U.S. vs. Spain Health Care: What America Can Learn

Introduction

In 2009, Spain's single-payer health care system was ranked the seventh best in the world by the World Health Organization (Socolovsky, 2009). By comparison, the U.S. health care system ranked 37th (Satiroglou, 2009). The Spanish system offers coverage as a right of citizenship that is constitutionally guaranteed. Spanish residents pay no expenses out-of-pocket, with the exception of a few select services. They do pay for drug costs themselves, and many complain about long waits to see specialists or to undergo certain procedures. However, on average the Spanish health care system ranks better than that of the United States across many categories.

Almost everyone agrees that the U.S. health care system is in need of serious reform. However, deciding exactly what those reforms should be remains a point of contention among providers, lawmakers, and average citizens. This paper explores both the U.S. and Spanish health care systems and addresses whether a national health care system—such as that found in Spain—could be a solution for the ailing system in the United States.

The U.S. Health Care System

Health care economists in the United States assert that although health care spending per capita may be higher than in any other OECD nation, long-term rates of spending have been similar to those of other nations. However, White (2007) demonstrates that long-term growth rates have been exceptionally high as well. The author surmised that institutional features were responsible for these high long-term growth rates in health care spending—a trend that had been occurring steadily for close to three decades. White considers several factors to be causal in this growth: an aging population, general economic growth patterns, expansion of technological capabilities in medicine, and other factors such as expansions in health insurance coverage and financing options within the delivery system (White, 2007).

Nearly 17.4% of the GDP in the United States was accounted for by health spending—9.5% higher than the OECD average (OECD, 2011a). Several features of the U.S. health care system draw the attention of researchers and critics. The U.S. has a higher number of MRI units and CT scanners per million population at 34.3, compared to the OECD average of 22.1. There are also 3.5 hospital beds per thousand people, compared to an average of 2.7 per thousand in other OECD nations (OECD, 2011a). The United States is one of the wealthiest nations in the world and has a high amount of technology and resources available to its citizens, yet it ranks considerably below Spain in terms of health care provision. Japan, Switzerland, Italy, Spain, and Australia have the highest life expectancies in the world (OECD, 2011a).

The United States has many resources available to its citizens, yet they have many health problems that could easily be resolved. For instance, the U.S. has one of the highest obesity rates among OECD countries, and these rates continue to climb (OECD, 2011a). One has to ask how a country with such abundant resources can rank so poorly in the provision of health care. The U.S. has one of the highest government spending rates for recipients of public aid among OECD countries (OECD, 2011a), yet it has some of the lowest standards of care among OECD nations.

Medicare is the primary delivery system for government-subsidized health care services. Currently, several sections of the Medicare system have been frozen due to inflationary increases in Social Security payments. Increases in Social Security offset small rises in Medicare premiums. The U.S. health care system must continually make adjustments to close gaps in coverage—such as the Affordable Care Act, which reduces prescription drug costs for people who fall into a gap in Medicare coverage (Sebelius, 2011). The government-subsidized portion of the U.S. health care system must continually adjust to prop up parts of the system and to provide coverage for those who need it. However, the focus remains on only one portion of the system at a time rather than taking a holistic approach to the problems that plague the entire system.

This piecemeal approach differs markedly from that taken by countries with a national health care system. The U.S. treatment of the health care system makes it seem as though the government is continually running around trying to fix portions that are falling apart, rather than providing the entire system with a solid operational base. One of the key differences between the health care systems of the United States and Spain is the viewpoint and approach taken by each country. The United States can be seen as trying to micromanage the system, while the national health care approach takes a more holistic view of national health care problems.

Demand for health care services in the United States has continued to increase at a rate of approximately 11% since 1960 (Klees, Wolfe, & Curtis, 2010). Health care in the United States is funded through a number of different sources rather than a single source. These sources include individuals' out-of-pocket expenses, private health insurance, philanthropy and charitable donations, non-patient revenues such as revenues from gift shops or parking lots, individual employers, and federal funds (Klees, Wolfe, & Curtis, 2010). This funding model is complicated and inefficient. As private payers become less able to pay for services, public funds must pick up the tab, placing an even greater strain on the system.

Government-subsidized programs in the United States—such as CHIP, Medicare, and Medicaid—are only available to certain segments of the population. They are not available to every citizen, as they are in countries with national health care programs. Government-funded programs in the United States are only available to those who are elderly, disabled, significantly below the federal poverty line, or uninsured children (InsureKidsNow.gov, 2011). The U.S. Census Bureau found that health insurance coverage was linked to family income for all demographic groups, and the survey linked a lack of health insurance coverage to poverty (DeNavas, Proctor, & Smith, 2011). Those who are very poor are eligible for government subsidies such as Medicaid. However, those who do not qualify for government programs and cannot afford health insurance remain uninsured. This means it is not the very poorest who most often lack health insurance in the United States, but rather those whose income falls just above the eligibility threshold. There is a segment of the population that is underserved by the current health care system.

The United States also differs from other OECD countries in how health care is financed. Three approaches to health care financing have been identified:

1. Public-integrated — the government acts as both insurer and provider of services.
2. Public-contract — the government or a centralized social insurer purchases services from private providers.
3. Private insurance/provider — private insurers purchase services from private providers (White, 2007).

Nearly all high-income OECD countries use either the public-integrated or the public-contract model. The United States stands out in its resistance to these models, relying almost entirely on the private insurance/provider model (White, 2007). Both the public-integrated and public-contract models give the government or another oversight agency considerable leverage over medical providers, enabling limits on medical spending. In some cases, this has led to a different mix of services than is seen in the United States. These models are effective cost-limiting tools (White, 2007).

Because the United States has resisted adopting the health care models used by the majority of OECD nations, insurance providers and medical service providers have almost complete control over their pricing structures and expenditures. This has contributed to the health care finance crisis in the United States. The net result of unbridled spending has led to per-capita spending that is more than double that of other OECD nations (Anderson & Frogner, 2006). Anderson and Frogner suggest that the United States is not getting a high return on its expenditure, based on life expectancy, quality of life, and other indicators of a healthy health care system.

The Spanish Health Care System

The health care system in Spain was still reeling from the recent global recession at the time of this writing. High unemployment rates were expected to continue, placing a strain on the ability to support the national health care system (OECD, 2011b). The ability of the national health care system to provide services depends on tax revenues, so anything that harms the economy also harms the national system—though the same is true in the United States, where the impact is somewhat cushioned because the system is not entirely dependent on government funds.

Spain's national health care system is known as the Sistema Nacional de Salud (SNS). It is operated by the National Ministry of Health and Social Policy and is structured as a hierarchy with a central governing agency that manages strategic areas such as policymaking and equitable functioning across the nation. The system is then broken down into 17 regional ministries that report to the central governing body (Garcia-Armesto, Abadia-Taira, & Duran et al., 2010). The National Health System Interterritorial Council has final decision-making authority in the adoption of SNS policies (ISPOR, 2009), though individual regions retain decision-making authority to meet the needs of their own citizens.

The reimbursement process for pharmaceuticals is governed by the Spanish Medicine Agency, which will only reimburse for pharmaceuticals that are approved and meet certain criteria of safety and effectiveness—a role similar to that of the Food and Drug Administration (FDA) in the United States (ISPOR, 2009). Reimbursement depends on the severity of the disease, the therapeutic value and efficacy of the product, the price of the product, and the budget impact on the SNS compared to similar products.

Every patient must see a "gatekeeper" physician before being referred to a specialist. One of the key complaints about the Spanish health care system is the resulting long wait times to see a specialist or undergo certain procedures. This can be especially distressing for patients who have been referred to specialists to diagnose a serious illness. Wait times of up to eight months have been reported for the results of a routine gynecological test (Expatica, 2004)—an argument also frequently raised in U.S. debates about national health care.

In a recent study, wait times were found to vary considerably from region to region and by specialty. An average wait time in Castilla-La Mancha was 23 days, while wait times for equivalent consultations in the Canary Islands were up to 140 days. On average, the national wait time was around 65 days for most tests (Expatica, 2004). It is more difficult to see an allergist than a neurologist, for example, simply because the patient load for allergists is much larger (Expatica, 2004). Spain faces a growing elderly population and a shortage of young professionals to fill health care jobs, which contributes to growing waiting lists in certain specialties.

In 2009, the population of Spain was 40,525,002, with a GDP per capita in 2008 of $34,600. The average life expectancy was 84 for females and 78 for males, and infant mortality rates were low ("International Health Systems," n.d.). The national health care system covered 99.5% of primary care, inpatient surgery, outpatient surgery, long-term disease management, emergency care, and some medications deemed medically necessary ("International Health Systems," n.d.). Some services—including mental health, dental, and long-term care—did require some out-of-pocket expense or supplemental insurance. Care of the elderly is underdeveloped in Spain, and many adult children tend to care for their parents well into old age. The national health system is financed through taxation and funds allocated to the various regions ("International Health Systems," n.d.).

Conclusion

The United States is in an intense battle over health care reform. A national system has been proposed, but faced such intense opposition that other alternatives were quickly explored. The ideology behind such a proposal is rooted in the success of national health care in countries like Spain and Japan. Supporters point to those successes and see a national system as a solution to the problems facing the United States. They note that even the current "free market" system faces many of the same problems as countries with national health care, and they argue that if the problems are inevitable, the nation should at least guarantee that access to health care is treated as a basic right.

Opponents of a proposed national health care system point to higher taxes, long physician wait times, and other problems that plague nationalized systems—but they fail to recognize that the U.S. market-based system faces many of the same challenges. Opponents acknowledge that solutions must be found quickly, but they disagree on the proper course of action. Thus far, proposed solutions have largely amounted to propping up the existing system.

The core challenge facing the United States in resolving its health care crisis is that neither proponents nor opponents of national health care have offered a complete solution. President Obama met extensively with Prime Minister José Zapatero to discuss implementing solutions to the health care crisis, and those meetings were influential in shaping the Affordable Care Act—a proposal that was, according to Diehl (2010), effectively destroyed before it could be fully understood by the public. Discussions of the Affordable Care Act were a source of continual debate, with more rumor than fact circulating about what it would or would not accomplish. Confusion regarding the proposed package persisted for years.

Prime Minister Zapatero expressed confusion over the U.S. health care debate on multiple occasions, baffled by how costly care remained compared to GDP and by the limited coverage the system provided (Diehl, 2010). His observations highlight a fundamental disconnect: the United States spends more on health care per capita than any other nation yet delivers outcomes inferior to those of countries that spend far less.

The Spanish health care system is so well regarded that some Americans travel to Spain specifically for medical procedures—a phenomenon known as medical tourism. Spain is a popular destination for U.S. and British medical tourists seeking elective surgery, orthopedic surgery, dentistry, cosmetic surgery, eyesight correction, and obesity surgery. Medical tourism in Spain can offer patients savings of 30–70% over having the same procedure in their home country (Medical Tourism Corporation, 2011). Patients can choose their doctor and facility, benefit from English-speaking professionals and interpretation services, and recuperate in a country with excellent environmental and dietary conditions. Spain's position as the seventh-ranked health care system in Europe (Medical Tourism Corporation, 2011), combined with its tourist attractions, restaurants, and historic sites, makes it an increasingly attractive destination for those who have learned they have a choice in health care and can achieve considerable savings.

The results of this research align with the conclusions of the OECD: the most expensive care is not always the best care. The United States and Canada have some of the best cancer-screening programs in the world, but Japan has the highest cancer survival rates (OECD, 2009). In 2007, U.S. spending on health care was more than double the OECD average, yet countries that spent less per person ranked higher in survivability and treatment success for chronic and life-threatening conditions (OECD, 2009). This represents an inefficient deployment of health care funds and supports the central finding of this paper: more expensive health care is not necessarily better health care.

The question of which system best addresses the health care crisis—in the United States and across OECD nations—resembles the proverbial notion that the grass is always greener on the other side. Both sides of the national health care debate believe their preferred solution resolves all existing problems. This research demonstrates that no single solution eliminates every problem. Rising costs and long waiting lists will persist regardless of which model is chosen.

A system similar to Spain's would resolve the most pressing issue: lack of access to care due to inability to pay. The term "nationalized health care" generates confusion among many Americans, who assume it means the end of free choice in doctors and the elimination of the market-based system. In reality, nationalized health care means the addition of a parallel public system to serve those who cannot access the current market system—giving everyone more options, not fewer. The public system would introduce competition that helps control costs, compelling private providers to improve quality and reduce prices to remain competitive.

The most significant finding of this research is that there is no perfect solution to the health care crisis. National health care does not restrict the choices available to people—it expands them. It can help control rising costs by introducing a low-cost alternative to private care, and it places greater constraints on health care providers not through legislation alone but through the introduction of meaningful market competition. As Tanner (2008) found, the most successful health care systems combine market and public components. The Spanish model appears to represent the best of both: all citizens are guaranteed a minimum standard of care, but those who prefer additional amenities and services can choose and pay for private care. For those who lack the means to pay, the public system is available unconditionally.

A health care system modeled on Spain's would close the gap created by the uninsured, introduce greater competition into the marketplace, and immediately resolve the most urgent concern: that millions of Americans have no access to health care at all. It would be unrealistic to expect any new system to fix every existing problem immediately, but such a reform would solve the greatest concerns at once. The introduction of such a system would mean higher taxes, but Americans must weigh those costs against the human cost of inaction. Every day the problem goes unresolved, uninsured Americans suffer needlessly. Nationalized health care offers the possibility of guaranteed access for all, combined with all the benefits of the free market system—not an elimination of choice, but an expansion of it.

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