La salud como derecho: sistemas sanitarios en el mundo

It is genuinely hard to explain to people outside the country how it works, or why it is the way it is.

A ver, yo lo intento explicar a mis lectores y siempre es difícil.

Well, I try to explain it to my readers and it's always difficult.

Estados Unidos gasta más dinero per cápita en salud que cualquier otro país del mundo, más que Alemania, más que Suecia, más que España.

The United States spends more money per capita on health than any other country in the world, more than Germany, more than Sweden, more than Spain.

Y sin embargo, millones de personas no tienen cobertura adecuada.

And yet, millions of people don't have adequate coverage.

Es una paradoja enorme.

It's an enormous paradox.

The number I always come back to is this: the U.S.

spends about seventeen percent of its GDP on healthcare.

Spain spends around ten.

And by most outcome measures, life expectancy, infant mortality, chronic disease management, Spain does as well or better.

That should stop everyone in their tracks.

Mira, la razón principal es que en los sistemas privados, hay muchos intermediarios que ganan dinero: las compañías de seguros, los hospitales privados, las farmacéuticas con precios sin control.

Look, the main reason is that in private systems, there are many intermediaries making money: insurance companies, private hospitals, pharmaceutical companies with uncontrolled prices.

En un sistema público, el Estado puede negociar precios directamente.

In a public system, the state can negotiate prices directly.

Tiene mucho más poder de negociación.

It has much more bargaining power.

Here's what gets me, though.

The U.S.

didn't land in this situation by accident.

There were specific moments, specific decisions.

The defeat of Truman's national health plan in the late forties.

The compromises around Medicare in sixty-five.

And every time, the same coalition of interests pushed back.

Es que la historia importa mucho en este tema.

History really matters a lot in this topic.

En Europa, los sistemas de salud se construyeron en gran parte después de la Segunda Guerra Mundial, cuando había un consenso social enorme sobre la responsabilidad del Estado.

In Europe, healthcare systems were largely built after World War II, when there was an enormous social consensus about the responsibility of the state.

En Estados Unidos, ese momento nunca llegó de la misma manera.

In the United States, that moment never arrived in the same way.

La cultura política era diferente.

The political culture was different.

And then the National Health Service in Britain, which is the other great model, that was built on exactly that postwar moment.

Nineteen forty-eight, Clement Attlee's government, and this idea from William Beveridge that healthcare should be free at the point of use for everyone.

It was a genuine rupture with everything that came before.

Bueno, y el modelo Beveridge influyó directamente en España, en Suecia, en Canadá, en muchos países.

Well, and the Beveridge model directly influenced Spain, Sweden, Canada, many countries.

La idea es simple pero radical: la salud no debe depender de cuánto dinero tienes.

The idea is simple but radical: your health should not depend on how much money you have.

Es un derecho, no un privilegio.

It's a right, not a privilege.

Esa es la base filosófica de todo.

That's the philosophical foundation of everything.

So then COVID comes along, and it stress-tests every single one of these systems simultaneously.

And I covered the early months of the pandemic pretty closely, and what was striking was how differently countries responded, and how much those differences came down to what they had built beforehand.

España lo pasó muy mal al principio, hay que ser honesto.

Spain had a very hard time at the beginning, we have to be honest.

El sistema estaba debilitado por los recortes de la crisis de 2008.

The system had been weakened by the cuts from the 2008 crisis.

Pero la estructura fundamental del sistema público permitió una respuesta coordinada que un sistema fragmentado como el americano no puede hacer tan fácilmente.

But the fundamental structure of the public system allowed for a coordinated response that a fragmented system like the American one can't do as easily.

Cuando el Estado controla la red, puede movilizarla.

When the state controls the network, it can mobilize it.

I want to push back on that slightly, because the U.S.

actually moved extraordinarily fast on vaccine development.

Operation Warp Speed, whatever you think of the politics around it, produced effective vaccines in under a year.

The market can move fast when the incentives are there.

La verdad es que no discuto eso.

The truth is I don't dispute that.

La innovación farmacéutica en Estados Unidos es impresionante.

Pharmaceutical innovation in the United States is impressive.

El problema no es la investigación, es el acceso.

The problem isn't the research, it's the access.

Puedes desarrollar la mejor vacuna del mundo, pero si millones de personas no tienen acceso al sistema sanitario, la distribución se complica enormemente.

You can develop the best vaccine in the world, but if millions of people don't have access to the healthcare system, distribution becomes enormously complicated.

Right.

And that tension, innovation versus access, that's actually one of the central arguments against fully public systems.

The critique you hear most often is: universal systems are great for routine care, but they're slow to adopt new treatments, they have waiting lists, they ration care in ways that feel uncomfortable.

A ver, las listas de espera son un problema real en España, no voy a negarlo.

Look, waiting lists are a real problem in Spain, I'm not going to deny it.

Para una operación de rodilla o para ver a un especialista, puedes esperar meses.

For a knee operation or to see a specialist, you can wait months.

Eso es frustrante.

That's frustrating.

Pero la pregunta es: ¿cuál es la alternativa?

But the question is: what's the alternative?

En el sistema americano, no hay lista de espera si tienes dinero.

In the American system, there's no waiting list if you have money.

Si no tienes dinero, esperas para siempre o no te atiendes.

If you don't have money, you wait forever or you don't get treated.

That's a fair point.

And the waiting list problem is also partly a political choice about how much you fund the system.

The NHS in Britain has been chronically underfunded for years, and the waiting lists have exploded.

Spain cut health spending significantly after 2008 and paid for it in capacity.

These aren't failures of the model, they're failures of political will.

Sí, y ahí viene el debate sobre la privatización.

Yes, and that's where the privatization debate comes in.

En los años de la crisis, algunas comunidades autónomas en España empezaron a externalizar servicios sanitarios a empresas privadas.

During the crisis years, some regional governments in Spain started outsourcing healthcare services to private companies.

La Comunidad de Madrid fue la más agresiva en esto.

The Community of Madrid was the most aggressive about this.

Hubo protestas enormes.

There were enormous protests.

Los médicos salieron a la calle.

Doctors took to the streets.

I remember covering those protests peripherally in 2012.

And what struck me was that it wasn't just the usual left-wing suspects.

You had senior consultants, surgeons, people who vote conservative, out there in their white coats.

Because the argument wasn't ideological, it was practical: you're going to break something that works.

Exacto.

Exactly.

Y mira, la sanidad privada tiene su papel.

And look, private healthcare has its role.

En España, mucha gente tiene también un seguro privado para evitar las listas de espera.

In Spain, many people also have private insurance to avoid waiting lists.

El sector privado y el público coexisten.

The private sector and the public sector coexist.

El problema es cuando el gobierno debilita lo público para que la gente no tenga otra opción que ir a lo privado.

The problem is when the government weakens the public system so that people have no choice but to go private.

Eso sí es una trampa.

That is a trap.

The thing is, this isn't just a European debate.

Let's talk about Latin America for a moment, because the picture there is incredibly varied and I think it gets overlooked.

You spent time in Buenos Aires and Mexico City.

These are countries with very different approaches.

Bueno, en América Latina la situación es muy compleja.

Well, in Latin America the situation is very complex.

Cuba tiene un sistema de salud pública universal con resultados sorprendentes en esperanza de vida, a pesar de las limitaciones económicas enormes.

Cuba has a universal public health system with surprising results in life expectancy, despite enormous economic limitations.

Costa Rica tiene uno de los mejores sistemas de salud de la región.

Costa Rica has one of the best healthcare systems in the region.

Brasil tiene el Sistema Único de Saúde, que es universal en teoría pero con grandes desigualdades en la práctica.

Brazil has the Sistema Único de Saúde, which is universal in theory but with great inequalities in practice.

Cuba is always the uncomfortable example in this conversation.

Because it's a country with real political repression and genuine poverty, and yet its healthcare outcomes are comparable to much richer countries.

And I've been to Havana, I've seen the hospitals, and the picture is complicated.

There's a two-tier reality there that doesn't fit any simple narrative.

Sí, la salud en Cuba es un caso fascinante y contradictorio.

Yes, healthcare in Cuba is a fascinating and contradictory case.

Lo que sí es cierto es que han invertido muchísimo en medicina preventiva y en formar médicos.

What is true is that they have invested enormously in preventive medicine and in training doctors.

Tienen más médicos per cápita que casi cualquier país del mundo.

They have more doctors per capita than almost any country in the world.

Eso no justifica el sistema político, pero tampoco se puede ignorar como dato.

That doesn't justify the political system, but you can't ignore it as a fact either.

So that brings up the preventive care question, which I think is where the real argument for universal systems is strongest.

Because if you have a system where people avoid the doctor because of cost, you end up treating conditions at a much more advanced, and much more expensive, stage.

Mira, hay estudios que demuestran que en Estados Unidos muchas personas evitan ir al médico porque no pueden pagar la consulta.

Look, there are studies that show that in the United States many people avoid going to the doctor because they can't pay for the visit.

Y entonces lo que era una infección tratable se convierte en una emergencia que cuesta diez veces más.

And then what was a treatable infection becomes an emergency that costs ten times more.

Es económicamente irracional, además de ser injusto.

It's economically irrational, as well as being unjust.

I want to talk about the pharmaceutical industry specifically, because it's a huge piece of this puzzle.

Drug pricing is where the American system looks most indefensible from the outside.

The same insulin that costs thirty dollars in Canada or Spain can cost three hundred dollars in the U.S.

It's the same product.

Es que eso es el resultado directo del poder de negociación que te mencionaba antes.

That is the direct result of the bargaining power I mentioned before.

En España, el Ministerio de Sanidad negocia directamente con las farmacéuticas el precio de cada medicamento.

In Spain, the Ministry of Health negotiates directly with pharmaceutical companies the price of each medication.

Las empresas prefieren vender a un precio más bajo que no vender nada.

Companies prefer to sell at a lower price than to sell nothing at all.

En Estados Unidos, durante años el gobierno federal no podía negociar precios para Medicare.

In the United States, for years the federal government couldn't negotiate prices for Medicare.

Era literalmente ilegal.

It was literally illegal.

It was, and that provision was written into the Medicare Modernization Act in 2003 by a Congress that was heavily lobbied by the pharmaceutical industry.

It's one of those legislative moments that's almost impossible to explain to someone outside the system without sounding like you're making it up.

La industria farmacéutica es poderosa en todas partes, no solo en Estados Unidos.

The pharmaceutical industry is powerful everywhere, not just in the United States.

En Europa también hay presión.

In Europe there is pressure too.

Pero la diferencia es que los sistemas públicos tienen más herramientas para resistir esa presión.

But the difference is that public systems have more tools to resist that pressure.

Pueden decir: si no bajas el precio, simplemente no incluimos tu medicamento en la lista de medicamentos financiados por el Estado.

They can say: if you don't lower the price, we simply won't include your medication on the list of state-funded drugs.

Here's something I don't think gets enough attention in this debate: mental health.

Because in almost every country, public or private, mental healthcare is the stepchild of the system.

It's underfunded, stigmatized, and the gap between physical healthcare and mental healthcare is enormous.

Tienes razón, y en España es un problema serio.

You're right, and in Spain it's a serious problem.

La sanidad pública tiene muy pocos psicólogos para la demanda que hay.

The public healthcare system has very few psychologists for the demand that exists.

Muchas personas que necesitan apoyo psicológico no pueden pagarlo en el sector privado y no reciben ayuda en el público.

Many people who need psychological support can't pay for it in the private sector and don't receive help in the public one.

Es una deuda pendiente del sistema.

It's an outstanding debt of the system.

La pandemia lo hizo mucho más visible.

The pandemic made it much more visible.

So let's talk about the future, because all of these systems, whatever model they use, are facing the same structural pressures.

Aging populations, more chronic disease, more expensive treatments, and in many countries, a shrinking working-age population that's supposed to fund everything.

A ver, el envejecimiento de la población es el gran desafío de todos los sistemas sanitarios europeos.

Look, population aging is the great challenge of all European healthcare systems.

En España, la proporción de personas mayores de sesenta y cinco años va a ser enorme en las próximas décadas.

In Spain, the proportion of people over sixty-five is going to be enormous in the coming decades.

Eso significa más gasto en enfermedades crónicas, en cuidados de larga duración, en demencia.

That means more spending on chronic diseases, long-term care, dementia.

El sistema tiene que adaptarse.

The system has to adapt.

And one thing that rarely gets discussed honestly in Europe is the role that immigration plays in sustaining these systems.

Because a younger workforce, paying taxes, paying into social security, is part of how you fund healthcare for an aging population.

That's not a political opinion, it's arithmetic.

Bueno, la inmigración y la sanidad es un tema políticamente muy caliente en España ahora mismo.

Well, immigration and healthcare is a politically very hot topic in Spain right now.

Hay partidos que dicen que los inmigrantes sin papeles no deberían tener acceso a la sanidad pública.

There are parties that say undocumented immigrants should not have access to public healthcare.

Pero la realidad es que los inmigrantes en general son más jóvenes y más sanos que la población media, y cuando trabajan, contribuyen al sistema.

But the reality is that immigrants are generally younger and healthier than the average population, and when they work, they contribute to the system.

Es una discusión que a veces ignora los datos.

It's a discussion that sometimes ignores the data.

Spain actually reversed a policy in 2012 that had excluded undocumented immigrants from the public health system, right?

And then reversed the reversal.

That back and forth tells you everything about how politically charged this is.

Sí, exactamente.

Yes, exactly.

El gobierno del PP en 2012 excluyó a los inmigrantes irregulares.

The PP government in 2012 excluded undocumented immigrants.

Después el gobierno del PSOE lo restauró en 2018.

Then the PSOE government restored it in 2018.

Desde el punto de vista de la salud pública, tiene mucho más sentido incluir a todo el mundo, porque las enfermedades no preguntan si tienes papeles.

From a public health point of view, it makes much more sense to include everyone, because diseases don't ask whether you have papers.

Which brings me to what I think is the deeper philosophical fault line in this whole debate.

Is healthcare a right or a service?

Because if it's a right, then the funding question is secondary, you find the money.

But if it's a service, then it's subject to market logic, and access depends on what you can pay.

Es que en España esa pregunta está respondida en la constitución.

In Spain that question is answered in the constitution.

El artículo cuarenta y tres reconoce el derecho a la protección de la salud.

Article forty-three recognizes the right to health protection.

No es un debate filosófico abstracto, es un compromiso legal.

It's not an abstract philosophical debate, it's a legal commitment.

La diferencia con Estados Unidos es que allí nunca se estableció ese derecho en la Constitución, y eso ha marcado todo lo que ha pasado después.

The difference with the United States is that there that right was never established in the Constitution, and that has shaped everything that has happened since.

No, you're absolutely right about that.

And I think that's the single most important structural difference.

When you build the right into the founding document, it constrains what future governments can do.

It changes the terms of the debate for generations.

La verdad es que el modelo que un país elige no es solo sobre medicina.

The truth is that the model a country chooses is not just about medicine.

Es sobre qué tipo de sociedad quieres ser.

It's about what kind of society you want to be.

Si crees que una persona no debería arruinarse económicamente por tener cáncer, entonces construyes un sistema de una manera.

If you believe that a person shouldn't be financially ruined for having cancer, then you build a system one way.

Si crees que cada uno es responsable de su propio destino, lo construyes de otra.

If you believe everyone is responsible for their own fate, you build it another way.

Es una decisión de valores, no solo de economía.

It's a decision about values, not just economics.

And I think that's where we should leave it, honestly.

Not with a verdict, because this conversation doesn't have a simple verdict.

Every model has real trade-offs.

But what I find, after all these years of watching it from the outside and living it as an American, is that the countries that decided health is a right tend to sleep better at night.

And that's not nothing.

Mira, estoy de acuerdo.

Look, I agree.

Y cada vez que alguien en España se queja de las listas de espera o de que el médico de cabecera está saturado, yo pienso: tienes razón, hay que mejorar esto.

And every time someone in Spain complains about waiting lists or that their GP is overwhelmed, I think: you're right, we need to improve this.

Pero también piensa en la alternativa.

But also think about the alternative.

Piensa en la persona que en otro país tiene que elegir entre pagar el alquiler o ir al médico.

Think about the person in another country who has to choose between paying rent or going to the doctor.

Ese miedo no existe aquí, y eso es algo que no podemos perder nunca.

That fear doesn't exist here, and that's something we can never afford to lose.