Spain can offer a healthcare lesson to the United States

A recent study trip to Spain brought into sharp relief for me a question that Americans spend a lot of time ducking: Is healthcare something we as citizens of a shared community owe one another or is it a commodity we purchase, governed by our ability to afford it?

What struck my fellow healthcare executives and me most during our time in Spain wasn't the efficiency of their system or their impressive data infrastructure, although both merit attention. It was the pride. From physician executives to hospital leaders to digital health entrepreneurs, each person we met spoke about healthcare with the kind of moral clarity that has largely vanished from American discourse on the subject.

Spain treats healthcare as what economists would call an "investment good" — something that strengthens the entire nation, citizens and noncitizens alike. We Americans, by contrast, have increasingly framed healthcare as a consumer good, something you earn through your income or, more troublingly, through behavior the government deems worthy. Consider the H.R. 1, or One Big Beautiful Bill Act. By limiting Medicaid expansion to those who meet work, education or volunteering requirements, it represents yet another step away from the idea that healing the sick is a collective responsibility rather than an individual achievement.

The Spanish system rests on principles familiar to anyone who has studied the health systems of Britain or the Nordic countries. Federal taxes finance approximately 71 percent of healthcare costs. Seventeen autonomous regions administer the system and contract with a mix of public and private clinics, specialists and hospitals. Citizens are assigned to neighborhood primary care clinics that serve as gatekeepers, ensuring coordination rather than the fragmented, duplicative care that plagues American medicine.

And here's an even more striking difference: In 2018, Spain made a choice. The nation decided that all residents — citizens, legal residents, and yes, even undocumented residents — deserve access to healthcare. Clinics employ social workers to help newcomers navigate the bureaucracy and obtain insurance ID cards that open doors to comprehensive care, including pharmaceuticals.

Compare this with our own patchwork system, where coverage depends on a bewildering array of conditions: citizenship status, age, disability, employment and income. H.R.1 has now stripped away Medicaid coverage from 100,000 legal residents who previously relied on it. We've decided, in effect, that these people, who are here legally and contribute to our communities, don’t merit the investment. Even more shamefully, 1.4 million Americans with low incomes who remain trapped in nonexpansion states remain ineligible for both Medicaid and marketplace subsidies, caught in a gap created by political dysfunction masquerading as principle.

Spain requires all 17 of its autonomous regions to provide a baseline of benefits — all medical visits and hospitalization — without copayment. Supplementary services, such as prescriptions and orthopedic prostheses, are available with modest copayments. Individual regions can add services using their own resources.

Yes, waiting lists exist. But ultimately, every resident receives the care they need. In the U.S., mandated benefits vary wildly by state, leaving coverage for fertility treatments, abortion services and emerging offerings like doula care subject to the accidents of geography and political winds.

The Spanish have also invested seriously in data and interoperability, which make modern healthcare work. At the federal level, they systematically track reports of adverse side effects of prescriptions, conduct national health surveys, and closely monitor mortality. Regional systems collect data on expenditures and health determinants. Individual electronic health records travel with the patient, and not just within Spain but across the European Union. Citizens can access data on hospital quality measures, waiting times, patient satisfaction and even medical errors. This investment in transparency and analytics gives government and individuals the tools to assess costs and benefits rationally. Meanwhile, American interoperability remains aspirational, hamstrung by the fragmented nature of a system that often seems designed to obscure rather than illuminate.

The results speak plainly. Spain spends 9.2 percent of GDP on health care; we spend 17.2 percent. Spaniards live to an average age of 84, the highest in the European Union. Americans make it to just over 78. In a year, Spain records 90 preventable deaths per 100,000 people. The U.S. rate of 177 per 100,000 people is nearly double.

We spend nearly twice as much but achieve worse outcomes. This isn't just inefficiency. It's a policy choice, rooted in a philosophy that treats human health as something to be rationed by market mechanisms.

Realistically, America won't adopt Spain's national health system anytime soon. Our history, our individualist traditions, our complicated federalism and our entrenched interests make such a transformation politically implausible in the near term.

But we could at least move toward acknowledging what most of the developed world accepts as self-evident: that health care is neither a privilege to be earned nor a commodity to be purchased. We could recognize that a healthy population is a public good, not just a private benefit—that when we invest in the health of all residents, we strengthen the entire nation.

Overturning the most punitive aspects of H.R. 1 would be a start. It would signal that the United States hasn't entirely abandoned the idea that we have obligations to each other that transcend market logic, that a society shouldn't ask people to prove their worthiness before treating their illnesses.

The Spanish example — and that of virtually every other wealthy democracy — proves that this is a choice we are capable of making. It's a test not just of our health care policy, but of what kind of country we mean to be.

Meg Murray, M.P.A., is CEO of the Association for Community Affiliated Plans and a member of the Managed Healthcare Executive editorial advisory board.