“The current context means that, for the first time in many years, the possibility of integrating the mutualist population into the public health system constitutes an option that is both viable and reasonable. The Ministry of Health has prepared a report to analyze the impact that the integration of the million Muface users who opted for private care would have on the health system if coverage is not ultimately granted and concludes that the situation can even become an opportunity. although the department led by Mónica García does not close the door to any exit.
The proposal that private insurers made to Health as part of the competition for the renewal of the Muface concert in 2025 and 2026 led the ministry to consider, perhaps for the first time realistically, putting an end to the system that currently allows public officials to choose between private and public each year. blanket. The report, to which this newspaper had access, studies for 17 pages what would happen if Muface were extinguished or profoundly modified, it accuses private insurers of the “more than obvious” practice of referring patients who are not economically cost-effective 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 the Civil Service, which explained on Friday that it was studying the possibility for mutualists to choose the type of health coverage they want “forever” and not annually, so that it would be “easier to plan the system’s sources of income and its sustainability,” as sources from the department headed by Óscar López explain.
Furthermore, according to the detailed analysis carried out by Muface Health users who have chosen private healthcare (those who should adhere to the public system), the autonomous communities of Andalusia, Castile and León and Extremadura, as well as the autonomous cities of Ceuta and Melilla would be the most affected both by the number of members of general mutual insurance companies and by the proportion of people over 65, patients who generate the most health expenses.
As you can see in the following table, these are the only regions that would add more than 3% new users to the system (or almost, in the case of Andalusia). The Balearic Islands, Catalonia, Euskadi and Navarra would be those 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 for a total amount of more than 1,337 million euros for 2025 and 1,345 million for 2026, with a total half-yearly increase of 304 million euros, neither Adeslas, Asisa or DKV, the three companies that currently provide the service, decided to participate, saying that the increase is “insufficient”, even if it was 25%. Companies claim that young mutualists (those who give profits to private insurers) are increasingly choosing public health while older ones, less economically profitable, remain in the private sector.
The data provided by the Health Report validates these assertions: the average age of mutual members has increased by 3.7 years in a decade and if we compare the distribution of citizens by age groups in the public health system and among Muface users with that of private insurance, it is observed that in the SNS, those over 65 represent 20.39% of the total, while in Muface they represent 31.9%. But the ministry analyzes this difference as another problem for the future: “This suggests that if the current model of service delivery continues, the population increases expected to occur in the future would be of a significant amount, as it there is no age distribution. (and, probably, the consumption of health resources) which allows the sustainability of the system in the medium and long term.
Translated: as there are no young people joining the private system – with the exception of babies and over 90s, with Muface’s under 20s and 30s – paying for this gig will get more and more expensive .
Faced with this rupture – for which the parties blame each other – Health is speculating on the two options available to it. The first is to increase the economic offer to convince private insurers. But, contextualizes the ministry, this is probably an “insufficient” solution (insurers demand an increase of more than 40% compared to current financing conditions); unsustainable (because it does not respond to the long-term dynamics of the aging of the Muface mutualist subpopulation); and unfair to assume percentage increases that would be unthinkable in the area of direct public provision. And he concludes that in reality one could consider that it is a question of “postponing a decision which will have to be taken sooner or later”.
Health denounces “the more than obvious existence of risk selection practices on the part of private insurers”. In other words, they direct economically unprofitable patients towards the public system.
But this possibility poses a problem, the report continues. “It should be noted that the more than obvious existence of risk selection practices on the part of private insurers who provide health care to members of the Muface mutual is a phenomenon which presupposes support by the SNS of risks and costs that private health insurers should assume.
Considering that the “risk selection” mentioned by Health is, in summary, the technicality with which private insurers “avoid covering those which, because they could cause frequent or high value losses, would cause an economic imbalance in the company results » By its own definition, Health accuses companies of sending the most expensive patients to the public system. “This represents a problem that there is no escaping when it comes to analyzing this issue.”
The alternative to increasing supply is to extend the agreement provided for by law by nine months and, during this period, prepare for the entry into the public system of these millions of mutualists with private insurance. In this case – for which a method is even proposed: “A progressive incorporation stratified by the letter of the beginning of the first name, age and service insurer could be proposed” – the system should take into account factors such as ‘identification of patients immersed in therapeutic processes that require continuity (oncology, for example), who would be the last to change network, or developing a transition plan to guarantee continuity in chronic treatments and other very complex elements, describes Health.
2% more
The report comprehensively assesses the impact of adding one million new users to the system. Overall, the SNS would welcome 2.1% of new users: 2% in the group between 0 and 14 years old, 1.3% from 15 to 34 years old, 2% from 35 to 64 years old and 3.3% 65 years and older. But the reality is very different depending on each autonomous community. Health has divided the autonomy groups into three groups based on the number of mutual members they have, by age group.
Those that come out worst, according to this analysis, are Andalusia, Castile and León, Extremadura, Ceuta and Melilla. All have an increase of more than half a percentage point compared to the average and, in all cases, the percentage of the private mutualist population over 65 compared to the total over 65 is even higher. Andalusia is the community that stands out the most in this regard, with a theoretical increase of 4.6% in this group, with the exception of Ceuta and Melilla, which exceed 9%.
In the middle, Aragon, Asturias, Canary Islands, Cantabria, Castilla-La Mancha, Galicia, Madrid, Murcia and La Rioja are slightly above or below average. In this group, Health highlights the case of Madrid, which despite the presentation of standard figures in general, increases slightly among those over 65, who would increase by 4.5%.
Finally, in the Balearic Islands, Catalonia, Euskadi and Navarre, the mutualist population does not exceed 1.2% of the general population “for different reasons”, figures which represent “a figure similar to the annual increase in population that an autonomous community can face. “. Health underlines in this case the anomaly of Euskadi, which, despite a high rate of mutualists over 65 years old benefiting from private health care (35.65%) would barely suffer an impact of 1.63% in the group.
The report does not indicate any course of action, although it explains that it would be “viable” and “reasonable” to integrate these million people into the public system. Or, in other words, turn off Muface, at least as it currently works. “This occurs due to the conjunction of two elements, one purely cyclical and the other structural,” explains the ministry. “The first is the lack of participation of private insurers in the conditions proposed by the Spanish government. The structural reason (…) shows an aging of the basic population of Muface with the absence of counterbalancing elements which serve to adjust the capital to lower and controlled amounts for the years to come. The Muface model is currently not viable, even with a significant increase in population, because no insurance system works if it does not have a pool of risks which makes it possible to exercise counterbalances between those who request the service the most and those who use it less intensively.
And to conclude: “If the funding currently allocated to the health care of Muface mutualists who address the private insurer were transferred to public health in the process of internalization of the management of this care, the SNS should have the capacity to provide this service. with appropriate management of the transition process.
