Context
Until 2012, health care coverage in the Spanish National Health System (SNS) was almost universal (99.5%) and guaranteed quite a comprehensive package of benefits to all citizens (García-Armesto et al., 2010). Entitlement used to be independent of the labour status and personal wealth of the individual. With regard to foreign residents, the Organic Law 4/2000 (BOE, 2000) on the rights and freedoms of foreigners in Spain and their social integration established the coverage conditions allowing the same entitlements for those residing and working permanently, providing access according to their country insurance scheme for those nationals from countries with bilateral agreements, or providing full access to registered undocumented migrants with annual incomes equal to or lower than the minimum inter-professional wage.
Impetus for the reform
In the context of the 2010 Stability Programme for Spain and, in the aftermath of the economic and financial crisis that started in Spain in 2008, the Royal Decree-Law (RDL) 16/2012 was introduced to guarantee the sustainability of the SNS (BOE, 2012a). The RDL 16/2012 and subsequent legislation (BOE, 2012b) changed the basis for entitlement to health care by linking the right to the legal and working status of the individuals. In practical terms, only undocumented immigrants ended up excluded from health care coverage, with the exception of emergency, and obstetric and child care. The exclusion of this population subgroup from full coverage was seen to potentially increase health inequalities and to result in negative consequences in public health (Bernal-Delgado et al., 2018). Despite this national regulation, some regional Health Authorities did not exclude undocumented migrants from health care coverage.
Content of the reform
Following a non-confidence vote taking place 1st June 2018, the conservative Prime Minister until then (Mariano Rajoy) was ousted by the social-democrat candidate (Pedro Sánchez), who was sworn as Prime Minister one week later and named a new Cabinet (see Reform Log 5/07/2018).
During the first weeks of mandate, the new Health Minister started working to restore the status quo before the RDL 16/2012. The Minister met first representatives of the civil society known for their defence of universal health care, such as Amnesty International or Doctors of the World, as well as some Professional Associations on Family and Community Medicine and Public Health and some of the trade unions in the sector (Ministry of Health, 2018a). These meetings were followed by a specific Interterritorial Council, held on June 28th, where the Ministry and the regional Health Authorities set up the path to increase the coverage entitlement basis as it used to be before 2012 (Ministry of Health, 2018b).
This process has come to an end, with the Spanish Parliament approving the RDL 7/2018 in September 6th, where the basis for entitlement returns to be linked to the condition of resident. In the new law undocumented migrants have recovered eligibility to full coverage as any other Spanish national. The RDL foresees exceptions related to having health coverage linked to bilateral agreements between countries or having a third party obliged to pay for the health services provided. Last but not least, under any circumstance, migrants are allowed to claim for the health coverage entitlement conditions of the country of origin.(BOE, 2018).
According to the new legislation, regional Health Authorities have to issue specific health insurance cards for those undocumented migrants accrediting more than 90 days in the country (otherwise, according to the Organic Law 4/2000, they are considered in temporal stay, that is, non-residents). In the eventual case that an individual requires health assistance within those 90 days, social services should first submit a favourable report.
Except for the case of pharmaceutical care, where the RDL also defines the pharmaceutical co-payment threshold for this population in a fixed 40% of the retailing price, irrespective of their income level (unlike the rest of the population), the remaining benefits are funded following the SNS general scheme – a tax-funded system which is free of charge at the point of care (Bernal-Delgado, et al., 2018). Finally, as a specific provision, the RDL establishes that the Interterritorial Council (the governing body for the SNS) will define access requirements for those migrants needing an organ transplant.
Final remarks
Although no formal procedure has been established to assess the impact of this new policy, the Interterritorial Council held in 28th June agreed with the creation of a joint committee, made up of representatives from the organizations defending universal insurance, whose aim will be to monitor the compliance of the new RDL (Ministry of Health, 2018b).