Intended for healthcare professionals

Feature Health Spending Decisions

Should healthcare be guaranteed for cancer but not diabetes?

BMJ 2014; 348 doi: (Published 04 March 2014) Cite this as: BMJ 2014;348:g1812
  1. Andrew Jack, deputy editor, analysis
  1. 1Financial Times, London, UK
  1. andrew.jack{at}

As healthcare costs spiral, debate is growing over whether countries should limit their healthcare coverage to certain medical conditions. Andrew Jack examines why Chile’s attempt is meeting a mixed reception and looks at the other options

Ten years ago Chile introduced a groundbreaking health insurance system designed to improve access, quality, and speed of medical treatment for its citizens. Auge (the Spanish acronym for Universal Access with Explicit Guarantees) offered legally enshrined coverage for several medical conditions.

Today, that system—like its equivalents in other countries around the world—is generating both interest and criticism as policy makers seek ways to balance ever rising demands for better and fairer access to healthcare against intensifying pressures on costs.

Auge, approved under Chile’s socialist president Ricardo Lagos in 2004, sought to expand coverage across the country with a pioneering system that incorporates the principles of access, quality, opportunity, and financial protection, funded through a mixture of taxes and copayments by patients. The scheme lists the conditions that will be covered, which now number about 80, ranging from breast cancer to hepatitis C.1

This has triggered criticism that it discriminates against people with conditions outside the defined categories. “On the positive side, it has created in public opinion a consciousness of the importance of health as a right,” says Vivienne Bachelet, editor in chief of Medwave, a Chilean medical journal.

“But Auge has come to the detriment of those conditions that are not covered, and in order to meet treatment guarantees it has forced providers to outsource the covered conditions to the private sector at four to ten times the cost. It has led to the impoverishment of the public health system.”

Inclusion or exclusion?

Chile is not alone. It is one of several countries that are debating or experimenting with an “inclusion list” of reimbursed …

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