In recent months, debates about the future of Spain’s healthcare system have reignited. The catalyst was a series of high-profile statements made by Ribera Salud executive Pablo Gallart at the Torrejón de Ardoz hospital. His remarks about medicine as a business sparked a wave of outrage and revived discussion about two opposing approaches to organizing healthcare. One is the private, profit-driven model; the other is the public system, established nearly forty years ago with the participation of Ernest Lluch, who served as Health Minister in the 1980s and played a key role in shaping Spain’s current healthcare structure.
When comparing these two approaches, it is clear that despite its shortcomings, Spain’s public healthcare remains one of the most effective systems in Europe. Looking at the experience of the United States, where healthcare is mostly private, the difference is striking. Americans spend more than twice as much on healthcare as Spaniards, yet have an average life expectancy six years shorter. Moreover, the US has a much higher mortality rate from illnesses that could be treated with timely medical care, and overall public health outcomes are considerably worse.
What is particularly concerning is that for many American families, medical expenses have become a leading cause of bankruptcy. Statistics show that two-thirds of personal bankruptcies in the US are linked to medical debt, affecting nearly 40% of the adult population. Such an experience is hardly one for Spain to emulate, where access to healthcare remains universal.
Privatization experiments
Despite the clear advantages of the public system, Spain has attempted to introduce elements of private management. One such experiment was the hospital project in Alzira, initiated by the then-ruling Partido Popular. Officially, it was presented as a public-private partnership aimed at boosting efficiency and reducing costs. In practice, however, expenses only increased: in 2002, the regional budget allocated €225 per patient, but by 2017, this amount had risen to €777. Meanwhile, the concession proved unprofitable, and the state was forced to pay more than €25 million extra.
The promised improvements in service quality never materialized. In fact, many processes—from equipment procurement to lab tests and hospitalization—were controlled by subsidiaries of a single company. This concentration of power resembled the practices of large American healthcare conglomerates, where a handful of corporations effectively set the rules for the entire market.
The American experience
In the US, the process of monopolization has gone even further. Just three companies control 80% of the prescription drug market, while the largest healthcare corporations wield enormous influence over legislation. They spend hundreds of millions of euros lobbying for their interests, funding election campaigns and politicians’ advertising. As a result, it is businesses that dictate terms to the government, not the other way around.
In Spain, a similar situation has not yet developed, but certain signs are already evident. After the hospitals of Alzira, Torrevieja, and Dénia returned to public management, private companies filed dozens of lawsuits against regional authorities. There were 26 legal proceedings recorded in Alzira alone, 20 in Torrevieja, and 19 in Dénia. This posed a significant challenge for officials who decided to bring healthcare back under state control.
Politics and business
Particular attention is drawn to the situation in Madrid, where private healthcare companies are closely linked to politicians. An example is businessman González Amador, partner of regional head Isabel Díaz Ayuso, and his connections with the management of Quirón, the largest private operator in the capital. His achievements in legal and political matters raise questions about the transparency of relationships between authorities and the healthcare business.
There are growing concerns that the Madrid model is starting to resemble the American one, where corporate interests take precedence over the public good. This worries supporters of public healthcare, who believe that access to treatment should not depend on income or connections.
The Spanish approach
In the Valencian Community (Comunidad Valenciana), the process of returning hospitals to public control was accompanied not only by legal battles but also by political pressure. Officials making unpopular decisions faced personal attacks and prolonged investigations. However, for many residents, these steps became a guarantee of maintaining accessible healthcare for all.
The future of Spain’s healthcare system remains uncertain. On one hand, there are examples of unsuccessful privatization attempts and negative experiences from other countries. On the other, pressure is mounting from businesses and some politicians interested in changing the current system. Only time will tell which path Spain will choose.
