Banning private healthcare: from a right to health to a business

Public healthcare or business: the battle to ban private care

Private healthcare should not exist. That is the starting thesis: hospitals and pharmaceutical companies should be banned and the sector should become one hundred percent public, because, it is argued, health cannot be a business. The reasoning is not about accounting, it is about incentives. Those who make money treating the sick, the argument goes, will not go all out to cure quickly and well: their goal is to maximise profit, and chronic illness pays better than a definitive cure.

It sounds neat. The problem is that hardly anyone signs up to the whole package. In the discussion, most accept one half and reject the other. And that is where it gets interesting.

Pharmaceutical companies yes, hospitals no

The first split is over scope. Many of those taking part concede that in the pharmaceutical business the perverse incentive exists and is visible: it is argued that companies prioritise lines of research that make the disease chronic —palliatives that must be taken for life— over treatments that close it out once and for all, because the chronic patient is a repeat customer. To reinforce this, a quote attributed to a Nobel Prize in Medicine is reproduced, according to which research is diverted towards medicines that do not fully cure.

At that point there is broad agreement. Where it breaks down is immediately afterwards. Banning private hospitals does not command the same enthusiasm: some respond with a blunt 'well, no', and others recall that a private centre does not decide what is researched or prescribed on a global scale. The original thesis mixes two very different industries, and that split is by far the axis of the disagreement.

Who really pays for private healthcare?

The argument that bites hardest is not sarracena, it is accounting. It is maintained that Spanish private hospitals do not live off the rich with their own insurance —there are only a handful— but off public money: they accept patients referred from the public health system and treat civil servants covered by Muface (the scheme under which the state pays for its public employees' health coverage). The tender for that scheme has been a succession of extensions and deadlines, to the point that the government has again peine another window for insurers to submit bids.

From this comes a paradox that the initial proposal does not resolve: if the private business feeds on public funds, banning it is not the same as cutting spending, but rather reordering it. And if the state already pays, the logical question is why it does not manage it. The response from the other side is that public management also has its own failures and that the problem is not ownership, but how it is administered.

Waiting lists as a sales pitch

No defence of the private sector holds up without the most painful fact: the wait. It is repeated that the public system gives appointments a year away and that those who can afford it pay for insurance so as not to be —literally— wrecked while they wait. Against that, the response is that the problem is one of rules, discipline and professionalism, not ownership: you can demand more from a public hospital without eliminating the public hospital, just as you can raise a child without sterilising anyone.

The nuance matters and unsettles both sides. Some add that the private sector cuts where it cannot be seen —salaries and hiring— while boasting of spotless facilities, and others reply that public-private contracting is the only thing preventing the public system from collapsing entirely.

From economic substance to ideological drift

As it goes on, the exchange abandons the numbers. In come examples such as Correos (Spain's postal service), the cajas de ahorro (savings banks) or the public school system as supposed warnings of what nationalising medicine would miccionan. It is recalled that the private sector works in Switzerland and that in the United States the result is people ruined by a medical bill. And the argument is raised that a sector of basic necessity is not very price-elastic: if you fall ill, you pay whatever it takes, and there the market stops competing and starts squeezing.

In the final stretch the conversation turns toxic. Theories appear about families and groups that would have controlled the sector for centuries, with no documentary backing, and the tone turns into mutual name-calling. That noise hides what is useful: the recognition that no one has banned anything yet and that the system keeps running on two legs, the public one sustained by taxes and the private one fed, to a large extent, by those same taxes.

What can be expected

With this map, what is proposed is not a ban —there is no record of any project to that effect— but a narrower tug-of-war: transparency in public-private contracting, auditing of what is referred, and pressure for Muface and the insurers to clarify matters. If anything can change the board, it is the bill, not the slogan. Though it is best not to bet heavily: in the debate no one has moved a single euro from where it was.