Spain, like most European nations, provides government-paid health care for its citizens, and though it spends a smaller fraction of its GDP on health care than does Germany and some other countries, its system has been considered a pretty good one. But the country has been going through some particularly tough economic times over the past several years, and one result is that the government has been slashing health care expenditures—more than 25 percent nationally over the past two years, and even more in some regions of the country. Now, reports from health care researchers are highlighting the toll these cutbacks have taken in Spain, serving as a reminder that policy and economics really do translate to population health, and sometimes in frightening ways.
Part of the problem is that Spain’s cuts do not seem to be well thought out from a health care impact point of view. Following in the footsteps of Greece, which preceded and has so far outdone Spain in running into severe economic difficulty, Spain has singled out its large immigrant population for many of the cutbacks, including access to vaccines and other basic services. Aside from the obvious and disturbing humanitarian considerations of this sort of policy, it is also an irrational policy from a simple health economics point of view. As The Economist put it in a recent blog post
Not vaccinating the children of migrants....is not only mean, but also inefficient. It is much cheaper to vaccinate than to deal with the outbreak of a contagious disease....The price tag of controlling a TB outbreak in New York City in the 1990s, a whopping $1.2 billion, proved the value of prevention, which would have cost an estimated one-tenth of that and saved much misery in the process.
Some of the likely dire and inequitable consequences of these cutbacks are laid out in the research reports, which are from the London School of Hygiene and Tropical Medicine. One of the reports, described in a blog post from the school, notes of Spain that
873,000 non-residents have lost entitlement to comprehensive care as a result of the decree, and the authors warn that these changes could have “serious consequences for population health, especially with regard to tuberculosis and HIV infections, and could threaten access to mental health, addiction, and chronic care services for vulnerable populations, such as the homeless.”
(In my last post here I myself noted that universal health care is not such a wonderful thing—nor is it “universal,” for that matter—if it excludes chunks of the resident population.)
An awful irony of this sort of policy is that it cuts health care to the very people who most need it, and at a time when there are more of them who need it, because of the economic hardships. As another blog post from the London School of Hygiene notes, Spain’s cuts are
particularly affecting the elderly, disabled and those with poor mental health....[and follow an] increase in depression, alcohol related disorders and suicides in Spain since the financial crisis hit and unemployment increased.
The same post also notes that the cuts were made without the benefit of good evidence that they would maximize savings while minimizing harm, and that they could lead to a “rise in drug resistance and spread of disease.”
In a way, it almost feels unfair to pick on Spain. The fact is, many countries could easily end up in similar positions if their economies go far enough south on them. That’s because even though the health care systems of many nations seem to be adequate and well-managed, as Spain’s did, they actually lack “capacitance”—that is, resilience to shocks to the system. A sudden surge in demand, rise in costs, or drop in resources can send the system into a tailspin from it which it can’t easily recover.
Capacitance is often poor when a system is operating on resources that are stretched thin, and lacks the flexibility and depth to reorganize itself around a change in the health landscape. A system with sufficient capacitance retains in a crisis the means—through some combination of good management, good policy and sufficient human and economic resources—to deal with blows to the system. It’s hard to measure capacitance, and sometimes you find out it’s lacking when a crisis strikes.
It’s probably true that the U.S. health care system, for all its shortcomings, has a fairly high capacitance. But that’s not to say that the U.S. and other heavily industrialized countries with relatively strong economies and high-capacitance health care systems aren’t vulnerable to catastrophic public health crises. For one thing, the personal behavior of Americans—driven, ironically, by our affluence—has led to a crisis of obesity, which is stealing an average decade of life from a third of the population. Our medical system hasn’t begun to come to grips with that. What’s more, many Americans are choosing to avoid vaccinating their children over ungrounded fears that vaccines cause, rather than prevent, serious health problems.
Economic difficulty isn’t the only road to a plunge in population health. But it’s probably a better excuse for one than not taking care of ourselves when we have the means for doing so.