Aser Garcia Rada: The chaos and injustice of excluding migrants from public funded healthcare—lessons from Spain

aser_garcía_radaOn 1 September 2012 the conservative Spanish government of the People’s Party ended 26 years of highly valued universal healthcare coverage. The Royal decree 16/2012 on urgent measures to guarantee the sustainability of the Spanish national health service changed our general taxation funded system back to the previous social security model dating from 1986, and divided citizens between the insured and the uninsured.

The law excluded certain groups, such as undocumented migrants, from healthcare coverage, except for emergency care, pregnancy care, and healthcare for their children. Victims of human trade or under political asylum maintain free access to all healthcare. For those no longer eligible for free healthcare, the alternative offered by the government was public insurance costing between €710.40 to €1864.80 per year–quite expensive for an  undocumented migrant. This law entered into force on 2 September 2013, a whole year after the Royal decree.

The arguments supporting these changes may seem familiar to the British, as an open consultation to debate whether migrants should be charged to access NHS services has just finished in the UK. It was triggered by the unsustainability of the system and the need to limit abuse from foreigners. As I have discussed in a previous blog it is based on ideology and opportunism, rather than scientific evidence. Worldwide evidence states that migrants are younger, healthier, and demand less care than nationals. When the decree was issued, one year ago, the Spanish minister of health, social services, and equality didn’t have any technical backup for this measure. The government didn´t know how many people were undocumented—for obvious reasons, but they also didn’t have any forecast of the amount of money expected to be saved, which raises the question—what were the real motives for such a measure?

On the first anniversary of this shameful decision the situation has not changed substantially. Neither central government nor the 17 autonomous communities have released any assessment. My repeated requests to the ministry have been met with silence, which doesn´t surprise me much given the level of transparency we are used to in Spain.

Therefore, the main sources of information are from non-governmental organizations (NGOs) who have been taking care of those left without healthcare. Doctors of the World has organized an extraordinarily persistent campaign against the measure and has assessed its impact throughout the country. I have been talking with Marta Cimas and Pedro Gullón, two resident public health doctors at the Instituto de Salud Carlos III in Madrid who are collaborating with Doctors of the World for their next report on the situation region by region, due for release at the end of September.

“It is a chaos,” concluded Cimas. This year, the autonomous communities, in charge of providing healthcare, have taken, or not taken, different decisions on how to deal with undocumented migrants requesting care. We could roughly divide the regions into four categories, they explain. Firstly, those regions that still provide full care and drug coverage in the same way as they do for Spaniards, which are Navarre, Asturias, and Andalusia—although in this one an affidavit must be signed stating indigence. Secondly, and on the opposite side, Cantabria, La Rioja, Murcia, and Castile-La Mancha only provide the minimum care stated by law.

In between there is a bureaucratic muddle. There are regions that provide care for chronic diseases, public health issues, or mental disorders, and others that maintain full care if, in a Kafkaesque move, patients provide documents such as their passport, a fiscal statement, or census data. Most undocumented migrants don’t have these documents or are reluctant to show them for fear of legal consequences. That is not all. “Inside each hospital or primary care centre, each administrative officer or healthcare worker does whatever they want. It depends on how well they are informed,” said Cimas. In fact several migrants have been billed even for care which they still have coverage for, such as emergency or maternity care.

In the UK, the British Medical Association has opposed David Cameron’s plan for charging migrants for healthcare as they argue it will become a bureaucratic mess and doctors need to focus their attention on delivering healthcare rather than dealing with border control issues. However, I haven’t seen further arguments based on health outcomes and social justice such as those used in Spain by many health professionals, medical societies and colleges, NGOs, and other civil groups.

Doctors of the World have reported dozens of cases of patients with infectious diseases, cancer, diabetes, or organ transplants, who have not received a proper follow up or treatment.  Can citizens of allegedly civilized countries such as Spain or the UK abide this happening to people who have left their families and friends to find job opportunities abroad, sometimes risking their lives in the process? Personally, I feel ashamed.

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