Daniela Estrada
SANTIAGO, Jun 29 2009 (IPS) – As a woman of childbearing age, I pay more than double what a man my age pays for the same health plan, 27-year-old Carolina Leyton told IPS.
Women waiting for treatment at a health centre. Credit: Daniela Estrada/IPS
Leyton is a subscriber of one of Chile s private healthcare providers, known as ISAPREs (Instituciones de Salud Previsional), which set different premiums depending on the risk associated with the beneficiary.
Since socialist President Michelle Bachelet came into office in 2006, her administration has worked to advance health policies with a gender perspective. But we re still weighed down by a huge debt to women, Health Ministry gender adviser María Isabel Matamala told IPS.
Seventeen percent of Chile s nearly 17 million people are currently insured through one of the ISAPREs, which were created in 1981 as a result of a partial privatisation of the country s healthcare system carried out by then dictator Augusto Pinochet (1973-1990) as part of his neoliberal recipe. The rest of the population receives health coverage through the public National Health Fund (FONASA) system.
In the ISAPREs everyone pays an identical basic rate, but they must also pay an additional risk factor, Alberto Muñoz, head of Funds and Insurance at the Office of the Health Superintendent (a ministerial-level body established as part of a series of health reforms implemented by Bachelet s predecessor Ricardo Lagos), told IPS.
The risks associated with women are the greater services they require and the benefits they receive for maternity leave.
Related IPS Articles
The ISAPRE Act, passed in 2005 as the culmination of Lagos wider health system reform, reduced the huge inequalities that women and the elderly suffered under these health insurers. Consequently, the law boosted the percentage of private subscribers.
But the law did not completely eliminate the perverse risk-based logic.
Patricia Encina is 30 years old and pays around 93 dollars a month for a plan that costs her husband also 30 only 35 dollars. The ISAPREs charge women three times more because we re mothers, even though it takes two to have a baby, she complained to IPS.
Before the reform, the cost of health plans available for women aged 25 to 45 could be as high as six times the cost of plans for men in the same age range, and while that difference was lowered substantially it s still around three times more.
The law also did away with the so-called no uterus plans that provided no maternity coverage and were created to lower the cost of insuring women, but which left them without coverage in the event of an unplanned pregnancy.
In addition to arguing that men share the responsibility of reproduction and child-care, women put forth other reasons for demanding equal charges from the ISAPREs.
According to the National Institute of Statistics, women make up nearly 40 percent of the workforce and earn on average 31 percent less than men. Moreover, their participation in the labour market is often interrupted by motherhood and because they are the first to be fired in times of crisis.
Women have less purchasing power, but their health plan rates are steeper and their out-of-pocket payments (for medicines and smaller reimbursements) are also higher, Matamala said.
Rafael Caviedes, the executive director of the Association of ISAPREs of Chile, argued that the difference in rates does not amount to gender discrimination because it s not arbitrary, but is justified by the greater expenses that women incur until the age of 60, which is when men begin to pay more than women, he told IPS.
According to Caviedes, the sector of the population that is truly discriminated against is the 80 percent of Chileans who lack the purchasing power to access high quality private health care. He said the industry is open to solving this discrimination, and proposed implementing transferable state subsidies that would benefit everyone.
Muñoz, in the Office of the Health Superintendent, pointed to other alternatives, such as the creation of a common solidarity fund to hold the contributions of all ISAPRE subscribers, distributing them among insurers according to the risk profiles of their clients. But a reform in that sense would only be possible by the mid 2010s.
In 2008, two different bills aimed at putting an end to gender discrimination in ISAPRE plans were introduced by lawmakers. Both legislative initiatives, however, are lying dormant in Congress.
But it s not just the private sector that discriminates. Under FONASA, only legally married women are eligible for coverage through their partners.
Moreover, in contrast to men, women cannot name their partners as beneficiaries in their coverage, except in cases of disability. A woman s contribution is worth less than a man s, Matamala said.
Heart attack versus emotional crisis
Health experts, women s organisations, health system administrators, and beneficiaries all agree that higher rates are just one of the forms of discrimination that Chilean women suffer when they seek health care. The treatment they receive is also different.
Prior to 2005 and the implementation of the AUGE (Universal Access with Explicit Guarantees) Plan a major component of the health reform, which established a list of 56 priority health problems that both FONASA and ISAPREs were required to cover with timely and quality services it was found that women who came into the hospital complaining of heart problems had a higher death rate from heart attacks than men who arrived in the same condition.
Particularly surprising was the fact that women were not treated with cutting-edge technology as often as men were, Matamala said.
When women came into the hospital presenting symptoms of a heart attack, such as chest pressure, they were usually diagnosed as suffering from an emotional condition, so there was a higher probability that an ECG would be ordered for male patients while female patients would be sent back home with a pill to calm them down, she said.
Now there are treatment protocols in place, which make no gender distinctions and are activated based on the medical diagnosis, but Matamala believes that it s likely that such practices continue in the health system, especially at the primary care level. Another problem is that health practitioners often underestimate their female patients, addressing them in patronising terms, which is ultimately discriminating because it basically treats them as children and disempowers them, the expert said.
The power exercised by health workers is evidenced in the alarming percentage of caesarean deliveries performed in private health services: over 60 percent of all births, when the maximum recommended by the World Health Organisation is 15 percent.
Physicians argue that they perform c-sections upon request of mothers-to-be who want the procedure, which is in turn more convenient for obstetricians because it allows them to plan their schedules. But behind all this there could be deliberate misinformation regarding the health risks associated with such procedures, to the detriment of natural births, Matamala said.
More responsibilities, less rights
According to Matamala, 70 percent of Chile s health workers are women, but most of them work in the less prestigious positions, earning lower salaries, with a greater risk of burnout and less recognition.
Women are not only chiefly responsible for patient care in health services, but are the primary carers at home, bearing an invisible burden and suffering an uncalculated strain on their mental health.
Meanwhile, decision-making in health is controlled by men, she said.
Gender activists highlight an additional paradox in the system: it lays the full load of sexual and reproductive responsibility on women, but denies them the power to make decisions over their bodies, in one of the few countries in the world where abortion is illegal under all circumstances, even when the mother s life is at risk.
Greater freedom of choice for women is even resisted by healthcare practitioners. Female health workers treat patients that come in for post-abortion care like criminals, Gloria Rey, a midwife, told IPS. They ll say to them: you enjoyed the sex, didn t you? So, don t complain about the pain now , without bothering to find out if they had a miscarriage or an abortion, she said.
Any discrimination in health services ultimately has to do with women having less power, whether in the economy and on the job, in terms of sexuality and reproduction, or with regard to citizenship and participation, Matamala concluded.
