The Independent Authority for Fiscal Responsibility (AIReF), an autonomous public institution tasked with ensuring the sustainability of public finances and promoting transparency and fiscal discipline across all levels of government, has published a pioneering study on Spain’s civil servant mutual insurance system, evaluating its effectiveness, efficiency, and equity. The analysis draws on 400 million anonymized microdata and a survey of 16,000 mutualists, combining administrative records, hospital activity, pharmaceutical use, and healthcare data.
Spain stands out as a unique case among peer countries, as it is the only country with universal coverage and tax-funded healthcare that sustains a mutual insurance system. The report finds a strong link between mutualists’ care preferences and the complexity of the required treatment. While only 24% of mutualists chose public provision overall, this rises to 70% in severe hospital cases. In turn, private healthcare offers better accessibility but higher pharmaceutical costs. Mandatory affiliation under the current framework limits access – especially for those choosing the private model – to the universal features of public provision available to other citizens. AIReF proposes transitioning to voluntary enrollment and integrating new mutualists into the NHS.