Double health insurance cover

20 Apr
Lluís Bohígas

A double health insurance cover occurs when a person that has the right to public healthcare also has a private health insurance which allows them to receive private health services. Anyone can go to private health services if they pay from their own pocket but it is only defined as a double insurance cover when one has taken out a specific private health insurance. The population has a right to healthcare because they have contributed to social security – or they may find themselves in any one of the contexts that gives them the right to access – and this covers almost the entire population but not all; there is a segment that does not have the right to public healthcare and only has private cover if they purchase an insurance.

In the 80s of last century, the self-employed were not covered by social security and the majority had a private insurance. At that time, in Catalonia the Quinta de Salut l’Aliança was very popular. Ernest Lluch, the Minister of Health, made it compulsory for the social security to offer healthcare to the self-employed and, all of a sudden, many of those insured by l’Aliança found themselves having a double insurance. Some left l’Aliança but others stayed on. The public healthcare system and the majority of insurance companies only cover a basic part of dental healthcare. If you want a wider dental healthcare cover you need to purchase a specific insurance. This insurance is not considered to be double cover because it does not cover the services which are covered by the public insurance.

In 2014, the Generalitat recorded 2.032.911 people with a health insurance in Catalonia but not all had double cover. State civil servants and their families can choose to be attended by the autonomous community or by a private insurance and 80%, 160.815, choose private healthcare and so they do not have double cover. The difference between the total number of insured and the civil servants that have chosen a private insurance are 1.872.096 people; that is, 24,9% of the population has double cover.

Why do one out of every four Catalans buy a private health insurance, despite having the right to public healthcare?

There are several reasons for this. On the one hand, a private insurance gives them access to private health centres and to independent doctors who are sometimes doctors that work in a public centre in the morning and a private centre in the afternoon. In the afternoon, one can choose the doctor that it wasn’t possible to choose in the morning. Another reason is waiting times. Private centres and independent doctors have shorter waiting times than in public centres. And another frequent argument is that private doctors spend more time on each patient and that private centres provide better attention to patients.

These are the reasons that have usually been given to justify a person spending more than 700€ a year on average on a private insurance to benefit from services they in fact have access to in the public system.

But there are also other arguments. One is to see an insurance as a salary paid in kind and another is the response people have to cuts in public health. Some companies give their employees a private insurance as a complement to their salaries, partly for tax reasons but also as an incentive for some employees and for managers. 31,6% of people insured in Catalonia in 2014 were insured by their companies.

During the period 2009-2013, while cuts were being made in public health, health insurance companies grew in Catalonia and in Spain as a whole. During this period the insurance companies raised their rates quite considerably but despite this rise, and despite a decrease in the purchasing power of families, health insurance policies didn´t so much as become cheaper but rather increased in price.

More women than men have a double cover, are between 45 and 64, have a university qualification and belong to the upper social class according to the Generalitat’s health survey. Notwithstanding, 11% are older than 75 and 10% have no higher education qualifications or only have primary education and 11,5% belong to the lower social class.

The Generalitat’s statistics tell us which services are paid for privately in hospitals. Thus, for example, 31% of births are private and a large part of surgery is private: 35% of elective surgery and 25,8% of major outpatient surgery. 26% of hospital admissions and 21% of emergencies are also private.

Some of these private services in hospitals are paid for directly by the user but the greater part is financed by health insurances. Statistics only provide us with information of hospital services but it is probable that the private part is even greater in visits to doctors and other services.

Proposals have been made in the past to offer tax incentives to people purchasing a private insurance who waive their right to have access to public services. The aim would be to reduce waiting lists in the public system. I do not think that this would work because the majority of people that have a double cover do not relinquish access to public services but rather want to be able to choose between receiving private or public care.

Double cover is a stable data in the Catalan health system. It already existed when INSALUD managed public health and continues to exist. The number of insured may vary in time but the phenomenon is constant: an important part of the population, those who can afford it, prefer being able to choose between public or private healthcare.

Nowadays, one needs the other: if there were no private healthcare, the public system would collapse; if there was not a public system, the private sector would be incapable of providing the care it does at the price it does. The usual discourse is an ideological criticism of the other, the public system criticises the private and vice versa. I think it would be better for Catalan health as a whole to reach an agreement.

Post written by Lluís Bohígas (@bohigasl), economist.

17 plus 1

14 Jan
Lluís Bohígas (@bohigasl), economist

Whenever the Spanish health system is described, the conclusion is that it consists of 17 different healthcare systems. The truth is that they are not very different as they all share a common past and the same rules inherited from the Instituto Nacional de Previsión (INP), but the discourse of diversity, (always excessive), is favoured by supporters of the new centralized model. There are, however, a significant portion of the Spanish people who do not receive healthcare cover from any of the 17 autonomous systems. These people are referred to as System 18. System 18 comprises almost 2 million Spaniards who are beneficiaries of the MUFACE, ISFAS and MUJEJU health insurance plans; in other words, senior state officials, members of the military, judiciary and their families. These individuals can choose where they want to be treated each year, either in an autonomous region, or, as in the majority of cases (80%), by a private healthcare insurance provider.

System 18 has a larger population than many of the autonomous regions in Spain. It is in fact similar in population to the Basque Country and has not been transferred to the autonomous communities, but is still managed by the state. We are unaware of all the healthcare data regarding this group: morbidity, infection, health care utilization, etc. Members of this group do not possess medical cards, electronic medical records, or use electronic prescriptions. Despite being the responsibility of the State, System 18 does not meet the criteria established by the State and required of autonomous regions. The service portfolio is similar to that available to the general public covered by Spain’s National Healthcare System, but with differences in the area of co-payments, although these differences have never been considered as inequalities. It is common for a beneficiary of System 18 to be treated in the autonomous region in the event that they require expensive medical treatment and tend to prefer the services of the NHS when they retire and make greater use of health services. When a MUFACE recipient uses an autonomous community health care system, the state is saved the expense.

System 18 is exclusively made up of civil servants who, despite all the anti-private controversy that has been unleashed, prefer private care. System 18 has been spared the health cuts inflicted on those of us whose healthcare services are provided by autonomous regions. It is possible that the members of System 18 are those responsible for deciding on the cuts to be made in public health, given that it is highly likely that the vast majority of the cabinet is made up of members covered by MUFACE.