Political economy of health system reform: evidence from Spain

This chapter discusses mainstream insurance reform using an analysis of the Spanish health care reform and its public administration despite being decentralized. We look at the debate on how to get extra finance for the system, either from taxes, complementary premiums, co-payments or direct prices. We see it is resolved in favour of taxes because of the identification of taxes with solidarity and co-payments with inequality. All the above is at the root of the difficulty in implementing financial reforms, leaving the system in a situation where the new is thwarted from being born and the old refuses to die. The stress test that is the pandemic has thrown many of the inertias observed up in the air, leaving us with the incognito of the future of our health system. As a result of these features, the system is “trapped” in its status quo, mostly at the hands of professional corporations, trade unions and stakeholders in general (industry, academy, policymakers, groups of patients).