For a Surgical Operation: 200 Pesetas

We are not the first country to wrestle with the effects of fee-for-service medicine, it seems. I recently picked up the book, The Forging of a Rebel, an autobiography of Spanish Civil War veteran Arturo Barea—and encountered the durable power of economic incentives in medical care.

First—a bit of set up. A year before the conflict breaks out, Arturo, the rebel-in-making, goes to the Casino, the drinking club for wealthier residents in the small town where he lives part-time. There, he is introduced by Jose, a servile functionary, to one of two physicians in town, Don Julian. After a brief conversation, Don Julian commands Jose:

“Jose, enter Don Arturo on the list.”

Jose produced a fat leather-bound notebook and thumbed it, giving me a glimpse of pages filled with columns of figures and headed by names.

“Now let’s see. How many are there in your family?”

“But surely I won’t have to enter all my children as members of the Casino.”

“Oh this hasn’t anything to do with the Casino. This is our local Medical Aid Association. I put you on the list and it gives you a right to medical assistance whenever you need it.”

“But I‘ve got a doctor in Madrid.”

Don Julian grunted:

“All right, if you don’t want to we won’t put you down. But I warn you, if you’ve an urgent case in your family and you aren’t a subscriber, my colleague here will send you a nice little bill. If you’ve a splinter in your thumb and he lances it, he’ll put it down as ‘for a surgical operation two hundred pesetas.’”

“And if I call you in?”

“It is he who makes the bills in any case. It would come to the same thing.”

“All right then, put me down. My wife, four children and myself. Six in all.”

“In what category please, Don Julian?”

“Don’t ask the obvious questions, Jose. In our category of course.”

“Five pesetas per month, Don Arturo. And what about your servant?”

“Isn’t she a member of your Association already?”

“Well yes, she is on our list, but she doesn’t pay. So she has been struck off. And if she has an accident at work, you have to pay.”

Don Julian sniggered:

“Say she burns her hand on the frying-pan. For a surgical operation and treatment, 200 pesetas.”

“Put the servant down, then.”

“Two pesetas. D’you want to pay now? I’m the cashier. It won’t take me a second to make out the receipts.”

Jose pocketed the seven pesetas and tripped away, to reappear with a pack of cards.

“One hundred pesetas in the bank, this deal.”

He went straight into the back room and sat in a high chair behind the biggest table.

“One hundred pesetas, boys, if nobody stakes more.” ¹

For health policy students, health care as we know it in the US in 2016 is all there in 1935 Spain—private insurance, out-of-network providers, fee-for-service medicine, differential charges, employer-sponsored health insurance, and premiums spent on risky speculation.

A year after Don Arturo’s encounter with clinician entrepreneurs and provider-sponsored insurance, the village was in tatters. In the throes of Spain’s Civil War, the working class of the town took violent revenge on Don Julian, Jose, and their peers, only to be chased by the advancing forces of Franco’s army into Madrid. There, many took refuge in squalid camps while the city was under siege for more than two years.

In the aftermath of the Civil War, perhaps humbled by the country’s experience and the ongoing suffering endured by the rest of Europe during World War II, the national government of Spain enacted broad employer taxes to better finance publicly delivered health care. In 1978, after Franco’s death, the country’s new constitution established a universal right to health care. National laws since then have developed a system of accountability for the delivery and financing of heath care, devolved to local autonomous units and built on “basic health zones” of five to 20,000 people served by a set of primary care centers sharing hospital and specialty services.

And now? Compared to the US, Spain has one-third fewer preventable deaths at about half of our per capita costs.

Faced with ever more “skin in the game,” limited provider networks, and higher premiums for less coverage, it is not likely that US patients will follow the example of the Spanish working class in the 1930s and take violent revenge on private insurers and providers. Instead, like Don Arturo, they just sigh and ante up—until they are forced to go without care.

The lessons of 1930s Spain extend beyond the perils of private health insurance schemes. They speak to the threats posed by persistent societal inequities and a loss of faith in the ability of government to curb personal greed and provide equal opportunities. They also speak to the ability of governments to implement policies that improve population health and spend public funds wisely. While we don’t have armed revolution in the US, one hopes that aggrieved citizens turn en masse to the ballot box, even if it means voting in strange and unanticipated ways.

1. Barea, Arturo. The Forging of a Rebel, Walker and Company, 2001, pp 443-4.