiamiento Nuevos recursos federales
-Nuevos Impuestos y Tarifas

Subsidios federales si ingreso
>138% y <400% de línea de pobreza
-Al mercado asegurador

Fondos federales para expansión del
Medicaid
-A los Estados

REFORMA: FINANCIAMIENTO: NUEVOS
RECURSOS!

!  Impuesto a los seguros más elevados (2018)

!  Aumentar impuestos al ingreso actualmente
destinados al Medicare

!  Fees a las prótesis, medicamentos de marca, y
compañías aseguradoras

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