Health care in Spain

The Spanish National Health Care System is a public system that is reasonably efficient and has been considered one of the best in the world. It was ranked seventh according to the World Health Organization in the year 2000, whereas countries like Canada and the United States were ranked 30 and 37, respectively. To become insured people need a social security (“seguridad social”) number, which is obtained by either working for an employer (usually a private or public company, who pays, along with the worker, a monthly amount that will provide cover for health care, unemployment, and retirement) or becoming self-employed (in which case, the person pays a monthly amount to be part of the system). Dependents (children and nonworking spouses) are included in the social security card of the worker. The system will continue to cover the health care of the worker when he or she retires (usually at 65 years of age), as well as his or her dependents (ie, nonworking spouses), but not his or her children when they are able to work. Spaniards who are unemployed or are very poor (even if they have never worked) are also usually covered by the system. In this way the system is nearly universal, covering 98.7% of the population.

The Spanish National Health Care System provides primary health care, including general health and pediatric care, outpatient and inpatient surgery, emergency and acute care, and long-term disease management. Prescription drugs require a 40% copayment by the patients, with the exception of retired people (who get medications for free) or hospital medications (such as immunosuppressants or rituximab, which are fully paid by the system). There are some exceptions to this; some medications, creams, moisturizing creams, shampoos, or dressings may not be covered by the system and the patients have to pay the total cost of these products.

The system is a highly decentralized one that gives primary responsibility to the country’s 17 autonomous regional governments. The central government provides the money to each autonomous region, and each region decides how to use it, hence health care spending varies from region to region. The regional variation is important because Spaniards usually face many bureaucratic barriers if they try to get nonemergency health care in another part of the country (eg, a consultation in a hospital in Barcelona rather than Madrid).

Spanish patients cannot choose their physicians in the public system, either primary care physicians or specialists. Patients are assigned a general family physician in their area, and if their general physician decides they need a specialist, they will be referred to a specialist who is generally working in a community clinic. Patients do not have direct access to specialists unless they have private health insurance. If patients need a higher specialist standard, they are sent by the community specialist to a community hospital or a large teaching hospital. In general, there are long waiting lists for specialist consultation and nonurgent surgeries.

Private health insurance has expanded in the last few decades in Spain, due to the waiting lists and qualitative problems of the public system. Different companies exist that provide coverage for most routine visits to general physicians, specialists, and procedures. About 12% of Spaniards have mixed coverage (public and private) because the public system is compulsory for everyone. In big cities such as Madrid and Barcelona, the number of privately insured is around 25% of the population. Many go private to avoid waiting lists, and to get simple procedures done in an easy and comfortable way. However, for important diseases (eg, a myocardial infarction or an autoimmune blistering disease [AIBD]) or complicated procedures (eg, organ transplantation), people prefer to make use of the public system, whereby they can usually find the best hospitals and doctors. Most of the large teaching university hospitals in Spain (where the highly specialized clinicians can be found) are public and are part of the system, with some exceptions (eg, the University Clinic of Navarra in Pamplona, which is private although it has agreements with the public system).