Change of healthcare system model in Spain

As was pointed out by Minué-Lorenzo et al.(1) in their recent comment, the Spanish healthcare system is moving back from a universal healthcare coverage based on the National Health Service system to a Social Security system according to the law from April the 20th (2). This decree law has excluded undocumented immigrants from the healthcare system. It has also excluded those people older than 26y, and disabled people with less than 65% of disability, both if they never contributed to the Social Security System (called uninsured), unless they are demonstrably under the poverty line. Now it seems that the Spanish government, attempting to solve several criticisms to this law, is drafting a new Royal Decree Law. According to a published note in the newspaper El País (3) the new draft aims to keep out of the system “only” undocumented immigrants and those who earn more than 100000 € / year. This new law determines that people who are legally resident in Spain are entitled to health benefits if they earn less than the above mentioned figure. Nevertheless, it continues using the terms "insured / uninsured" and "beneficiaries" and claims people that never contributed to Social Security to request access to healthcare system within the next 3 months of the entry into force of the law (next August 31st). The latter contradicts the previous definition of beneficiaries like people legally resident in the country, and breaks one more time the universality of the system.

These and other factors already commented on by Minue-Lorenzo et al(1) on the proposed portfolio of services suggest that the rupture of universalism is the ultimate goal of all these measures. In any case, this intention of changing from a Beveridge to a Bismarckian model is fraught with contradictions that are reflected in recent legislation passed (and awaiting approval) by the government. This changing of paradigm does not solve financial problems but transforms the Spanish healthcare system into a mixture of National Health Service and Social Security system (probably more costly and bureaucratic) and can potentially generate an enormous health gap in Spain.

Politicians emphasize the restriction of access for the immigrant population, and it may be a way of moving attention away from the previously mentioned decisions. At the same time this fact stimulates the xenophobic sentiments of the population, with accusations that immigrants are "abusing" the Spanish National Healthcare Service in periods of crisis. As Minue-Lorenzo et al. pointed out(1), “the beginning of the end of the national health service in Spain may be getting closer” if we do not remediate it.

References
1 Minue-Lorenzo S, García-Gutiérrez JF, Mercader Casas JJ. Citizen or insured? The assault on universalism in Spain. BMJ 2012;344:e3213.
2 Real Decreto-Ley 16/2012, de 20 de Abril, de medidas urgentes para garantizar la sostenibilidad del Sistema Nacional de Salud y mejorar la calidad y seguridad de sus prestaciones. Available at: http://www.boe.es/boe/dias/2012/04/24/
3 De Benito E. El gobierno rebaja los requisitos para obtener la tarjeta sanitaria. El País; 13/06/2012. Available at: http://sociedad.elpais.com/sociedad/2012/06/13/actualidad/1339589523_839...

Luis Rajmil
María José Fernández de Sanmamed

E-mail: lrajmil@aatrm.catsalut.cat

Competing interests: None declared