A recent study by the National Commission for the Defense of Competition (Pro-Competencia) reveals that three Health Risk Administrators (ARS) control 70% of the Dominican Republic’s health insurance market, raising concerns about competition and access to affordable care.
The report, titled “Study on Market Competition Conditions in the ARS Sector (2010–2024)”, also highlights that private ARS entities manage 85% of the funds for the Family Health Insurance System (SFS), which has seen its revenues surge from RD$24 billion in 2010 to RD$114 billion in 2023—a 363.24% increase.
Pro-Competencia president María Elena Vásquez said the report identified a 33% profit margin per affiliate for private ARS, based on a Lerner Index of 0.33. She called the finding a “wake-up call” for policymakers.
The high yields of the ARSs come at a time when affiliates of private companies have seen increases of obligatory large co-payments on services and consultations, and there are complaints on the restrictions in coverage by the private companies.
The study, presented by Pro-Competencia, found that three ARS—Senasa (government-owned), Primera (Humano), and Mapfre Salud—dominate the market. Senasa accounted for 35.8% of all affiliates as of August 2024. Senasa, the sole public ARS, is noted for its role in reducing costs and improving access to services for beneficiaries.
The number of affiliates has expanded rapidly, with the number of contributing workers rising from 1.18 million in 2010 to 2.25 million by March 2024. This growth is attributed to formal labor market expansion, economic growth, and increased social protection program enrollment. However, the study notes that rising health inflation (5.30% in 2024, compared to 3.34% for the overall GDP) and reduced public investment in health have increased out-of-pocket expenses for users.
The report underscores the need for sustained monitoring to ensure fair competition, as market concentration has risen from 72.5% in 2010 to 74.5% by November 2024.
“We are not at the end of the road, but the beginning of generating public policies to improve services in a sector as vital as health, which directly impacts the quality of life and even the lives of citizens,” Vásquez emphasized. She stressed the need for clear, equitable rules to ensure ARS compete to deliver better care for beneficiaries. She also pointed to structural barriers to entry for new competitors, including stringent regulatory requirements, the need for extensive provider networks, and high operational costs. The larger ARS benefit from economies of scale, creating a competitive imbalance.
Recommendations for reform
Pro-Competencia warns that the current market structure risks inefficiencies and limited access for vulnerable groups. Key recommendations include:
• Strengthening regulatory frameworks and increasing transparency in pricing and service quality.
• Implementing primary care as the first point of entry in the health system to improve efficiency.
• Reviewing the automatic assignment of beneficiaries, which disproportionately benefits larger ARS.
• Amending the Social Security Law to reduce regulatory hurdles for new ARS and foster competition.
Affiliate distribution
As of August 2024, Senasa leads with 1.69 million affiliates (35.8%), followed by Primera ARS Humano (1.198 million, 25.35%) and Mapfre Salud (507,831, 10.74%). ARS Universal, Futuro, Semma, and La Monumental de Seguros hold smaller shares, collectively accounting for less than 20% of the market.
The study, based on data from the Superintendence of Health and Occupational Risks (Sisalril), the Social Security Treasury (TSS), and the Central Bank of the Dominican Republic (BCRD), underscores the urgency of addressing market concentration to ensure equitable access to essential health services.
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Diario Libre
4 June 2025