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.