Public health coverage is mandated by the Spanish constitution and covers its entire population. Foreign nationals, along with family dependents, are also included as long as they participate in the seguridad social (social security) network every month, which entitles them to an array of benefits including sick pay, unemployment benefits, maternity leave and free healthcare. Also eligible are Spain’s undocumented children under the age of 18, and undocumented pregnant women.

Spain was one of the latest countries to adopt universal healthcare coverage in a trend that began in 1870 after the Franco-Prussian war, and was created by Otto von Bismarck who viewed the program as a societal obligation. A cluster of European countries then followed suit, but it especially gained momentum in the 1940s after World War II left Europe in shambles.

In the United States we have been taught to be disdainful of government involvement in healthcare from as early as the 1930s when conservative politicians distributed propaganda warning Americans of the "ravages" of universal healthcare when President Franklin Roosevelt supported it as a viable option. This has run opposite to the trend in Europe where the sociopolitical pressures have leaned towards more rather less government responsibility in matters as important as healthcare. Europeans recognize health coverage as a moral, ethical issue based not on one’s purchasing power, but on need.

Therein lies the fundamental difference between the United States and Europe.

The Spanish health expenditure is modest by American standards: at $2,099 per capita, it is one-third of the American expenditure and accounts for 8.5% of its GDP. Spanish results reveal a better outcome than ours: infant mortality rates stand at 4 per 1,000 (6.3 in the U.S.), childhood immunization rates are higher, life expectancy longer by 4 years, and “preventable deaths” – fatalities that could have been prevented by access to medical care – are far below U.S. levels.

As in other industrialized countries in the EU, Spain’s healthcare system is tax based. Spanish tax rates are relatively low for European standards: about 25-30%, and 45% for those with an annual income of €53,000 or higher.

Doctor’s visits are paid in full, as are surgeries, prenatal care, birth control, cancer treatment, physiotherapy, prosthetics and births. “Everything except [plastic] surgery,” says Dr. Vincent Riambau, Professor and Chief of Vascular Surgery Division at the Thorax Institute in Barcelona in an email interview – unless it interferes with the wellbeing of the patient. For instance, breast reduction is covered if it is the cause of back problems. There are no co-payments. No claim forms. No mountains of paper work to fill out. Other types of surgeries that would be considered “elective” in the U.S. are covered by regional governments. Case in point: sex-change operation. The governments of Andalusia and Extremadura in the South passed legislation in 2006 to pay for this type of procedure.

The government subsidizes about 60% of most prescription medication, including costly HIV medications. For those retired and over the age of 65, medication is fully covered, as is elderly home care by nurses and doctors. The government sponsors a yearly visit to a private dentist for all children, but dental care is generally not covered under the national system.

To be sure, Spain is not immune from the challenges of universal healthcare. While the Ministry of Health sets standards and outlines minimum requirements, it is Spain’s 17 autonomous regions that decide how to best implement the national health legislation. As a result, more affluent regions like Cataluña have more resources than their poorer counterparts. Patients have been known to relocate for better treatment since the public system requires users to seek care within their own communities.

Waiting lists are another drawback to Spain’s public system. The average wait to see a specialist is 65 days, and for a non-emergency procedure such as a hip replacement or cataract surgery, appointments can be months away.

Fortunately, an excellent private health insurance system exists right alongside the public system. An estimated 15% of the population holds private insurance and uses this as a supplement rather an alternative to the national coverage.

I have personally experienced the private side of the system. Ineligible for public coverage when I first arrived in 2005, I signed up for Sanitas, one of Spain’s foremost private health insurance providers. There were no lengthy interrogations on “pre-existing” conditions, past medications or hospitalizations. I completed and signed a form, and within days my card arrived in my mailbox. My initial worry that private healthcare would cost me a fortune was quickly dismissed. As a 33-year-old woman at the time, my comprehensive monthly coverage came to no more than €50 (approximately $71 USD).

In the end, most Spaniards are content with their system. “There are things that could be improved, but having universal care is a wonderful asset,” says Aitor, a 33-year-old social worker from Barcelona who does not take the Spanish system for granted. “The first time I heard there are countries where you have to pay to see a doctor, I was shocked.” Susana, a 44-year-old history teacher agrees. “No one worries about their health coverage in Spain,” she explains. “If you lose your job, or have a chronic condition, the system won’t let you down.”

Indeed, a 2007 Harris Interactive poll survey validates these observations: while one-third of all Americans said that they believe the U.S. healthcare system needs a complete overhaul, only 12% of Spaniards believed change was in order.

Perhaps there is no better index of the wellbeing of a nation than its health record. By creating an alliance between the sick and the healthy, where the former are willing to take responsibility for healthcare, Spain has fostered one of the world’s healthiest populations.

What is most bueno about the system? It cultivates patient choice: all Spaniards have free (or virtually free) access to highly qualified doctors and hospitals. For those seeking a market-based system, a plethora of affordable choices in private insurance, private doctors and private hospitals exists.

There is your model, America.

Handan's article is part of our series that examines the benefits and drawbacks
of various healthcare models around the world. - Ed.

About the Author
Handan Tülay Satiroglu is a Turkish-American independent journalist who divides her time between the U.S. and Europe. She has an MA in Sociology from New Mexico State University, and a B.A. from Colorado State University. In addition to her writing career, she has also taught at Northern Virginia College in the United States. Her articles have been featured in various online and print venues including, World Politics Review, The World & I Online, The Smart Set, Vision and Positive Health Magazine, among others. She was born in Colorado and has lived in Turkey, Spain, and Belgium. Visit her website at www.handansatiroglu.com.