Some time ago I wrote a letter to the Spanish daily El Mundo, saying that co-payments –an extra charge for accessing medical services in the public healthcare system, should be considered as a measure to help the public system. Co-payments have traditionally been a forbidden issue among politicians as they amount to paying twice for something we already fund with general taxes –some people call it repayment. But I argued that we should debate the issue.

Currently, access to public healthcare is free, and the only extra thing we have to pay for is that people under 65 years old pay 40% of the cost of prescribed drugs. Against the backdrop of the 20 November general elections, all political parties rejected co-payments, but the debate is growing together with healthcare debt, and different kinds of co-payment are beginning to be implemented.

In a poll of the Spanish Society of Primary Care Physicians (SEMERGEN) 86% of responding doctors thought that some kind of co-payment was necessary, owing to their perception that a lot of people abuse the system by visiting their doctors despite not having any problems. At the time that I wrote the letter I agreed with this widespread perception, but now I have realised that this view is very limited.

Firstly, and most importantly, we don´t know how many patients are not “abusing the system” because we don’t see them. Secondly, patients may misinterpret or ignore the significance of their symptoms. If we have doubts sometimes, how can we expect patients not to have them? Thirdly, indiscriminate co-payments would primarily limit access for the poorest while the establishment of a means tested co-payment —as commonly suggested— is difficult, and if achieved, would not take into account the real incomes of those defrauding the treasury –the underground economy may account for 23.7% of Spanish GDP. And finally: it will not serve its purpose.

According to Jose Ramón Repullo, an expert in health economics from the National School of Health, although a “devastating effect on mortality” is unlikely in developed countries, co-payments will “surely” affect morbidity.

Repullo refers to two articles. The first one is a US study stating that “the rising cost sharing for ambulatory care among elderly patients may have adverse health consequences.These effects would be magnified among those with lower incomes,less education, and those with chronic diseases such as hypertension, diabetes, or a previous myocardial infarction. It may increase total spending on health care.” The second article concludes that a low co-payment for outpatient care established in Germany “failed to reduce the demand for physician visits.” Furthermore, costs of healthcare in Spain are lower than those of other countries applying co-payments.

Beside, concurrent circumstances occurring in Spain suggest that co-payments are being used as a smokescreen to promote growing public private partnerships (PPP).

Interested parties have been spreading  continuous and distorted messages about the unsustainability of the public system which is driving citizens to swallow the co-payment pill. According to a survey by the General Nursing Council, 63.5% of the population would accept a co-payment based on income.

Surely media positioning is contributing to population’s distorted view, strikingly so that of the two most important Spanish newspapers. The  centre-left El País has asked for co-payments in some editorials, and the conservative El Mundo has done so repeatedly. The editor of El Mundo didn´t answer my question via Twitter asking whether their position had something to do with the fact that their editorial group signed an agreement last year with a company of private hospitals. 

Meanwhile, the Institute for Development and Integration of Health (IDIS), a lobby involving most private health sector operators that has already been accused of lying with its unreal arguments, insists that to avoid unfair measures like “co-payment or benefit cuts,” PPP must be promoted, though evidence of its efficiency is lacking.

And the Madrid Business Confederation (CEIM) just called for co-payments. Are they worried about the population’s health or about the sustainability of public healthcare? They could be. But notably in Madrid, nine public hospitals —and two more next year— are already managed by a private company, receiving a fixed annual amount to provide care independently of the number of patients who attend. Do they think that co-payments may reduce demand and make their business more profitable? If that was the case, the more PPP, the more likely it is that employers will demand co-payment in a spiral of unknown consequences that contradicts IDIS’s arguments.

These events may be causal, but if linked they seem to lead to a rather vicious circle.

Aser García Rada is a paediatrician at the Hospital Infantil Universitario Niño Jesús in Madrid, Spain, and a freelance journalist.