Is SENASA Collapsing? An Analysis as a User, Lawyer, and Dominican Citizen

In recent months, SENASA’s crisis has gone from being just a rumor whispered in medical offices to a reality affecting thousands of Dominican families. As the largest state-owned health insurer and the one that concentrates most of the subsidized regime, its sustainability should be a priority public concern.

Today, I want to share my personal experience, some hard data, and a reflection I consider urgent both as a lawyer and as a user.

My Experience with SENASA Contributive vs. Private Insurance

Like many people, I decided to trust the recommendations insisting that SENASA Contributive was the best option: supposedly broader coverage, fewer hurdles, and more security because it is state-owned.

But the reality has been quite different. Let me share a specific case I lived through in November 2024. My son and I went to the doctor with exactly the same prescriptions: laboratory tests, specialized studies, and medications. I presented both insurances, SENASA Contributive and a private one (Universal). The difference was striking.

For lab tests, with Universal I paid less than RD$200 out of pocket. With SENASA, I paid over RD$1,700. For diagnostic studies, Universal covered a high percentage, while SENASA limited coverage to somewhere between 20% and 50%. For medications, Universal covered up to 80%, while SENASA only a partial percentage. In practice, every time I visit a center that accepts both plans, staff almost always suggest using Universal first, because “it covers more and faster.”

This is not anecdotal: it reflects the perception and the reality of SENASA Contributive members who faithfully pay a percentage of their salaries but face services that do not match that contribution.

Why Are People Talking About a Possible Collapse?

It is no secret that SENASA has grown exponentially over the past ten years. According to official data, there are over six million people enrolled in the subsidized regime alone. The 2023 Statistical Bulletin from the Superintendency of Health and Occupational Risks (SISALRIL) stated that SENASA manages about 47% of all system affiliates, with an average cost per person that has increased by over 35% in the last five years.

One of the main reasons for this deficit was an eminently political decision during the pandemic: to massively incorporate millions of non-contributing citizens with the goal of expanding social coverage in a critical moment. While this measure was understandable from a public health perspective, it was not accompanied by a sustainable financial plan to guarantee timely payments to clinics and pharmacies. Since then, SENASA has been assuming a volume of affiliates that exceeds its budgetary capacity, while medical and pharmaceutical costs keep rising.

In addition, other factors compound the situation: reimbursement rates that are not updated in line with inflation, delays in payments to providers, budget restrictions that force coverage limitations, and the fact that many members of the contributive regime end up indirectly subsidizing care for those in the subsidized regime. All of this creates a vicious cycle that affects both the most vulnerable affiliates and those who contribute monthly from their salaries.

What Does This Mean for the Future?

If anything is clear, it is that a system that is not financially self-sufficient cannot last indefinitely. And it must be said plainly: SENASA is already collapsing, even if it is not officially acknowledged.

Providers are demanding payment for arrears. Users are demotivated and considering leaving. Coverage is increasingly limited. And the deficit is quietly growing.

This is not just a health policy issue. It is about transparency, financial planning, and citizens’ rights.

A Note About My Perspective

I want to clarify that I am not an economist or a specialist in public macro-finance. However, as a corporate lawyer, my work involves analyzing the financial viability of businesses, identifying economic risks, evaluating the sustainability of operations, and projecting future scenarios, especially in the context of acquisitions, mergers, or restructurings. For this reason, even though this is my personal opinion as a user and a citizen, I share it from a technical perspective that combines legal experience with the basic financial analysis any corporate law professional performs.

My Conclusion as a User and Professional

As a citizen, I appreciate that there is a public insurer that guarantees coverage for the most vulnerable. As a taxpayer, I question the sustainability of a model partially funded by salaries from those of us enrolled in the contributive regime. As a mother, I will not expose my son to a system that, in practice, covers less and forces much higher out-of-pocket payments.

If no profound changes occur, many of us will end up migrating to private plans. And that will only deepen the crisis.

References and Sources

• Superintendency of Health and Occupational Risks (SISALRIL). Statistical Bulletin 2023.
• Law No. 87-01 establishing the Dominican Social Security System.
• Official SENASA website: www.arssenasa.gob.do
• Personal documented experience (November 2024).