Competing health policies: insurance against universal public systems

Objectives: This article analyzes the content and outcome of ongoing health reforms in Latin America: Universal Health Coverage with Health Insurance, and the Universal and Public Health Systems. It aims to compare and contrast the conceptual framework and practice of each and verify their concrete results regarding the guarantee of the right to health and access to required services. It identifies a direct relationship between the development model and the type of reform. The neoclassical-neoliberal model has succeeded in converting health into a field of privatized profits, but has failed to guarantee the right to health and access to services, which has discredited the governments. The reform of the progressive governments has succeeded in expanding access to services and ensuring the right to health, but faces difficulties and tensions related to the permanence of a powerful, private, industrial-insurance medical complex and persistence of the ideologies about medicalized 'good medicine'. Based on these findings, some strategies to strengthen unique and supportive public health systems are proposed.

The neoliberal reform basically challenges the idea of heath as a human and social right, and moves toward its commercialization. This policy is based on neoclassical economics with its premise that the market is the best distributor of resources, and that competition improves quality and abates costs (3) ; a premise that has never been proven in health. It redefi nes, on the one hand, the responsibilities of the State, market and family/individual with regard to health and, on the other hand, it redefi nes the words 'private property' and 'public goods' (4) , which have created serious epistemological Laurell AEC. confusion.
The new distribution of responsibilities places the private market in the center, whether these are for-profi t companies or families/individuals, while the state's role is subsidiary and only serves those proven to be poor, in targeted health program packages which are costeffective and restricted, and produce 'public goods' (5) .
In its new defi nition, 'private property' is that which is consumed by individuals; a category that includes individual health care. In this situation, the UHC model focuses on individuals. This means that the actions of public health or those aimed at the community belong to another category.
The 'public goods', which must be borne by the government, are defi ned as those which are characterized by 'non-inclusiveness' (cannot exclude anyone from consumption) and 'non-rivalry' (consumption by someone prevents consumption from another). Although they do not strictly conform to the above criteria, goods with 'large externalities' are located in this group. These are directed to the individual but also protect the community, namely, essentially public health actions such as epidemiological surveillance or vaccines. Another staple element in the neoliberal reform is the decentralization of services which, in practice, is equivalent to the decentralization of the political responsibility of the central state, at the request of lower-level political and administrative authorities (6) .
The initial neoliberal health policy faced ideological complications, political protests and economical exclusions, such as the rest of the social and economic policies. This forces neoliberal governments to push for a second reform or modernization of the state (7) in which the proposal from the UHC (8) is located. It differs from the fi rst health reform that emphasized the strict separation of functions between: regulation by the State; public or private fund/purchasing services management; private or public provision of these services; and free choice of the insured fund administrator and service provider. It is a variant of managed competition, but it is known in Latin America as structured pluralism (9) . This separation is necessary to stimulate market forces and competition, to ideally channel fi nancial resources to the demand, the users, and eliminate the funding of the offer has been suggested, meaning the budget of the public institutional providers of services.
The second innovation is precisely the assurance of 'universal' quality which allows the State to guarantee the public market through insurance, managed by private or public agents, which amounts to a state subsidy to the private sector, as an administrator or service provider (10) . The logic of this model is the same as a private insurance, leading to the defi nition of explicit service packages for each type of insurance. Another way to enforce competition and commodifi cation is with the New Public Management (NPM), with payment to public or private providers on the basis of services actually rendered; which drives outsourcing and job insecurity in the sector (11) .
The best known cases of the UHC via health The Colombian reform has another institutional arrangement (14) . Simply put, the Solidarity and Guarantee Fund (FOSYGA) receives insurance quotations and allegedly a state subsidy for non-contributors. The reform process has weakened social security, the strongest part of the public health system, but its resistance to private sector attacks is remarkable. It is on the government's agenda to create a "Universal National Health System" (UNHS) through mechanisms of: insurance portability between public and private institutions, with a package of unique services; unique treatment protocols and funded services; and, health market development (18) . This approach does not seek to establish a single public health service with universal access, ensuring the right to health. If it materializes, the ones with the biggest loss would be the population with social security, which would have its health benefi ts signifi cantly reduced; the potential winners would be the private insurers, given the need to purchase insurance that covers illnesses and treatments not included in the basic package. However, the SNSU has not advanced so far because of the lack of fi scal resources and disagreements over fi nancial and institutional design.

Health policy of social democratic rule of law or progressive states
The historical trajectory of the progressive governments has been different, but can roughly be They also all tend to be sub-funded and require more budgetary resources. However, the conception of health-disease and its social determination is crucial when making decisions on priorities to guide technicalscientifi c development, and to calculate the required fi nancial resources. No one denies the need to provide quality and technically satisfactory services. It is in this context that we should settle the case for a single public health system, which is the most suitable and inexpensive institutional arrangement to respond to health needs, but also to combat the commoditization and dehumanization of health (29) .
In the budgetary process that includes other social areas, it seems insuffi cient to consider health as just one more social right. It may be helpful to take up the idea of positive freedoms, which are those that allow full participation in a democratic society. One is health as a basic human need, (30) the satisfaction of which is essential for such participation. Also, it reinforces the idea that health is not an object of consumption (1)  They are the fi rst to say that public institutions offer "poor medicine for poor people". The best strategy to counter this argument is to strengthen and enhance institutional capacity by providing technically competent and humanly satisfactory public services that displace private services. This is not enough if the ideological content of 'good medicine' and its articulation with the capital accumulation is not revealed. There are many elements needed to do this, because there is extensive literature on the abuse and damage caused by the desire for gaining from the medical-industrial complex. In this context, when strengthening state regulation, technology assessment, production of medicines and other supplies is also crucial.
Another key issue is facing the insurance or private health plans that persist and even grow in the conceptually unique and public health systems (24, 31-32). This is necessary because they channel signifi cant amounts of public resources into private ones in various ways that weaken the public system (26) . A paradoxical obstacle is that employment benefi ts are usually negotiated by the large unions, meaning the natural class basis of the public, solidarity and egalitarian systems (32) .
Thus there is the governmental temptation to encourage private insurance, arguing that decompressed demand in the public system is equivalent to naturalizing inequality in access to required services, especially when the door opens to large corporations of international health. The most effective antidote is informed popular participation, which promotes political-ideological and cultural change. Another temptation is to adhere to the model of 'universal' assurance that, as discussed above, means that the private use of public resources for the sake of unproven ideological premise.

Conclusion
Health reforms in Latin America are taking place in two opposing ways: the UHC and the SUS. They are inserted into two different developmental models which are in the composition and role of the state in economic and social policy. Neoliberal governments have adopted the neoclassical economic thought, and consider health a fi eld of free market economy. The UHC, through health insurance, is the health policy that has strengthened the medical-industrial-insurer complex and increased profi ts, but at the expense of universal and equal access to health services and governmental legitimacy.
Progressive governments have increased access and guaranteed the right to health through their unique, public and supportive health systems, but they face several challenges related to growing demands of the population and the persistence of an aggressive private sector.