Spain shows that a humane response to migrant health is possible in Europe
Authors: Helena Legido-Quigley, Leire Pajin, Gonzalo Fanjul, Elena Urdaneta, Martin McKee
Journal: The Lancet Public Health (2018)

For many years, people advocating for the right to health care of undocumented migrants looked to Spain as a positive example. The General Health Law, enacted in 1986, was based on the principle of universality. Subsequent reforms throughout the 2000s culminated with the 2011 Public Health Law, which gave an explicit right to free health care for all people living in Spain, both Spanish and migrant, irrespective of their legal status, making Spain one of the most migrant-friendly health systems in Europe. In 2012, this situation changed. The Spanish Government, acting by Royal Decree (law 16/2012), thereby bypassing the parliamentary process, restricted access to health care by undocumented migrants. Henceforth, these people were entitled initially only to emergency care, unless they were children or pregnant women, although people with tuberculosis were later also provided unrestricted access to health care. The government sought to justify this measure on economic grounds, arguing that public spending needed to be reduced in the aftermath of the financial crisis, which had badly affected Spain. However, the government did not present estimates of the sums that might be saved. Indeed, several experts argued that restricting access to health care by migrants might cost more, as easily treatable conditions progressed until people presented as emergencies, as well as increasing the risk of spread of untreated infections and antimicrobial resistance.1Legido-Quigley H Otero L la Parra D Alvarez-Dardet C Martin-Moreno JM McKee M Will austerity cuts dismantle the Spanish healthcare system?.BMJ. 2013; 346: f2363Crossref PubMed Scopus (151) Google Scholar The way the measure was introduced, coupled with the absence of a clear economic justification and the obvious moral arguments, generated widespread opposition, with critics also pointing to Spain's relatively low expenditure on health, at 7·0% of the gross domestic product, when the average in the European Union was 7·6%,2Organisation for Economic Co-operation and DevelopmentHealth statistics 2017.http://www.oecd.org/els/health-systems/health-data.htmDate: 2017Date accessed: June 20, 2018Google Scholar and when the Spanish health system was viewed as performing better than many other countries in Europe.1Legido-Quigley H Otero L la Parra D Alvarez-Dardet C Martin-Moreno JM McKee M Will austerity cuts dismantle the Spanish healthcare system?.BMJ. 2013; 346: f2363Crossref PubMed Scopus (151) Google Scholar Concerns were exacerbated by restrictions on services and increased copayments for Spanish citizens. These developments resulted in popular discontent, the creation of new social movements (eg, the White Tide), and street demonstrations. Some autonomous regions (eg, Valencia, Catalonia, and Andalusia) refused to comply with the central government, arguing that to do so could create a public health crisis. Instead, these regions continued providing services for free. In some other regions that did formally implement the Royal Decree, health-care professionals refused to comply, arguing that they still had an ethical duty to treat undocumented migrants. The available evidence suggests that the Royal Decree has severely impacted migrant populations. One study by Mestres and colleagues,3Mestres AJ López-Casasnovas G Castelló JV The deadly effects of losing health insurance. Centre de Recerca en Economia i Salut, Barcelona2018Google Scholar who looked at mortality among migrant people in the 3 years before the Royal Decree and in the period after the decree had been implemented, reported a 15% increase in the mortality rate among the migrant population. The Spanish example is thus one in which a policy on access to health care by migrants was entirely ideological. No evidence was presented to justify this change in policy, and it seems likely to have led to a substantial number of avoidable deaths. Recent developments do, however, offer hope. In June, 2018, a new Spanish government came to power, following the resignation of Prime Minister Mariano Rajoy. This government has announced that the Royal Decree will be rescinded, as will other measures that had restricted services and increased copayments. The new Health Minister has said "It is a fallacy to say that excluding migrants benefits the system."4de Benito E Seco R "Es una falacia decir que excluir a los inmigrantes beneficia al sistema".https://politica.elpais.com/politica/2018/06/08/actualidad/1528481580_056839.htmlDate: 2018Date accessed: June 20, 2018Google Scholar The new government has also made a very visible statement to the international community by granting permission to the ship Aquarius, which had been drifting in the Mediterranean with 629 migrants on board, to dock and disembark these people after they had been refused entry by Italy and Malta. In these ways, the new Spanish government is sending a clear message to the world that a humane and dignified response to migration is possible. We declare no competing interests.