Spanish
The main Health Risk Administrators (ARS) face a serious financial distortion derived from the current capitation model in the Family Health Insurance.
By the end of July 2025, the system's technical losses exceed RD$2,000 million, while net losses already surpass RD$1,000 million, which demonstrates a critical and progressively unsustainable situation for the current model.
The technical report published by the Superintendency of Health and Occupational Risks (SISALRIL) clearly demonstrates the magnitude of the problem. According to the analysis, the single-capitation model has caused a progressive deterioration in the financial sustainability of the sector, especially in those ARS that serve aging populations or those with greater use of services.
The economist Henri Hebrard warns that the uniform per capita scheme —in effect for years without adjustments for inflation, risk, or consumption— generates deep inequities among insurers, financially punishes those who serve high-risk populations, and limits the sustainability of the system as a whole.
"The system is penalizing those who do their jobs better. If the model is not urgently corrected, many of the ARSs will face unsustainable operating scenarios before the end of the year," says Hebrard.
Although Law 87-01 explicitly allows the use of differentiated risk-based fees, the National Council for Social Security (CNSS) has not yet implemented an adjusted capitation model. This contradicts international best practices. Countries like Chile, Uruguay, Germany, and the Netherlands have already adopted risk models that adjust payments according to age, sex, multimorbidity, and specific clinical conditions, achieving greater financial equity and macro efficiency.
"There are actuarially and economically validated models that can be adapted to the Dominican context. The lack of implementation of such a scheme is generating avoidable losses for the system," Hebrard points out. The health sector urgently needs a change in its financial architecture. The lack of action puts at risk not only the stability of the ARS, but also sustainable access to quality health services for millions of Dominicans.
