El Ministerio de Hacienda y Crédito Público emitió concepto favorable al impacto fiscal del proyecto de ley que reforma a la salud en Colombia, radicado como el Proyecto de Ley 312 de 2024 y acumulado con el 135 de 2024 en la Cámara de Representantes. La entidad concluyó que, bajo determinadas condiciones y ajustes presupuestales, la reforma puede implementarse sin comprometer la sostenibilidad de las finanzas públicas, aunque advierte sobre múltiples desafíos operativos, riesgos de ejecución y necesidades crecientes de recursos durante los próximos años.
El concepto, remitido el 13 de mayo de 2025 a la presidenta de la Comisión Séptima del Senado, senadora Nadia Blel Scaff, se basa en información proporcionada por el Ministerio de Salud y Protección Social (MSPS), incluyendo estimaciones de ingresos, gastos y proyecciones macroeconómicas del Marco Fiscal de Mediano Plazo (MFMP) de 2024.
Gasto proyectado: más de 100 billones de pesos anuales – Reforma a la salud
Según el informe técnico, la implementación de la reforma iniciaría en 2025 y requerirá una inversión anual que superará los $100 billones de pesos constantes. El gasto total del sistema de salud crecería progresivamente hasta alcanzar los $163,9 billones en 2034, lo que representa un incremento del 62% en una década.
De ese monto, la atención primaria en salud pasaría de $19,1 billones en 2025 a más de $40,2 billones en 2034, mientras que los servicios de mediana y alta complejidad subirían de $74,2 a $103,8 billones. El fortalecimiento de la red pública hospitalaria, que parte de $516 mil millones en 2025, escalaría a $5 billones para el cierre del período.
Otros componentes como incentivos a la calidad, saneamiento de pasivos, atención a migrantes irregulares y mecanismos especiales de formalización laboral para trabajadores del sector salud también están contemplados, representando gastos adicionales e incrementales.
Fuentes de financiación: cuatro pilares y nuevos recursos
El Ministerio de Hacienda agrupó las fuentes en cuatro grandes categorías: cotizaciones al sistema, aporte de la Nación, recursos del Sistema General de Participaciones (SGP-Salud) y otras fuentes (como rentas cedidas, aportes de cajas de compensación, Coljuegos, SOAT y contribuciones del FONSAT).
Para 2025, se estiman ingresos por $101,2 billones, los cuales aumentarían a $172,3 billones en 2034. Entre las nuevas fuentes, se destacan el 100% del recaudo de impuestos saludables y el 0,5% del IVA social, que se incorporarán como cupos presupuestales adicionales sin sustituir otras fuentes ya existentes.
No obstante, Hacienda enfatiza que estos ingresos deben ser redistribuidos internamente dentro del Presupuesto General de la Nación, lo cual requerirá decisiones políticas y fiscales anuales que podrían afectar la planeación de largo plazo.
Balance proyectado: superávit creciente, pero con condicionamientos
El balance entre ingresos y usos proyectados arroja un superávit fiscal creciente, que pasa de $292 mil millones en 2025 a $12,6 billones en 2034. Esto sustenta el aval técnico al proyecto. Sin embargo, el Ministerio de Hacienda aclara que su aprobación está sujeta a que las obligaciones corrientes del sector salud acumuladas al cierre de 2024 sean atendidas prioritariamente por el MSPS, en cumplimiento de su autonomía presupuestal y del Estatuto Orgánico del Presupuesto.
Asimismo, el documento advierte que el costo fiscal seguirá cambiando a medida que el articulado del proyecto sea modificado durante el trámite legislativo y que existen riesgos operativos asociados a la transformación institucional propuesta.
Cambios estructurales: transformación de EPS y rol de ADRES
El proyecto de ley contempla una profunda transformación del modelo actual, pues las Entidades Promotoras de Salud (EPS) serán reemplazadas por Gestoras de Salud y Vida, que coordinarán las Redes Integrales de Servicios de Salud junto con entidades territoriales. Se fortalecerán los Centros de Atención Primaria (CAPS) y equipos territoriales, y se establecerán mecanismos especiales de contratación y seguimiento de calidad.
La ADRES será la entidad encargada del recaudo, administración y pago de recursos, con facultades ampliadas para auditorías, evaluación del gasto, reconocimiento de pagos y coordinación del nuevo Sistema Público Unificado e Interoperable de Información en Salud (SPUIIS).
Riesgos fiscales y alertas institucionales
Aunque Hacienda considera que el proyecto es viable dentro del marco del MFMP, también lanza alertas sobre varias decisiones del articulado que pueden comprometer la ejecución técnica y el control fiscal. Entre ellas:
- La creación de cuentas de destinación específica para atención primaria y red hospitalaria, que podrían introducir rigideces presupuestales.
- El uso de saldos de cuentas maestras del régimen subsidiado solo será posible el primer año, generando una presión temporal en la implementación.
- Los recursos del Fondo de Solidaridad de Fomento al Empleo y Protección al Cesante (FOSFEC), estimados en $347.625 millones, solo podrán usarse durante dos años.
- La presión por integrar a la población migrante no afiliada podría exceder los recursos actuales, si no se estructuran fuentes adicionales permanentes.
Formalización laboral y determinantes sociales: objetivos ambiciosos
El proyecto incluye compromisos de formalización progresiva del talento humano en salud, con estímulos especiales para quienes trabajen en zonas rurales o de alta complejidad. También busca intervenir los determinantes sociales de la salud mediante articulación intersectorial con Planeación Nacional y otras carteras, aunque dichos recursos deberán programarse dentro de sus respectivos techos fiscales.
En conclusión, el Ministerio de Hacienda considera que el proyecto puede implementarse sin afectar la sostenibilidad macrofiscal, siempre y cuando:
- Se mantenga la coherencia con el MFMP y el Marco de Gasto de Mediano Plazo.
- El MSPS administre con rigor los recursos asignados y priorice obligaciones pendientes.
- Se eviten decisiones legislativas que fragmenten el presupuesto o creen inflexibilidades.
El documento cierra reiterando que toda implementación debe respetar los principios constitucionales de disciplina fiscal, legalidad y planificación presupuestal. Aunque el proyecto cuenta con respaldo técnico en este momento, su viabilidad operativa dependerá de las decisiones futuras del Congreso y del Gobierno Nacional.
Descargue aquí el documento de MinHacienda:
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