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Insurance in Spain

Does Spain really have universal healthcare for everyone?

Insurance in Spain Catherine Gaa

Nowadays, and quite especially in the wake of the COVID-19 pandemic and the push for medical coverage for all societies and people, universal healthcare is an important buzzword. For expats in Spain, what does universal healthcare mean, and who covers the cost?

What is universal healthcare?

The World Health Organization (WHO) categorizes universal health care as the access that all citizens or people residing in a nation have to health care services without facing financial hardship. The WHO states that this is a key element in improving overall well-being of a national: this is also considered an investment in human capital, a way to reduce both poverty and exclusion and a fundamental element in positive economic growth and development.

It's common knowledge that Spain has one of the highest life expectancies in the world, to which Spain has been touted as having an accessible and formidable healthcare system. This post will uncover more specifics about Spain universal healthcare, costs to consumers and how to become a part of the Spanish social security system.

Does Spain really have universal healthcare for everyone?

In Spain universal healthcare means what, exactly?

In Spain, everyone – yes everyone – has the right to access healthcare via the Spanish constitution, ratified not 50 years ago. The National Health System (Sistema Nacional de Salud) in Spain is overseen by the Spanish Ministry of Health for policy and budgetary concerns, though it is decentralized at the regional level, which has led to disparities in care and quality as well as budget crises in recent years.

Spain spends just around 10% of the annual GDP on healthcare, or approximately 2,000€ per resident annually.

That said, about 90% of all Spanish citizens use the public healthcare system, and Spanish citizens and residents can also access private and public healthcare. It’s estimated that about 20% of citizens use private healthcare, and this number is on the rise – most policy takers confirm that budget cuts have led to less access to their preferred professional and long wait times for treatments and appointments.

Who has access to Spain universal healthcare?

According to the UN, Spain ranks 13th in terms of coverage index for essential health services, coming in with a score of 83 out of 100. This puts Spain in company with Switzerland, Germany and Japan, among others. (source: Countries ranked by UHC service coverage index (indexmundi.com)

State healthcare is considered free of charge in one of the following cases:

  • You are a Spanish citizen;
  • You are a working, non-Spanish resident;
  • You are a resident receiving certain benefits;
  • You are a non-working resident who contributes monthly to the social security system;
  • You are the child of a resident in Spain;
  • You are pregnant and legally residing in Spain;
  • You are a student under 26;
  • You are an EU or UK pensioner permanently living in Spain;
  • You are a European temporarily in Spain with an EHIC card.

If you do not fit one of the aforementioned cases, you can still access the healthcare system for a monthly premium and enjoy the same level of care as a citizen or legal resident via the convenio especial.

So, is public healthcare really free in Spain?

It’s common knowledge that Spanish healthcare professionals, particularly those who are employed by the government in the social security system, earn a good living but are still held to a high professional and practice standard and must pass extensive tests – Spaniards hold social security doctors in high regard as a result.

But the cost isn’t exactly free because the operating costs from both government subsidies but also the social security payments deducted from your wage, which are close to 300€. So, it’s like money that you don’t really see because your employer automatically “deducted” the quantity from your paycheck.

What does that expense mean? Prescriptions are heavily subsidized by the Spanish government – close to 70% for workers and 90% for pensioners. Ambulance rides, ER visits or hospital stays, analytical tests or blood draws and surgeries are free or extremely low cost. For me, it’s the peace of mind in knowing that I can receive treatment as a permanent, non-EU resident, and that it won’t cost me what it would back home in the US.

What’s not included?

  • Dental, except in the case of young children whose parent(s) receive social security benefits.
  • Psychology, limited appointments and only for people with specific needs.
  • Physiotherapy, limited appointments available and also restricted to specific cases, is not a universal service. Long waiting list due to the shortage of professionals working in this field at the Spanish Social Security.
  • Last but not least, be aware that any test you need to have, must be prescribed by the family doctor in order to get access to a specialist.
Does Spain really have universal healthcare for everyone?

Do expats get free healthcare in Spain?

This depends largely on the expat’s individual situation, as seen above. If you are working in Spain or the spouse of a Spanish national or European with residency, you’re allowed to use the social security system.

Expats who are required to purchase private health insurance for visa purposes can begin to pay into the social security system after one year and upon renewal of their residency status via the convenio especial. This scheme is a way to pay, on a sliding scale according to your income, your way into public healthcare. While it isn’t free, it may very well be cheaper than in your home country.

How can I get public healthcare in Spain?

If you qualify for public health coverage, you must first register for a social security number with your passport, residency certificate or card, and proof of registration with your local town hall, called a padrón. Once you have this number, you must go to your nearest clinic and ask for a primary care doctor; you will then be issued a health insurance card for your autonomous community, called a tarjeta sanitaria individual.

Keep in mind that, due to the decentralized organization, you will need to inform local authorities of a change in autonomous communities and re-register at the local center in your new comunidad.

The takeaway: my experience with Spain universal healthcare

II have been living in Spain since 2007 under both the private and public healthcare schemes; since 2013 I have been a recipient of public healthcare due to my social security contributions and also have private health coverage due to personal choice.

Before becoming pregnant with my first child in 2016, I wanted to explore the option of private healthcare for my pregnancy, labor and postpartum health. One benefit to my private health insurance via the Caser Activa plan is that I have my choice of doctor and clinic rather than it being assigned to me, and I usually experience less wait time – for about 46€ a month plus co-pays currently.

Since 2010, I have been in the public social security system and have benefitted by way of wellness check, tests and analyses, ER visits, a COVID-19 booster and the knowledge that any ailment or serious injury will never put me in the whole. In my opinion, access to healthcare should be the responsibility of a government and the right of every citizen. So, while universal coverage is not “free” for me, it does free me to live my life in a healthy way in which the stress of potential medical payments does is non-existent.


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Catherine Gaa

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