Running head: SPAIN 1

Health Care In Spain

Group 2 Spain: Dawn Carley(Contributor), Chad Laswell(Contributor), & Adam Neal(Lead)

Northern Arizona University

SPAIN 2

Introduction

The Kingdom of Spain boasts soaring mountains, raging rivers, and beautiful islands. Spain is known

worldwide for its rich history of exploration and art. Spain can be found in the Iberian Peninsula of

southwestern Europe (European Union). The Kingdom of Spain consists of a mountainous mainland as

well as several sets of islands (Nations Online.) The population of Spain is approximately 46 million as of

2012 and its citizens are spread out over 194,000 square miles (Nations Online.) The nation’s capital of

Madrid is home to 5.5 million people (Nations Online). Natural resources consist of various metals, wine

grapes, olives, fruits, and vegetables (Nations Online). According to the European Union, leading

industries in Spain include textiles, metal manufacturing, food and beverage, and tourism.

The Spanish government is a constitutional monarchy which includes a monarch and parliament

(European Union). The country is separated into 17 autonomous regions which each have their own

government authorities (European Union). The European Union is a political and financial alliance

consisting of 28 countries in Europe. Spain became a member of the European Union in 1986 and has

continued its membership through current times (European Union). Spain also joined military forces with

numerous countries in 1982 when it became a member of the North Atlantic Treaty Organization (Nations

Online).

Spain utilizes a universal health care system that provides medical care to nearly all of its citizens

(Garcia-Amesto, Abadia-Taira, Duran, Hernandez-Quevedo& Bernal-Delgado, 2010). This health care

system has resulted in a life expectancy of 79 and 85 for males and females respectively (World Health

Organization). 5 out of every 1,000 children will die before their fifth birthday in Spain (World Health

Organization). Spain’s prevalence of elevated blood glucose levels in adult males is 11% and the rate of

hypertension in adult males is 27.7% (World Health Organization). The rate of obesity in Spain for adult

males is 24.9% and the portion of the adult male population who use tobacco is 36% (World Health

Organization).

According to the World Health Organization, citizens of the United States have a male life

expectancy of 76 and a female life expectancy of 81. The probability of dying under age five is 7 out of

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every 1,000 children in the United States (World Health Organization). Elevated adult male blood glucose

is 12.6 % and hypertension is seen in 17% of the adult male American (World Health Organization). The

rate of obesity in adult males is 30.2% and 33% of adult men in America use tobacco (World Health

Organization).

Life expectancy is often seen as the ultimate tool in which a population’s health status is measured.

The United States lags behind Spain in this category by 3 to 4 years suggesting that Spain is a healthier

nation than America. Fewer children die in Spain before age 5, less adult males in Spain have elevated

blood glucose, and smaller number of adult male Spanish are obese than Americans. However, Americans

are healthier in the areas of hypertension and tobacco use. Each country possesses traits that exhibit

superior health rates, however Spain still leads America in the key statistic of life expectancy.

This essay serves to compare the health care systems of Spain and the United States. General health

policies including government involvement of each country will first be compared. Next the methods that

each country employ to finance medical care will be examined. The cost of health care and other medical

services will be observed for both Spain and the United States. Finally, each country’s approach to public

health and prevention will be inspected.

Health Policies of Spain

The general health policies of Spain provide a universal healthcare system that affords health coverage

to 99.4% of residents (Gracia-Amesto, et al., 2010). High-income non-salaried individuals have the

option to opt out of the national health care system (Gracia-Amesto, et al., 2010). This universal health

care system provides free health care services at the time of use. Coverage includes primary care,

specialized care including in-patient and out-patient medical procedures, public health initiatives such as

immunization, as well as some complementary services such as prosthetics, wheel chairs, and specialized

diets (Gracia-Amesto, et al. 2010). Pharmaceuticals are also covered to some extent as a co pay is

required (Garuccio, 2012). Dental and vision services are not covered by the national health system and

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must be paid out of pocket or through private insurance (Gracia-Amesto, et al. 2010). Spain’s health care

system earned high marks with the World Health Organization ranking them seventh in the world.

Spain is divided into 17 different territories with each region being responsible for its own health care

(National Health System of Spain 2010). The national standard requires these regions to provide adequate

health care services within a 15 minute driving radius to all residents to ensure prompt, efficient,

accessible care (National Health System of Spain, 2010). However, due to high demand of public

healthcare resources, many people choose to pursue private health care to receive more comprehensive

care and to avoid extensive wait times for procedures (Gracia-Amesto, et al., 2010). Private health is not

covered under the national healthcare system and must be paid for out of pocket or with the use of private

health insurance.

Health Policies of the United States

Although United States government plays a vital role in healthcare delivery, the methods used are far

from a universal healthcare system. According to the World Health Organization, the United States was

ranked number 37 in the year 2000. Americans obtain health coverage in a number of ways including

private insurance and government programs. More than half of Americans receive their health insurance

through employer funded private insurance plans (U.S. National Library of Medicine, 2013). Americans

that do not receive health benefits through an employer may choose to purchase insurance on their own

through a private insurance company. The extreme cost of obtaining health insurance through this venue

has left nearly 15 percent of Americans without health insurance (U.S. National Library of Medicine,

2013). This group of uninsured Americans must pay all of their health care costs from their own pockets.

Medicare is a government program that ensures health coverage to citizens age 65 and over as well as

qualifying disabled individuals regardless of income (Kovner&Knickman, 2011). Medicaid is another

government program that grants health coverage to qualifying low-income populations

(Kovner&Knickman, 2011). While there are several other government programs available for health

coverage, the majority of the population is responsible for their own health insurance. Americans may

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lack freedom in choosing their practitioner or medical facility as the insurance or government program

often dictates where the patient can receive services (Kovner&Knickman, 2011). In spite of adequate

health insurance, many patients will be limited to “in network” providers or clinics and may be required

to receive a referral to seek specialized care.

The Patient Protection and Affordable Care Act (ACA) of 2010 made health insurance accessible to

many more Americans. The ACA has allowed young adults to remain on their parents’ health insurance

plan until age 26 which often provides students and young professionals coverage (Kovner&Knickman,

2011). The ACA also makes it difficult for private insurance companies to deny coverage based on

preexisting illness or disease (Kovner&Knickman, 2011). The year 2014 will require nearly all

Americans to have some form of health insurance or pay penalties through tax codes

(Kovner&Knickman, 2011).

Methods of Health Care Finance in Spain

The universal healthcare system in Spain is funded primarily by the people through general taxation.

According the National Health System of Spain (2010), “Healthcare is one of the main instruments of the

Spanish redistributive income tax system, aimed to redistribute income amongst Spanish citizens: all

citizens contribute according to their wealth level and receive healthcare services according to their own

health needs” (p.16). The main source of funding for the national health care system is public with

general Taxation providing approximately 94% of public resources (National Health System of Spain,

2010). The remaining 6% is paid by payroll and employer contributions to cover work related injuries and

illnesses (Gracia-Amesto, et al., 2010). Funds are allocated to the 17 different regions based on

demographics and public providers are paid with government funding.

In 2009 the healthcare budge for Spain was 58,960 million euro, or 1,320 euro per covered person

(National Health System of Spain, 2010). Approximately 70% of the population utilizes the universal

healthcare coverage offered by the government. However, this system is often criticized for not providing

comprehensive service and requiring long wait times for appointments and procedures (Gracia-Amesto, et

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al., 2010). As a result, there is a very active private healthcare system working in Spain. These private

practices receive no funding from the government and are funded through self pay or private health

insurance funds (Gracia-Amesto, et al., 2010). Approximately 30% of the population uses private

healthcare in Spain (Gracia-Amesto, et al., 2010). The national health system only provides medical and

pharmaceutical coverage. The private sector is responsible for providing dental and vision services.

Methods of Health Care Finance in the United States

While the methods used to finance health care in Spain are relatively simple, the system used to

finance health care in the United States is a bit more complex. In the United States health care is financed

in a number of different ways. The majority of Americans receive health insurance coverage through a

private insurance company. Coverage is financed through one’s employer or their own pocketbook. When

it comes to financing healthcare in the United States, private insurance companies are the industry’s

heavy hitters (U.S. National Library of Medicine 2013). Patients often pay a deductible or co-pay and the

insurance company reimburses the provider for the remainder of the bill (U.S. National Library of

Medicine 2013). In the case of a government program such as Medicare or Medicaid, the provider may be

reimbursed for a portion or the remainder of the bill. These programs are funded primarily through tax

dollars from the state and federal government (Kovner&Knickman, 2011). The U.S. spent nearly $2.8

trillion on health care or $8,915 per person last year; this is nearly 8 times that of Spain

(Kovner&Knickman, 2011). In the U.S. health care system public resources are aimed at prevention,

living and working conditions and public safety, while private resources are aimed more at individual

medicine (Kovner&Knickman, 2011). There are number of federal and state organizations that are tasked

with different aspects of public health and are funded through the federal and state governments.

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Cost of Health Care and Methods of Public Health and Prevention in Spain

According to an article from Health Affairs, (2010) in the year 2007 Spain spent $2,671 per person, or

8.5 percent of gross domestic product (GDP) on health care. Compare that amount of $7,290, or 16

percent of GDP, that the United States spends on health care.

In Spain, health care is provided through the publicly funded health care system, the Sistema Nacional

de Salud (National Health System) (Marketline, 2012). There is a two-tier system in the health care

structure in Spain, the first tier is the National Health Service and the second is the private health care

sector, which is covered by private health insurance (Roberts, 2009).

Health care is paid for by government funds and every resident of Spain has a right to healthcare. In

Spain the healthcare system is “non-contributory,” it is paid by tax money and each autonomous

community has its own budget (Borkan, et al., 2010). There are health centers in each autonomous

community that provide primary healthcare services which include general family practice, nursing and

pediatrics, social workers and physiotherapists. The healthcare centers were put in place to be

approximately within fifteen minutes of a person’s place of residence (Allianze, 2014). The goal for

setting these health care centers so close is to promote comprehensive health care, including disease

prevention (Borkan et al., 2010).

Private health insurance plans/coverage enable policy holders to access private hospitals, of which

benefits may include shorter wait times, more privacy, unrestricted visiting hours and uninterrupted care

(seeing the same doctor throughout one’s treatment.) Private hospitals receive revenues from individual

customers paying with private insurance and insurers (Marketline, 2012). Non-private hospitals are

publicly funded on a per-diem rate (Mendoza, 1995).

According to Roberts (2009), he states the quality of healthcare in Spain is exceptional and many

doctors and nurses speak English. The healthcare system in Spain is considered to be very good; they are

very modern and well-equipped. The doctors and nurses are also excellent. There are even “house calls,”

made if it is possible for the medical professionals to go to the patient’s residence and such circumstances

would require (Allianze, 2014).

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All health care professionals working at any care center, including physicians are paid on a salary

basis. General practitioners salaries contain some incentive pay along with their larger fixed payment.

The incentive pay might vary due to the number of patients assigned to practitioner, certain criteria filled,

pattern of prescriptions prescribed and a pay for performance (Borken, et al., 2010).

Spain uses a co-payment system where residents are required to pay a percentage of the cost of their

prescription medication (Gov.UK, 2014). According to Mendez (1995) patients pay 25 percent of the

pharmaceutical costs and generic drugs are sponsored.

There were no region-wide estimates for health care cost for various procedures were available

(AACR, 2010). Just as treatments and /or surgeries may vary from a small, one simple treatment to an

expensive, long-term treatment, the revenues fluctuate too (Marketline, 2012).

The costs of health care and pharmaceuticals are controlled by the Spanish Ministry of Health and

Consumer Affairs which guarantee the effective right of all citizens to health protection. This is the key

authority in charge of the general coordination of public health and health care services, and is

responsible for the drafting of health policy and any basic enabling legislation required and to negotiate

the cost of medications with multinational corporations (Borkan, et al., 2010).

According to Garuccio (2012), he stated that Spain has one of the best universal health care systems

because the government has considered it their duty to supply each and every citizen medical treatment.

On the other hand, the European Observatory on Health Care Systems (2000) stated, only 94.8 percent of

the Spanish population was covered under the imposed association to the social security system; public

health care coverage, while it may be characterized as “universal”, it does not in fact cover 100 percent of

the population. This is because it is still linked to social security on an employment-related basis and not

to citizen-ship or residency.

The role of Spain regarding public health prevention is to demonstrate projects to best develop

practices, share lessons learned regarding clinical process in all the autonomous communities, generate

enough knowledge to improve health care organizations, and facilitate a partnership among the public

(Borkan, 2010). By strategically placing the autonomous centers approximately within fifteen minutes of

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a person’s place of residence and allow close access in order to promote health care and take preventative

measures. The Spanish population overall is considered healthy. The Spanish lifestyle is considered to be

good due to good eating habits, a Mediterranean diet, and regular exercise (Garuccio, 2012).

The world has much diversity when it comes to comparing countries health care systems, each system

has its own approach (Garuccio, 2012).

Cost of Health Care and Methods of Public Health and Prevention in the United States

The U.S. health care system is incomparable among other countries. There is no uniform health system

in the United States, there is no universal health care coverage and most health care is delivered privately,

even if it is publically financed. Until the Affordable Health Care ACT (ACA), there was not legislation

to mandate health care coverage. The uniqueness of the U.S. health care system can best be described as a

hybrid system. It does not have an operating national health service such as a single-payer national health

insurance system, or a multi-payer universal health insurance fund.

“In 2010, 50 percent of U.S. health care spending came from private funds, compared to 38

percent from federal funds and 12 percent state and local funds. Experts are focusing more on

preventative care in an effort to improve health and reduce the financial burdens associated with chronic

disease. One provision of the Patient Protection and Affordable Care Act, commonly referred to as simply

the Affordable Care Act, implemented in 2013 provides additional Medicaid funding for states providing

low cost access to preventative care” (DPE, 2013).

According to Kaiser Family Foundation (2010) the average monthly premiums in the state of Arizona,

paid by individuals in 2010 was $241.00. The cost of healthcare per individual can vary depending on the

health care coverage you have. There are so many health care plans available to meet the criteria of each

family and individual. One guarantee the American health care system offers is emergency care. An

individual cannot be denied care if it is an emergent situation regardless of health care coverage

(Garuccio, 2012).

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There are coverage programs that are federally funded such as Medicare and Medicaid for those who

cannot afford health care plans (Garuccio, 2012).

Here are some facts regarding the U.S. health care coverage given by the Department for Professional

Employees Fact Sheet (2013) state, “In 2011, 263.7 million people in the U.S., over 84.6 percent of the

U.S. population had some type of health insurance, with 63.8 percent of workers covered by an

employment-based health plan. Among the insured, 119 million people, 38 percent of the population,

received coverage through the U.S. government in 2011 through Medicare (47.6 million), Medicaid (55.6

million), and VA or other military care (15.8 million). Nearly 1.5 million people used the Indian Health

services in 2011. Of those, approximately 30 percent did not have other insurance. In September 2011,

15.3 percent of the U.S. population, 47.6 million people, had no health insurance.”

The United States health care costs go towards salaries (administration) and insurance premiums

(medical expenses). There is a significant amount of funds spent on medical treatment and newer medical

technology (Garuccio, 2012).

There are various ways physicians, hospitals and other health care providers get paid in the United

States. There is the traditional way, by private health insurers and by government funds, Medicare and

Medicaid programs; this is called 'fee-for-service.' The way the fee-for service reimbursement plan works

is, the person responsible for the health care service pays a reasonable amount, being aware to take in

account certain guidelines under Medicare and Medicaid programs. The physicians, hospitals or other

health care provider charge a certain reasonable amount and the rest is submitted as an insurance claim

(Hagland, 2000).

Capitation was put in place to be a better way of generating incentives for efficiency, cost control, and

adding to preventive health care measures. Under capitation, a monthly flat fee is paid to the physicians,

medical groups, hospitals or integrated health system that is taking care of an individual enrolled in a

managed health care plan, regardless of what the individual pays for coverage. Here is an explanation of

the way capitation works:

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There are essentially two kinds of capitation, with many variations. The first is called

'global capitation,' in which whole networks of hospitals and physicians band together to

receive single fixed monthly payments for enrolled health plan members; under global

capitation, the providers sign a single contract with a health plan to cover the care of

groups of members, and then must determine a method of dividing up the capitated check

among themselves. Capitation that is not global is simply capitated payment contracted to

a specific provider group: a physician group, or a hospital, individually. (Hagland, 2000)

In the U.S. the coverage and costs for drug plans vary for each health care plan. A person

will pay a certain percentage of the costs and coverage for a particular drug and this will differ

depending on which health care plan one has. The drug companies also rely heavily for

physicians to prescribe a drug to their patients and dispensed by pharmacists (Field, 2008).

Certain procedures vary in cost in the U.S., depending on the procedure being performed and

the area of residency. According to Kane (2012) an appendectomy procedure cost is $7,962, a

knee replacement is $14,946 and coronary artery bypass is $34,358, just to name a few.

In the U.S. there are government agencies on the state and federal, local and even by a large

diversity of private organizations that focus on policies to help regulate and implement public

health care programs for promoting awareness and preventing diseases. This regulatory system is

not uniform nor is it consistent; at times they operate without coordination or consistency (Field,

2008).

Prior to the ACA, the majority of the population either did not have health care coverage or simply

could not get coverage. Citizens of the U.S. were denied health care coverage due to pre-existing

conditions, some they might not have any control over and some families not able to afford the cost of the

plans offered to them, not everyone was covered. Now with the ACA in place, health care coverage will

be offered to all individuals and families at an affordable cost.

The money applied toward better drinking water in the U.S. along with sanitary living environments

allows for people to have an overall healthier lifestyle which leads to better health (Garuccio, 2012).

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Health care prevention and promotion in the U.S. is focusing more on preventative care for example the

implementation of (ACA) “Affordable Care Act, was implemented in 2013 provides additional Medicaid

funding for states providing low cost access to preventative care” (DPE, 2013). Some other public health

preventions include, bringing awareness to the community, education, better eating habits and promoting

physical activities. Some companies offer incentives (wellness programs) to receive better rates on

insurance coverage. The United States is mandating individuals have health care coverage and allowing

the accessibility to receive health care coverage, without the stigma of pre-existing conditions. Individuals

need to be proactive in preventative care and screenings for public health prevention.

Conclusion

As illustrated in this essay, the health care systems of Spain and America employ drastically different

methods to reach the same goal of a healthy nation. The European nation of Spain uses a public

healthcare system to accomplish this goal. The vast majority of citizens use the no fee public health care

system with a small percentage using private insurance. (Gracia-Amesto, et al., 2010). Spain is divided

into 17 separate divisions in which each area is responsible for providing health care to its citizens

(National Health System of Spain 2010). Spain uses general taxation and distributes funds to each of the

17 regions (National Health System of Spain, 2010). Spain spent $2,671 per person which equates to 8.5

percent of GDP on health care in 2007 (Health Affairs, 2010). Health centers are placed within 15

minutes of travel time from most residential areas. This increases access and convenience in both

prevention and treatment of illness. Overall, the Spanish health care system has resulted in a male life

expectancy of 79 and a female life expectancy of 85.

In contrast to Spain, the United States utilizes a combination of public and private health insurance in

with over 50% of Americans using private health insurance (U.S. National Library of Medicine, 2013).

Private insurance is often paid through a patient’s employer or their own funds. Government programs

such as Medicare and Medicaid provide health coverage to the elderly, disabled, and poor. Government

programs are paid through federal and state tax funds. The Patient Protection and Affordable Care Act

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(ACA) of 2010 has increased access to health care for many Americans. In the year 2007, the United

States spent $7,290 per person on health care which works out to 16 percent of the GDP.

The United States has often been criticized for its lack of prevention and abundance of intervention.

The ACA has promised to take greater strides in stopping illness before it occurs and increasing health

care coverage. (DPE, 2013). In spite of the United States spending over 2.5 times per person on annual

health care costs over Spain, positive results are yet to be seen. America’s health care system has

produced a male life expectancy of 76 and a female life expectancy of 81. This is 3 to 4 years shorter than

the averages of Spain. A shift from reactive to proactive medicine and increased access to health care

coverage may just be the recipe to increase the performance of the United States health care system.

SPAIN 14

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