3.4 Out of pocket payments
OOP payments play a significant role in Spain. They represented 23.9% of total health expenditure in 2015 with a growing trend since 2008.
3.4.1 Cost-sharing (user charges) and direct payments
According to the latest data from the General Household Budget Survey conducted by the INE, annual household expenditure on health rose from €14 179 million in 2006 to €18 203 million in 2015 (INE, 2017e). The average expenditure on health by household increased from €876 in 2006 to €1010 in 2008, decreasing to €895 in 2011 and increasing again to €991 in 2015. Throughout the period, the percentage of household expenditure on health increased from 2.9% to 3.6% (Table3.3). Specifically, spending on drugs and medical appliances increased both in terms of share of the family budget (1.21% in 2006 compared with 1.56% in 2015) and average expenditure, rising from €365 in 2006 to €427 in 2015 (Table3.4). The most plausible reason for this growth is the 2012 reform on pharmaceuticals cost-sharing (González López-Valcárcel & Barber, 2017). Table3.4 represents the scheme for co-payments regulated in the 2012 reform (RDL 16/2012). Basically, before 2012, outpatient drugs prescription was the only service in the statutory SNS subject to cost-sharing – 40% of the price for active workers and beneficiaries, with no caps or corrections according to income; in specific chronic disease the maximum contribution was 10%. In any case, pensioners were excluded from co-payments. The remaining services (outpatient and inpatient care, including hospital drugs dispensing) were exempted from cost-sharing. In aggregate terms, the actual contribution of co-payments to the total health expenditure fell from 15% in 1985 to 6% in 2011.16
The reform issued in 2012 (RDL 16/2012) changed the cost-sharing system. First, the system foresees cost-sharing for drug prescriptions and other benefits that are in the common supplementary and accessory package – the common basic package remains exempted. However, cost-sharing in services other than outpatient pharmaceutical prescriptions has not yet been implemented and it is not expected to be developed in the near future. Second, pensioners are not excluded from cost-sharing, albeit with a monthly payment cap. Third, the level of co-payment is linked to household income. In detail, for pensioners: (a) annual income lower than €18 000, 10% co-payment with a monthly maximum ceiling of €8.23; (b) annual income between €18 000 and €100 000, 10% co-payment with a monthly maximum ceiling of €18.52; and (c) annual income above €100 000, 60% co-payment with a monthly maximum ceiling of €61.70. With regard to active workers (this category includes unemployed covered by unemployment benefits) these divisions are: (a) those with an annual income lower than €18 000 assume 40% co-payment; (b) those with annual income between €18 000 and €100 000 bear 50% co-payment; and, (c) those with annual income above €100 000 assume 60% co-payment. No ceilings are applicable to this group. Any drugs prescribed to AIDS patients and dispensed in retail pharmacies as well as most chronic disease treatments are subject to a 10% co-payment capped at €4.26 per prescription, irrespective of whether the patients are active workers.
When it comes to direct payments, in 2015, with an average of €990.80 spent by families, payments for dental care represented 45.9% of household expenditure on health, pharmaceuticals (drug prescription co-payments and over-the-counter payments) accounted for 22% and prosthetic and medical devices (corrective lenses, orthopaedic material, etc.) reached 21% of the households budget for health (INE, 2015).
In mid-2012, the current co-payment for outpatient prescriptions underwent a major reform, with the level of co-payment for individuals becoming linked to income. Regarding active workers, those with an annual income lower than €18,000 endured 40% co-payment; those between €18,000 and €100,000, bore 50% co-payment; and those with annual income above €100,000, 60% co-payment. Notably, pensioners, once exempted, were charged with a 10% co-payment (with a monthly cap) if their annual income was below €100,000, and 60% if it was above.
On May 2020 and January 2021, new exemptions were issued. People receiving the minimum living wage (RDL 20/2020), pensioners with an annual income lower than 11,200€, people receiving social security benefits for being in charge of one child, and underage having a recognised disability of 33% or more (Law 11/2020), are now exempted of pharmaceutical co-payments. This has substantially increased exemptions, with six million people benefiting from this new policy.
More information (in Spanish):
Royal Decree Law 16/2012 https://www.boe.es/buscar/act.php?id=BOE-A-2012-5403
Royal Decree Law 20/2020 https://www.boe.es/buscar/act.php?id=BOE-A-2020-5493
Law 11/2020 https://boe.es/diario_boe/txt.php?id=BOE-A-2020-17339