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La cuestión de la reforma del sistema de salud ha puesto sobre la mesa un dato alarmante: sólo el 65% de la población posee cobertura de salud, es decir que el 35% no tiene ni obra social, ni prepaga y depende de la atención en los hospitales públicos. Formalmente, todos tenemos acceso a la salud, pero sabemos, del dicho al hecho…

La atención en los hospitales públicos está minada por el desfinanciamiento de décadas, con profesionales (muchas veces los mejores) terriblemente mal pagos y saturados, con el grueso de la atención en manos de residentes con salarios de pobreza, concurrentes sin salario y enfermeras superexplotadas en dobles y triples jornadas para llegar a fin de mes. Sin insumos y en instalaciones que reciben a lo sumo, cada tanto, una mano de pintura. Conseguir turno en un hospital público es una odisea, no sólo por la disponibilidad de turnos (unas pocas decenas por días, por lo que muchas familias hacen vigilias en los establecimientos para conseguir atenderse) sino por la lejanía (como mostramos, hace algunos meses, para el caso de la salud dental en esta nota).

Sin embargo, la salud pública en la Argentina es y debe ser defendida como una gran conquista y un derecho de los trabajadores. Otra es la realidad, en cambio, en los Estados Unidos, donde incluso el hospital público está arancelado y el tratamiento de cualquier afección más o menos seria es vedado a todo un sector de la población trabajadora empobrecida. Es como lo que vemos una y otra vez en los dramas televisivos. Gobiernos y patronales son conscientes de esto, y la pandemia ha sido un nuevo impulso, no para mejorar la salud pública, sino para avanzar en una nueva etapa de privatización sanitaria. 

El sistema de salud está dividido en tres subsistemas: público, obras sociales y privado. El 55% se atiende en las obras sociales que se financian a partir de los aportes de los trabajadores en blanco y las patronales, el 35%, dijimos, lo hace exclusivamente en el hospital público, y apenas un 11% se atiende a través de las empresas de medicina prepaga. El negocio de la medicina sin embargo excede a ese pequeño porcentaje de la población y se sostiene en el drenaje constante de fondos tanto de las obras sociales como del Estado. A la vez que el Estado y los sindicatos (de cuya burocracia depende las obras sociales) financian a los capitalistas de la salud, desfinancia a los hospitales públicos y la atención de las obras sociales impulsando a los trabajadores que pueden costearlas a pasarse al sistema privado ¿Cómo?

Hasta el año 1993 todos los trabajadores en relación de dependencia aportaban y tenían los servicios de su obra social sindical (y de los obras sociales provinciales o direcciones de salud para los empleados del Estado en algunos casos, como IOMA en la Provincia de Buenos Aires). La desregulación implicó que cada trabajador pudo elegir si mantener su aporte a la obra social o que este descuento vaya al pago de otra obra social o una empresa de medicina prepaga, solventando de su bolsillo la diferencia. Así, las prepagas captaron a los trabajadores de más altos ingresos, que con sus aportes llegaban a pagar la cuota de la prepaga. Del 11% afiliado a prepagas, el 7% lo hace derivando aportes, y apenas el 4% lo hace individualmente.

Los empleados que pagan un extra por la prepaga, pueden además deducir este gasto del impuesto a las ganancias, por lo que es otra forma en la que el Estado financia a las prepagas. Y a su vez, estas empresas pagan menores aportes por sus empleados, ya que están eximidas del 95% (casi la totalidad) de los aportes al sistema previsional que se desfinancia para inflar los bolsillos de los grandes grupos de la salud privada. No olvidemos, claro, los subsidios directos, tanto de fondos públicos como de los que debieran ir a las obras sociales, como los 400 millones al mes de IOMA que Kicillof destinó a las clínicas privadas.

Las burocracias sindicales no han dejado pasar la oportunidad de hacer negocios con las obras sociales. No solamente los ilícitos (recordemos el escándalo de los medicamentos por el que terminó preso Zanola, jefe de los bancarios). Algunas de las obras sociales o bién se asociaron con empresas de medicina y buscaron captar afiliados, funcionando en los hechos como prepagas, otras, en cambio, crearon sus propias prepagas o dentro de las obras sociales ofrecen planes con más beneficios, como es el caso de Unión Personal, de UPCN, con planes premium y una prepaga propia (Accord). Otro de los negocios de las obras sociales es el uso de las clínicas y hospitales para la atención de los pacientes de la medicina prepaga o de otras obras sociales con menores recursos, por lo que muchas veces sus afiliados reclaman la dificultad para conseguir un turno. Ésto último no es privativo de los centros dependientes de las obras sociales. Los viejos hospitales y mutuales de comunidad, que servían por cuotas módicas a los trabajadores inmigrantes y sus descendientes, se convirtieron también en empresas de medicina prepaga y venden también el uso de sus instalaciones, como es el caso del Hospital Italiano, el Alemán o el muy venido a menos Centro Gallego.

Las empresas de medicina no parecen haberse alarmado ante las intenciones, de un sector del Kirchnerismo de reformar el sistema de salud para “integrarlo”. Claro, no se trata de dar al conjunto de la población la misma atención, estatizando los centros de atención o poniendo los centros privados al servicio de quienes no tienen recursos, sino de todo lo contrario. En palabras de la propia CFK: “vamos a tener que empezar a repensar un sistema nacional integrado de salud en el que podamos articular todo esto para ser un uso más eficiente de lo que hay en la Argentina». Si el problema es el “uso más eficiente de los recursos” para la vicepresidente, en salud, se gasta demasiado. En la misma nota del diario La Nación que reseña los planes de reforma otro dirigente kirchnerista decía:  «Debería existir un costeo cruzado. Donde hay un resonador en el sistema privado que lo use también el sistema público, y viceversa, para reducir costos». 

Diversos funcionarios del gobierno han salido sin embargo a poner paños fríos en el asunto, para rápidamente aclarar que el problema del sistema de salud es la financiación, y que para resolverlo se estaba discutiendo aumentar los aportes de los trabajadores al sistema. Tomamos el guante y señalamos: muy bien, las obras sociales, principales prestadoras, están desfinanciadas ¿es responsabilidad del bajo porcentaje de aportes? Los únicos que aportan a las obras sociales son los trabajadores en blanco, sin embargo es política de estado el trabajo en negro y precario. Apenas un 50% de la población trabaja en blanco y hace aportes jubilatorios y a las obras sociales. Otro 25% trabaja en negro, hace changas o son monotributistas (desde los modestos changueros que pagan el montributo para poder tener obra social y una jubilación minima hasta los profesionales, pasando por todos los trabajadores a los que se hace facturar todos los meses). Ese porcentaje de trabajadores en negro y cuentapropistas (y los millones de desocupados) explica que el 35% de la población no tenga cobertura. Por otro lado, el monotributo esconde relaciones laborales en negro. El propio Estado tiene a una buena parte de sus trabajadores como contratados a los que hace facturar como monotributistas. El monotributo incluye la obra social, pero su aporte a las mismas es muy menor en comparación al de los trabajadores en relación de dependencia (no hay aporte patronal), por lo que es otra forma de desfinanciar a las obras sociales. El negreo a los trabajadores, la desocupación y el trabajo precario es responsable del desfinanciamiento. La primera medida que tendría que tomar el gobierno es el blanqueo laboral, comenzando por los propios contratados del Estado.

La cuestión del financiamiento tiene que ver no con la “crisis de las obras sociales” sino con el financiamiento de las prepagas, que parasitan a las obras sociales y las finanzas públicas, como mostramos más arriba. El verdadero plan oficial no es la integración de nada sino el simple y llano recorte, reemplazado PMO por una “canasta de prestaciones” mucho menor, y que quien necesite más que contrate un plan superior y el aumento de los aportes de los trabajadores. No debemos olvidar, que hace poco más de un mes se aprobó la telemedicina, un negoción para las empresas en términos de reducción de costos. Una orientación, evidentemente, al servicio de las empresas de medicina.

La reforma del sistema de salud, para que se trate realmente de una mejora en la atención global, debe tener como base una verdadera planificación del sistema de salud, que integre al hospital público con las obras sociales, acerque la atención primaria a los sectores y barrios que hoy no acceden a desbordado hospital público, con la supervisión de los trabajadores y con salarios y condiciones acordes para el personal de salud. Sólo la supervisión obrera sobre la salud pública podría erradicar que los hospitales continúen funcionando como centros de grandes negociados. Ninguna “canasta de prestaciones” ni aumento en los descuentos, defensa irrestricta de la salud pública y las obras sociales frente al lucro capitalista.

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