Enrolling the self-employed in mandatory health insurance in Colombia: are we missing other factors?

We assess the impact that Colombia’s 1993 health sector reform had on the enrollment of self-employed workers in mandatory social health insurance scheme, with a especial focus on the independent contractors. This group grew dramatically in the form of workers cooperatives between 1993 and 2003, becoming a source of self-employed evasion and a way to disguised employment. We use two national-level Living Standards Measurement Surveys conducted in Colombia in 1997 and 2003, and follow a methodology that corrects for sample selection, decomposing health insurance coverage variation into changes attributed to the reform and to the characteristics of independent contractors. We find that: (i) Between 1997 and 2003, enrollment increased in 28 percentage points reaching an insurance rate of 62%, still below the reform goal of 80%, (ii) enrollment of independent contractors in 1997 was only 35% (compared to 50%) after adjusting by the selection bias due to disguised employment, (ii) the new legislation and stringent monitoring implemented in 2003 to cope with evasion seem to be effective since the sample selection due to disguised employment was not statistically significant in 2003. Addressing the interaction of the labor market with the health reform, as well as, accounting for the heterogeneity within the self-employed group are the main contributions of this paper to the literature on health insurance reforms in developing countries.