Trabalho doméstico remunerado e resistência: interseccionando raça, gênero e classe / Paid domestic work and resistance: intersecting race, gender, and class / Trabajo doméstico remunerado y resistencia: intersección entre raza, género y clase

No Brasil, o trabalho doméstico remunerado é essencialmente feminino e emprega cerca de 5,9 milhões de mulheres, correspondendo a 16,8% da ocupação feminina. Desse contingente, 61 % são compostos por mulheres negras. As empregadas domésticas estiveram historicamente submetidas a uma série de aspectos excludentes, como baixa remuneração, contratações à margem da legalidade e discriminação de gênero e raça. Esta pesquisa objetivou compreender a resistência enquanto categoria fundamental para compreensão do trabalho doméstico. Ao falar sobre essa categoria, destacamos a subjetividade que constitui os fenômenos sociais, partindo de uma compreensão dialética e histórica do sujeito e da relação indivíduo-sociedade, inserida em uma historicidade. Os resultados encontrados, coletados por meio de documentos, notícias, reportagens, participações no sindicato da categoria e da realização de entrevistas com cinco domésticas apontam a existência de formas de resistência no campo do trabalho doméstico, compondo movimentos de oposição e reação ao modus operandi colonial e às hierarquias de gênero-raça-classe que formam a sociedade brasileira. A psicologia sócio-histórica foi escolhida como abordagem teórico-metodológica, pois possibilita compreender do homem como ser ativo, social e histórico. Ao investigar as formas de resistência presentes nesse tipo de trabalho, compreende-se a trabalhadora doméstica não como mera consequência da realidade social em que se insere, mas como sujeito ativo que constitui essa realidade e é simultaneamente constituído por ela. Com esta pesquisa, pretende-se contribuir com a crítica à ideologia dominante que subalterniza essas trabalhadoras e as relega à subcidadania, uma condição sem reconhecimento e direitos.(AU)

In Brazil, paid domestic work is essentially female and employs about 5.9 million women, corresponding to 16.8% of the female occupation. Of this contingent, 61% is made up of black women. Domestic workers have historically been subjected to a series of exclusionary aspects, such as low remuneration, hiring outside the legal system and gender and race discrimination. This research aimed to understand resistance as a fundamental category for understanding domestic work. When talking about this category, we highlight the subjectivity that constitutes social phenomena, starting from a dialectical and historical understanding of the subject and the individual-society relationship, inserted in a historicity. The results found, collected from documents, news, reports, participation in the category union and interviews with five domestic workers, point to the existence of forms of resistance in the field of domestic work, composing movements of opposition and reaction to the colonial modus operandi and the gender-race-class hierarchies that make up Brazilian society.Socio-historical psychology was chosen as a theoretical-methodological approach, since it provides an understanding of man as an active, social and historical being. When investigating the forms of resistance present in this type of work, the domestic worker is understood not as a mere consequence of the social reality in which she is inserted, but, as an active subject, who constitutes this reality and is simultaneously constituted by it. This research intends to contribute to the criticism of the dominant ideology that subordinates these workers and relegates them to a sub-citizenship, a condition without recognition and rights.(AU)

El trabajo doméstico remunerado en Brasil es predominantemente femenino y emplea casi 5,9 millones de mujeres, lo que corresponde al 16,8% de la ocupación femenina. El 61% de este grupo está compuesto por mujeres negras. Históricamente, las trabajadoras del hogar han sido sometidas a una serie de aspectos excluyentes, como la baja remuneración, la contratación fuera del sistema legal y la discriminación de género y raza. Esta investigación tuvo como objetivo comprender la resistencia como categoría fundamental para entender el trabajo doméstico. Al hablar de esta categoría, se destaca la subjetividad que constituye los fenómenos sociales a partir de una comprensión dialéctica e histórica del sujeto y la relación individuo-sociedad, insertada en una historicidad. Los datos recogidos de documentos, noticias, participación en la categoría unión y entrevistas con cinco sirvientas permitieron concluir que existen formas de resistencia en el ámbito del trabajo doméstico, que se componen de movimientos de oposición y reacción al modus operandi colonial y a jerarquías de género-raza-clase que conforman la sociedad brasileña. La psicología sociohistórica fue el enfoque teórico-metodológico utilizado, ya que proporciona una comprensión del ser humano como ser activo, social e histórico. El análisis de las formas de resistencia presentes en este tipo de trabajo permite identificar la trabajadora doméstica no como una mera consecuencia de la realidad social en la cual se inserta, sino como sujeto activo que constituye esta realidad y, a la vez, es constituido por ella. Se espera que esta investigación pueda contribuir a la crítica de la ideología dominante que subordina a estas trabajadoras, relegándolas a una subciudadanía, una condición sin reconocimiento y sin derechos.(AU)

Seguridad social y medicamentos Mecanismos de cobertura de dos obras sociales en contexto de inflación 2011-2019 / Social security and medicines: coverage mechanisms of two health insurance organizations in the context of inflation, 2011-2019

INTRODUCCIÓN: La elevada inflación argentina puede comprometer el acceso a los medicamentos, incluso con cobertura de la seguridad social. El objetivo de este estudio fue describir la evolución entre 2011 y 2019 de la cobertura del Instituto Nacional de Servicios Sociales para Jubilados y Pensionados (INSSJyP, también conocido como PAMI) y del Instituto de Obra Médico Asistencial (IOMA) para una selección de medicamentos de uso ambulatorio, fuera de patente, de consumo frecuente en patologías prevalentes, y evaluar si la evolución del ingreso de los beneficiarios acompañó el aumento del gasto de bolsillo para estos fármacos. MÉTODOS: Se registró la evolución del precio de venta al público (PVP) y de la cobertura por INSSJyP y por IOMA en los cuatrienios 2011-2015 y 2015-2019 para una selección de 10 fármacos utilizados en enfermedades crónicas de alta prevalencia. Se calculó la evolución del gasto de bolsillo para las presentaciones promedio, más barata y más cara de cada fármaco, y se comparó con la evolución de los ingresos de los beneficiarios. RESULTADOS: La cobertura promedio del INSSJyP para los fármacos estudiados subió de 63% en 2011 a 73% en 2019. La cobertura del PVP promedio por el IOMA fue de 55% en 2011 y descendió a 36% en 2019, debido a la demora en la actualización de los montos fijos. Para los beneficiarios de ambas instituciones el gasto de bolsillo creció menos que el ingreso en 2011-2015 pero lo superó ampliamente en 2015-2019. DISCUSIÓN: El sistema de cobertura por monto fijo tiene ventajas conceptuales, pero requiere una actualización oportuna de los valores con la inflación

Health Insurance Coverage among Puerto Rican Adults in Same-Sex Relationships.

OBJECTIVE: The primary objectives of this study were to measure and compare health insurance coverage between nonelderly Puerto Rican adults in cohabiting same-sex relationships and their counterparts in cohabiting different-sex relationships. METHODS: This study used data from the 2008-2014 Puerto Rican Community Survey on nonelderly adults (18-64 years) in cohabiting same-sex (n=274) and different-sex (n=58,128) relationships. Multinomial logistic regression models estimated differences in primary source of health insurance while controlling for key demographic and socioeconomic characteristics. RESULTS: Compared with men in different-sex relationships, men in same-sex relationships were less likely to have employer-sponsored insurance (ESI). Women in same-sex relationships were less likely than others to have ESI, insurance purchased directly from an insurer, and public health insurance after controlling for socio-demographic factors. CONCLUSIONS: Employment-based discrimination and policy barriers may have prevented same-sex couples from enjoying the full benefits associated with marriage and cohabitation in Puerto Rico, including employer-sponsored health insurance.

Value-based Insurance Design.

The increasing awareness of the scarcity of health care resources is forcing the health care industry to improve quality while lowering the cost. One method by which employers and insurance companies are attempting to do this is with value-based insurance design. In these plans, patients pay a lower amount for certain services that are considered high value and a higher amount for services that are considered low value.

Contratos coletivos de assistência médica suplementar: estudo de caso em empresa empregadora e sindicato no ramo metalúrgico em Minas Gerais / Collective contracts for supplementary medical care: a case study in an employer company and a union in the metallurgical sector in Minas Gerais

Introdução: A Constituição Federal de 1988 instituiu o Sistema Único de Saúde (SUS) e mesmo com a sua criação, a assistência à saúde dos trabalhadores no Brasil é predominantemente realizada pelo setor privado suplementar de saúde. A trajetória histórica da assistência médica aos trabalhadores carrega traços herdados da estrutura médica previdenciária. A atual conformação do Sistema de Saúde brasileiro se dicotomiza em dois subsetores: o público e o privado. Este último, ainda estratificado em um segmento suplementar e um segmento liberal/autônomo. De especial interesse é o estudo do setor suplementar constituído por 48,8 milhões de beneficiários em planos de assistência médica e/ou odontológica. Destes, aproximadamente 80% possuem planos de assistência médica coletivo. Tais planos têm sido objeto de negociação nas pautas reivindicatórias de assistência entre sindicatos e empresas, processo que contribui para a privatização do setor saúde no Brasil. Objetivo: Buscou-se compreender a contratação coletiva de planos de saúde para assistência médica a trabalhadores formais, utilizando como análise central os discursos dos atores sociais envolvidos. Metodologia: Trata-se de um estudo de caso exploratório com aporte qualitativo, realizado com um representante sindical e um representante da empresa empregadora, do ramo metalúrgico. Os dados foram coletados por meio de análise documental e de entrevista semiestruturada e analisados na perspectiva da análise de discurso proposta por Michel Foucault. Resultados: Ao longo de 19 anos a categoria metalúrgica pesquisada realizou 26 convenções coletivas de assistência médica, e destas 16 (61%) são cláusulas de planos de assistência à saúde médico-ambulatorial ou hospitalar e odontológica. A empresa empregadora realizou 42 acordos coletivos de assistência médica, sendo 21 (50%) sobre o mesmo tema. A percepção dos entrevistados sobre a assistência à saúde dos trabalhadores serem atualmente responsabilidade dos planos coletivos de saúde deu origem a três temas. O primeiro diz sobre o papel do sindicato e da empresa na contratação coletiva de assistência à saúde, o segundo ressalta o posicionamento dos entrevistados sobre a regulação do setor suplementar exercida pela ANS e o terceiro discorre sobre a utilização pelos trabalhadores dos serviços ofertados pelo SUS. Considerações Finais: Os discursos correlacionados resultam em reflexões sobre o movimento histórico de contratações coletivas de plano de saúde para a classe dos trabalhadores no Brasil. Nos enunciados, vimos emergir inúmeros problemas do passado que ainda se arrastam sem solução, dentre eles, a privatização cada vez mais crescente do sistema de saúde brasileiro.

Introduction: The Federal Constitution of 1988 establishes the Unified Health System (SUS) in 1988 and, even with its creation, health care for workers in Brazil is predominantly performed by the supplementary private health sector. The historical trajectory of medical care to workers carries traits inherited from the social security structure. The current shape of the Brazilian Health System is dichotomized in two sub-sectors: the public and the private. The latter, still stratified in a supplemental segment and a liberal / autonomous segment. Of special interest is the study of the supplementary sector constituted by 48.8 million beneficiaries in medical and / or dental care plans. Of these, approximately 80% have collective health care plans. Such plans have been the subject of negotiation in the demands for assistance between unions and companies, a process that contributes to the privatization of the health sector in Brazil. Objective: To understand the collective contracting of health plans for medical care to formal workers, using as central analysis the speeches of the social actors involved. Methodology: This is an exploratory case study with a qualitative contribution, carried out with a union representative and a representative of the employing company, from the metallurgical branch. The data were collected through documental analysis and semi-structured interview and analyzed from the perspective of discourse analysis proposed by Michel Foucault. Results: Over 19 years, the metallurgical category surveyed carried out 26 collective health care conventions and of these, 16 (61%) are clauses of medical-ambulatory health care or hospital and dental care plans. The employer made 42 collective health care agreements, 21 (50%) on the same subject. The perception of the interviewees about the health care of the workers being currently the responsibility of the collective health plans gave rise to three themes. The first one says about the role of the union and the company in the collective contracting of health care, the second emphasizes the position of the interviewees on the regulation of the supplementary sector exercised by the ANS and the third talks about the use of the services offered by the SUS by the workers. Final Thoughts: The correlated discourses result in reflections on the historical movement of collective contractions of health plan for the class of workers in Brazil. In the enunciated ones, we have seen to emerge innumerable problems of the past that still creep without solution, among them, the increasing privatization of the Brazilian health system.

Association between employee benefits and frailty in community-dwelling older adults.

AIM: The phenotype of frailty has been associated with an increased vulnerability for the development of adverse health-related outcomes. The origin of frailty is multifactorial and financial issues could be implicated, as they have been associated with health status, well-being and mortality. However, the association between economic benefits and frailty has been poorly explored. Therefore, the objective was to determine the association between employee benefits and frailty. METHODS: A cross-sectional study of 927 community-dwelling older adults aged 70 years and older participating in the Mexican Study of Nutritional and Psychosocial Markers of Frailty was carried out. Employee benefits were established according to eight characteristics: bonus, profit sharing, pension, health insurance, food stamps, housing credit, life insurance, and Christmas bonus. Frailty was defined according to a slightly modified version of the phenotype proposed by Fried et al. Multinomial logistic regression models were run to determine the association between employee benefits and frailty adjusting by sociodemographic and health covariates. RESULTS: The prevalence of frailty was 14.1%, and 4.4% of participants rated their health status as "poor." Multinomial logistic regression analyses showed that employee benefits were statistically and independently associated with the frail subgroup (OR 0.85; 95% CI 0.74-0.98; P = 0.027) even after adjusting for potential confounders. CONCLUSIONS: Fewer employee benefits are associated with frailty. Supporting spreading employee benefits for older people could have a positive impact on the development of frailty and its consequences. Geriatr Gerontol Int 2016; 16: 606-611.

Type of Insurance and Use of Preventive Health Services Among Older Adults in Mexico.

OBJECTIVE: The main purpose of this article was to assess the differences between Seguro Popular (SP) and employer-based health insurance in the use of preventive services, including screening tests for diabetes, cholesterol, hypertension, cervical cancer, and prostate cancer among older adults at more than a decade of health care reform in Mexico. METHOD: Logistic regression models were used with data from the Mexican Health and Nutrition Survey, 2012. RESULTS: After adjusting for other factors influencing preventive service utilization, SP enrollees were more likely to use screening tests for diabetes, cholesterol, hypertension, and cervical cancer than the uninsured; however, those in employment-based and private insurances had higher odds of using preventive care for most of these services, except Pap smears. DISCUSSION: Despite all the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in health care access and utilization still exist in Mexico.

Can health insurance improve employee health outcome and reduce cost? An evaluation of Geisinger's employee health and wellness program.

OBJECTIVE: To evaluate the impact of a health plan-driven employee health and wellness program (known as MyHealth Rewards) on health outcomes (stroke and myocardial infarction) and cost of care. METHODS: A cohort of Geisinger Health Plan members who were Geisinger Health System (GHS) employees throughout the study period (2007 to 2011) was compared with a comparison group consisting of Geisinger Health Plan members who were non-GHS employees. RESULT: The GHS employee cohort experienced a stroke or myocardial infarction later than the non-GHS comparison group (hazard ratios of 0.73 and 0.56; P < 0.01). There was also a 10% to 13% cost reduction (P < 0.05) during the second and third years of the program. The cumulative return on investment was approximately 1.6. CONCLUSION: Health plan-driven employee health and wellness programs similarly designed as MyHealth Rewards can potentially have a desirable impact on employee health and cost.

Employer Health and Productivity Roadmap™ strategy.

The National Institute for Occupational Safety and Health Total Worker Health™ Program defines essential elements of an integrated health protection and health promotion model to improve the health, safety, and performance of employers and employees. The lack of a clear strategy to address the core drivers of poor health, excessive medical costs, and lost productivity has deterred a comprehensive, integrated, and proactive approach to meet these challenges. The Employer Health and Productivity Roadmap™, comprising six interrelated and integrated core elements, creates a framework of shared accountability for both employers and their health and productivity partners to implement and monitor actionable measures that improve health, maximize productivity, and reduce excessive costs. The strategy is most effective when linked to a financially incentivized health management program or consumer-directed health plan insurance benefit design.

Small group employer participation in New Mexico's State Coverage Insurance program: lessons for federal reform.

OBJECTIVE: To identify factors associated with small group employer participation in New Mexico's State Coverage Insurance (SCI) program. DATA SOURCES: Telephone surveys of employers participating in SCI (N=269) and small employers who inquired about SCI (N=148) were fielded September 2008-January 2009. STUDY DESIGN: Descriptive and multivariate analyses investigated differences between employer samples, including employer characteristics, concerns that applied to the business when deciding whether to participate in SCI, prior offerings of insurance to workers, and perceived affordability of the program. DATA COLLECTION/EXTRACTION METHODS: Unweighted employer samples yielded 88 and 75 percent response rates for the participating and inquiring employers, respectively. PRINCIPAL FINDINGS: The administrative issue most commonly selected by inquiring employers as applying to their business was difficulty understanding how eligibility requirements applied to their business and its employees (53.5 percent). Inquiring businesses were significantly more likely to report concern about affording to pay the premiums in the first month (35.6 versus 18.7 percent) and the cost to the business over the long run (46.5 versus 26.6 percent) relative to participating employers. From the model results, businesses with the fewest full-time employees (zero to two) were 19 percentage points less likely to participate relative to businesses with six or more full-time employees. CONCLUSIONS: Administrative and cost barriers to participation in SCI reported by employers suggest that the tax credit offered to small businesses under new federal provisions, which merely offsets the employer portion of premium, could be more effective if accompanied by additional supports to businesses.

Dynamic Inefficiencies in an Employment-Based Health Insurance System: Theory and Evidence.

We investigate the effects of the institutional settings of the US health care system on individuals' life-cycle medical expenditures. Health is a form of general human capital; labor turnover and labor-market frictions prevent an employer-employee pair from capturing the entire surplus from investment in an employee's health. Thus, the pair underinvests in health during working years, thereby increasing medical expenditures during retirement. We provide empirical evidence consistent with the comparative statics predictions of our model using the Medical Expenditure Panel Survey (MEPS) and the Health and Retirement Study (HRS). Our estimates suggest significant inefficiencies in health investment in the United States.

[Job satisfaction among primary care physicians at the IMSS]. / Factores de satisfacción laboral en médicos familiares del IMSS.

OBJECTIVE: To know factors related to job satisfaction among primary care Physicians from the Mexican Social Security Institute. MATERIAL AND METHODS: Cross-sectional survey applied to physicians of outpatient visit areas in four Family Medicine Units in Leon, Guanajuato, from February to May 2007. The survey explored six areas. We used 95% confidence intervals and One-Way ANOVA to compare means among clinics and Chi square and OR'95% confidence intervals to compare proportions. RESULTS: One hundred sixty physicians participated (response rate 88.9%), three were excluded. Most physicians were satisfied with their work (86%). Half of the doctors feel satisfied with their economic benefits (48%), non-economic benefits (52%), and those from the collective bargaining agreement (53%), as well as with the labor union (46%) and their actual insurances (45%). Only one third or less of participants refer to receive incentives (31%) or recognitions for their work (33%), were satisfied with the opportunities for training (31%), the economic incentives (29%), or the salary (24%). The satisfaction's means of work, benefits, insurances, labor union and collective bargaining agreement were significantly higher than the means of salary and economic incentives. Satisfaction means were significantly higher in Clinic #53 than in Clinic #51 for job satisfaction and opportunities for training, as well as percentages of response in institutional support, incentives and recognitions for their work, were higher in Clinic 53 compared to all other clinics; however, it's the smallest clinic in this study. CONCLUSIONS: Family doctors find satisfaction in their practice, and factors such as institutional support, recognition and incentives may improve their general job satisfaction.

Boletín informativo sobre el sistema de prestaciones económicas / Information bulletin on the system of economic benefits

Brinda información sobre los procedimientos y requisitos a seguir para obtener los servicios y beneficios que brinda EsSALUD

Boletín informativo sobre el sistema de prestaciones económicas / Information bulletin on the system of economic benefits

Brinda información sobre los procedimientos y requisitos a seguir para obtener los servicios y beneficios que brinda EsSALUD(AU)

[The impact on costs and care of two approaches to reduce employees' dental plan expenses in a private company]. / Análise do impacto econômico-assistencial de duas abordagens para redução de custos em um plano odontológico de autogestão.

The present study evaluated the dental care plan offered to 4,000 employees of a private hospital and their respective families. The analysis covered three stages: (1) baseline (control), when dental care was provided by an outsourced company with a network of dentists paid for services, (2) a renegotiation of costs with the original dental care provider, and (3) provision of dental care by the hospital itself, through directly hired dentists on regular salaries. Monthly economic and clinical data were collected for this research. The dental plan renegotiation reduced costs by 37% in relation to baseline, and the hospital's own dental service reduced costs by 50%. Renegotiation led to a 31% reduction in clinical procedures, without altering the dental care profile; the hospital's own dental service did not reduce the total number of clinical procedures, but modified the profile of dental care, since procedures related to the causes of diseases increased and surgical/restorative procedures decreased.

A regulamentação do setor de saúde suplementar no Brasil: a reconstrução de uma história de disputas / Government regulation of the private health care market in Brazil: a history of disputes

O artigo reconstrói a disputa travada entre os principais atores sociais interessados diretamente no processo de regulamentação da saúde suplementar no Brasil, no período imediatamente anterior à edição da Lei n°. 9.656/98, destacando convergências e divergências destes atores em relação a 28 temas centrais para a configuração do arcabouço regulatório vigente no Brasil desde 1998. O material utilizado para a descrição e sistematização das posições em disputa no processo regulatório resultou de um estudo empírico, descritivo, de natureza comparativo-contrastante, baseado em análise documental e entrevistas com atores-chave. O estudo sistematiza os principais pontos de polêmica e/ou consenso entre os vários atores, destacando, em particular, as muitas convergências das propostas das entidades médicas com aquelas defendidas pelas organizações de usuários e pelos institutos de defesa dos consumidores, apontando para a possibilidade de construção de um bloco ético-político compromissado com a defesa de uma melhor qualificação da assistência, em contraposição a uma lógica meramente de mercado.

This paper reconstructs the dispute between the main social actors with direct interests in the regulation of private health care in Brazil during the period immediately prior to the passage of Act 9.656/98, highlighting the divergences between these actors in relation to 28 central topics for shaping the regulatory framework prevailing in the country since 1998. The material used in the description and systematization of the positions in the regulatory dispute resulted from an empirical, descriptive, comparative study based on document analysis and interviews with key actors. The study systematizes the main points of controversy and consensus among the various actors, particularly highlighting the many points of agreement between proposals by medical organizations and those of users' organizations and consumer defense institutes, thereby suggesting the possibility of establishing an ethical and political bloc committed to the defense of improved health care as opposed to sheer market logic.

[Government regulation of the private health care market in Brazil: a history of disputes]. / A regulamentação do setor de saúde suplementar no Brasil: a reconstrução de uma história de disputas.

This paper reconstructs the dispute between the main social actors with direct interests in the regulation of private health care in Brazil during the period immediately prior to the passage of Act 9.656/98, highlighting the divergences between these actors in relation to 28 central topics for shaping the regulatory framework prevailing in the country since 1998. The material used in the description and systematization of the positions in the regulatory dispute resulted from an empirical, descriptive, comparative study based on document analysis and interviews with key actors. The study systematizes the main points of controversy and consensus among the various actors, particularly highlighting the many points of agreement between proposals by medical organizations and those of users' organizations and consumer defense institutes, thereby suggesting the possibility of establishing an ethical and political bloc committed to the defense of improved health care as opposed to sheer market logic.

An analysis of equity in Brazilian health system financing

Health care in Brazil is financed from many sources-taxes on income, real property, sales of goods and services, and financial transactions; private insurance purchased by households and firms; and out-of-pocket payments by households. Data onhousehold budgets and tax revenues allow the burden of each source except firms’ insurance purchases for their employees to be allocated across deciles of adjusted per capita household income, indicating the progressivity or regressivity of each kind of payment.Overall, financing is approximately neutral, with progressive public finance offsetting regressive payments. This last form of finance pushes some households into poverty.

An analysis of equity in Brazilian health system financing.

Health care in Brazil is financed from many sources--taxes on income, real property, sales of goods and services, and financial transactions; private insurance purchased by households and firms; and out-of-pocket payments by households. Data on household budgets and tax revenues allow the burden of each source except firms' insurance purchases for their employees to be allocated across deciles of adjusted per capita household income, indicating the progressivity or regressivity of each kind of payment. Overall, financing is approximately neutral, with progressive public finance offsetting regressive payments. This last form of finance pushes some households into poverty.

Progressive segmented health insurance: Colombian health reform and access to health services.

Equal access for poor populations to health services is a comprehensive objective for any health reform. The Colombian health reform addressed this issue through a segmented progressive social health insurance approach. The strategy was to assure universal coverage expanding the population covered through payroll linked insurance, and implementing a subsidized insurance program for the poorest populations, those not affiliated through formal employment. A prospective study was performed to follow-up health service utilization and out-of-pocket expenses using a cohort design. It was representative of four Colombian cities (Cendex Health Services Use and Expenditure Study, 2001). A four part econometric model was applied. The model related medical service utilization and medication with different socioeconomic, geographic, and risk associated variables. Results showed that subsidized health insurance improves health service utilization and reduces the financial burden for the poorest, as compared to those non-insured. Other social health insurance schemes preserved high utilization with variable out-of-pocket expenditures. Family and age conditions have significant effect on medical service utilization. Geographic variables play a significant role in hospital inpatient service utilization. Both, geographic and income variables also have significant impact on out-of-pocket expenses. Projected utilization rates and a simulation favor a dual policy for two-stage income segmented insurance to progress towards the universal insurance goal.