Can people afford to pay for health care? New evidence on financial protection in Spain

Abstract

This review is part of a series of country-based studies generating new evidence on financial protection in European health systems. Financial protection is central to universal health coverage and a core dimension of health system performance. Despite worsening during the economic crisis from 2008 to 2014, the incidence of catastrophic health spending in Spain is much lower than would be expected given Spain’s relatively heavy reliance on out-of-pocket payments. This can be explained by strengths in the design of coverage policy in the National Health System (NHS): entitlement to the NHS based on residence, with the same degree of entitlement for undocumented migrants; a generally comprehensive benefits package; limited use of co-payments; and multiple mechanisms to protect people from co-payments. There are gaps in coverage, however. Catastrophic spending is driven by dental care and medical products in all consumption quintiles, mainly because dental and optical care for eyesight problems are largely excluded from NHS coverage. Catastrophic spending in the poorest quintile is also driven by outpatient medicines, reflecting co-payments and inadequate protection for low-income households of working age. To reduce unmet need and financial hardship, policy should focus on expanding NHS coverage of dental care and optical care and further improving the design of co-payments to strengthen protection for poorer households in all age groups.