First, what you pay for health care
Public health care is paid out of tax income, and taxes are higher in Spain than the U.S. The U.S. is a relatively low-tax country: taxes represent 26% of GDP, while in Spain they are 34%. This includes all national and local taxes, property taxes, and sales taxes.
Since I am a full-time employee of the University of Navarra in Spain, I pay income tax and social security to the Spanish government, which comes to 24% of gross income (tax details here). My tax rate is slightly higher than normal because I am a foreigner. I pay no tax on this income in the U.S.
I do pay taxes in the U.S. on investment income and any income earned from consulting work performed in the U.S. for U.S. companies. But those taxes are at a lower rate than in Spain.
However, Spain has a highly regressive sales tax of 21% (it falls more heavily on the poor than the wealthy). You pay this rate on almost everything, with the following exceptions; the rate is 10% on hotels and drinks, and 4% on food, school books, and medicine.
What you get in terms of health care
You don't choose your doctor. Cindy and I were assigned to a public health clinic and a primary care doctor in our neighborhood. The clinic is a five-minute walk from the house. There are many around Pamplona, in every neighborhood.
Our primary care doctor is in her 50s and has medical degrees that meet European standards, which means that they are equivalent to the U.S. We are very happy with the attention she gives us.
When you go for a checkup, you can expect to spend around a half-hour with the doctor, who asks a lot of questions, makes notes, and, the next time you come, always knows the most important elements of your health situation. (Of course, everything is in Spanish, so when Cindy goes, I come with her to translate.)
I am very impressed with the time, attention, and listening of all the people we have dealt with in this system.
Making an appointment. We have never had to wait more than a day or two to get an appointment. Friday, on my way to work, I walked in to the clinic to make an appointment, and the clerk said, "The doctor could see you now, if you like". I said OK. She looked over a three-page printout of blood and urine tests, identified a problem area, recommended another test, which was done on the spot, and I left 20 minutes later.
Bill for the visit to the clinic and the doctor, zero. Bill for the lab tests, zero.Cost of drugs
A few days later, the doctor called me. Again, the doctor--not an assistant--called me to tell me that test results indicated I had an infection and needed an antibiotic. The prescription was entered into a database that every pharmacy is connected to. No need for me or the doctor to specify the pharmacy.
I just walked in to the pharmacy that was most convenient on my way home from the office--I could have gone to any of three or four in my neighborhood--handed the clerk my national health service card, and paid for the antibiotic: the equivalent of $7 for a one-week course of this antibiotic. Don't really know what you would pay in the U.S.
Another prescription drug that I take costs me about $50 a month here because the national health insurance doesn't cover it. In the U.S., the same prescription drug, also not covered by any health insurance plan, costs four times as much.
An Epipen prescription for life-threatening allergies that our son, Patrick, has costs more than $600 in the U.S. If he lived in Spain, and had a prescription written by a Spanish doctor, it would cost 90% less, the equivalent of $60.
Waiting list happy endings and horror stories
I have heard horror stories from some of my colleagues about waiting lists of months for surgical procedures of various kinds. If you are in pain and you want surgery to correct that pain, you will probably have to wait. Not sure how different this is in the U.S., but read on.
The two local newspapers--one with a left-wing slant and one with a right-wing slant--report on the waiting-list issue making arguments that show either health-care management is better now that we have a leftist government in the province of Navarra or that it was better under the previous rightist regime.
The left-leaning newspaper said "waiting lists have been reduced by 10,000 people in 2017, with 1,300 fewer waiting for surgery", a reduction of 15%. The waiting list for mammograms, colonoscopies, and MRIs was reduced by 20%.
The critics of the left-wing government in the provincial legislature said that the reduction in waiting lists came at a cost of about $70 million in additional spending that was done wastefully.
The conservative critics added that the waiting lists for some types of procedures were longer than the limit guaranteed by law--8% of those on the surgical waiting list had been waiting more than six months. (More-urgent surgeries, such as for heart and cancer conditions, have priority; the official standard is that a patient's condition should not worsen while on a waiting list.)
From a customer-service perspective, I am very happy with the treatment I get at all the public service offices we deal with in Spain--visa service, tax service, public health service, local residency card, police (to report a credit-card fraud). Waiting rooms are orderly, waits are no more than half an hour for anything, the government employees are pleasant, helpful, and often friendly.
Private insurance and health care are available, if you don't want to go on a waiting list and if you want to choose your own doctor. And of course you pay more. So you still have a choice.
Is the expense of the public-health system worth it? I think if you are only counting dollars, you might say no, we want our system in the U.S. where we choose our doctor and the level of insurance we want.
But the unbelievable bureaucratic gymnastics you have to go through in the U.S. to deal separately with doctors, hospitals, independent labs, insurance companies, Medicare, Medicaid, and more, creates many hidden costs and inefficiencies. All of this rigamarole exacts a tremendous personal toll on us--the patients and customers--in terms of time spent and stress.
And even after you take into account that 18% (and growing) of the GDP in the U.S. is spent on health care, far higher than any other developed country, our health outcomes are worse. Go figure.
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Thanks, Jim, for telling your story. I'm on Medicare here, and find it a pretty simple and effective system.
ReplyDeleteI favor the idea of Medicare for all, as it is called. I think it makes good sense to take worries about health care, especially crises off people's minds. But as you point out, the question is what will it cost in taxes.
Bernie Sanders has been arguing for this for years, but I don't think he's been forthcoming on the actual text hit it will require. We need to take a hard look at that and have a debate about what's best overall.
Thanks for starting this discussion.
All best to you,
Frank Abate
Great perspective, Jim!
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