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Austerity, healthcare provision, and health outcomes in Spain

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Abstract

The recession that started in the United States in December 2007 has had a significant impact on the Spanish economy through a large increase in the unemployment rate and a long recession which led to tough austerity measures imposed on public finances. Taking advantage of this quasi-natural experiment, we use data from the Spanish Ministry of Health from 1996 to 2015 to provide novel causal evidence on the short-term impact of changes in healthcare provision and regulations on health outcomes. The fact that regional governments have discretionary powers in deciding healthcare budgets and that austerity measures have not been implemented uniformly across Spain helps isolate the impact of these policy changes on health indicators of the Spanish population. Using Ruhm’s (Q J Econ 115(2):617–650, 2000) fixed effects model, we find that medical staff and hospital bed reductions account for a significant increase in mortality rates from circulatory diseases and external causes, but not from other causes of death. Similarly, mortality rates do not seem to be robustly affected by the 2012 changes in retirees’ pharmaceutical co-payments and access restrictions for illegal immigrants. Our results are robust to changes in model specification and sample selection and are primarily driven by accidental and emergency deaths rather than in-hospital mortality, which suggests a larger role for decreases in accessibility rather than decreases in healthcare quality as impact channels.

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Fig. 1

Source: Spanish NHS Statistical Site and Spanish Statistical Institute

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Notes

  1. There is, however, some controversy over the interpretation of this result. The American Journal of Public Health retracted the work of Cabrera de León et al. [62]. This paper estimated a much greater increase in mortality after the crisis, because it used different population figures, as pointed out by Hernández-Quevedo et al. [63] and Regidor et al. [17].

  2. However, there is related literature, basically concerning the United States, on the causal impact of the expansion of coverage of public health insurance (Medicare, Medicaid and the so-called Obamacare) [64] and different healthcare reforms [33, 65, 66] on health outcomes. Our study is underpinned by an institutional framework of national health systems with universal coverage that is already established; that is, it falls within the European model, not the US model.

  3. See however Russo et al. on the resilience of healthcare workers during the economic crisis [67].

  4. See the Healthcare Access and Quality Index (HAQ) 1990–2015, where Spain scored 90 points out of a maximum 100, placing it eighth in the world rankings, above the healthcare systems of Italy (89), France (88), Greece (87), Germany (86), the UK (85) and Portugal (85) [68].

  5. According to the data of the Encuesta de Presupuestos Familiares [Family Budget Survey] undertaken in 2018, one of every five Spanish households had private health insurance in 2018, with an average annual cost per household of 1227 euros (INE: Spanish Statistical Institute). This information is consistent with the data provided by Cantarero et al. on the basis of the Spanish National Health Survey (SNHS) (2011/2012) [51].

  6. The transfer of health care competencies to the autonomous regions followed the following schedule: 1981 (Catalonia); 1984 (Basque Country and Andalusia); 1987 (Valencia); 1990 (Galicia and Navarre); 1994 (Canary Islands); 2001 (Aragón, Asturias, Balearic Islands, Cantabria, Castile La Mancha, Castile León, Extremadura, La Rioja, Madrid and Murcia).

  7. Data on illegal immigrant numbers are difficult to obtain. According to the Clandestino project there were around 280,000–354,000 irregular migrants in Spain in 2008 [69]. More recent estimates for 2018 give a similar number [70]. The reform required immigrants to have a legal residence permit with three exceptions: emergency care, pregnancy care and healthcare for individuals under 18 [71].

  8. Puig Junoy et al. estimate reductions in the number of prescriptions ranging from 23.9% in Catalonia to 3.8% in Basque Country in the first 12 months [48].

  9. We investigated the possibility of using healthcare data from the National Catalogue of Hospitals, available also from the NHS Statistical Site and amenable to provincial, instead of regional, disaggregation. Data on doctors and nurses was only available from 1995 to 2009, however. Moreover, in Spain, health policy was transferred to the autonomous communities from 1981 to 2002 [44] and is, therefore, decided at the regional level. Besides, as defended by Lindo [72], given that our identification method is based on the within-location variation of healthcare provision indicators and mortality rates, potential spillovers could mean that more disaggregated analysis would severely understate the impact of healthcare provision on health outcomes. In addition, the potential problem of adverse patient selection emphasised by Gaynor et al [73], which arises under medically driven migration, is also mitigated by the use of larger geographical units. Using the region of residence meant leaving a very small number of deaths (less than 0.5%) out of the analysis, involving non-residents and for which no information on population and economic controls could be attached.

  10. We conducted the analysis for the following 3 most common causes but found no significant impacts.

  11. Robust standard errors clustered at the region level used. As noted by Cameron and Miller [74], using few clusters may understate the standard errors. We additionally estimated results with simple White robust standard errors. Estimated standard errors were systematically lower than those reported in the tables and thus are not reported.

  12. Research using more disaggregated data is needed to clarify this result.

  13. A break in the series in 2010 prevents us from replicating the analysis controlling for the proportion of hospital beds privately operated.

  14. Dropping the observations of one of the 17 regions at a time also yielded virtually identical estimated impacts in all the seventeen exercises. Results available upon request.

  15. If anything, we find that medical personnel cuts led to slightly longer, not shorter, lengths of stay.

  16. The Spanish Ministry of Health stopped inquiring about waiting lists in 2009. Using a different methodology, it has started offering waiting lists for first visits and elective surgery interventions disaggregated by region since 2012.

  17. Ischemic heart diseases include (ICD-10 code in parenthesis): angina pectoris (I20), acute myocardial infarction (I21), subsequent myocardial infarction (I22), complications following acute myocardial infarction (I23), other acute ischemic diseases (I24), and chronic ischemic heart diseases (I25). Cerebrovascular diseases include subarachnoid, intracerebral and other non-traumatic intracranial haemorrhage (I60–63), cerebral infarction and stroke (I64–I65), occlusion and stenosis of precerebral and cerebral arteries (I66–I67), and other cerebrovascular diseases (I67–I69). Other circulatory diseases include: acute rheumatic fever (I00–I02), chronic rheumatic heart diseases (I05–I09), hypertensive diseases (I10–I15), pulmonary heart disease (I26–I28), other forms of heart disease (I30–I52), diseases of arteries, arterioles and capillaries (I70–I79), other diseases of veins and unspecified disorders of the circulatory system (I80–I99). The use of broad categories of death causes minimises risks of misclassification (see note 5 above).

  18. Accidental causes include (ICD-10 code in parenthesis): transport accidents (V00-V99), burns (X00–X19), poisoning (X40–X49), falls (W00–W19) and drowning (W65–W84) and other accidents (W19–W64, W85–W99, X19–X40, X49–X59). Non-accidental causes include: suicide(X60–X84), homicide (X85–Y09), and other external causes (Y10–Y89). The use of broad categories of death causes minimises risks of misclassification (see note 5 above).

  19. Accidents usually display a pro-cyclical pattern along the business cycle [75]. Note that this fact does not contradict our finding that reductions in healthcare provision resulted in a smaller drop in the accident mortality rate during the recession.

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Funding

This work was supported by the Spanish Ministry of Economy and Competitiveness, under the projects entitled ‘The historical keys of hospital development in Spain and its international comparison during the twentieth century’ [Ref. RTI2018-094676-B-I00] and ‘Parental Background and Inequality in Children's Outcomes’ [Ref. RTI2018-098217-B-I00].

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  1. Universidad de Sevilla, Seville, Spain

    Cristina Borra & Jerònia Pons-Pons

  2. University of A Coruña, A Coruña, Spain

    Margarita Vilar-Rodríguez

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  1. Cristina Borra
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Appendix

Appendix

See Tables 4, 5, 6, 7.

Table 4 Summary stats of dependent variables.
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Table 5 Summary stats of independent and control variables.
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Table 6 Impact of health care provision on age-specific mortality.
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Table 7 Robustness checks: impact of health care provision on total, sex-, cause-, and cause and sex- specific mortality.
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Borra, C., Pons-Pons, J. & Vilar-Rodríguez, M. Austerity, healthcare provision, and health outcomes in Spain. Eur J Health Econ 21, 409–423 (2020). https://doi.org/10.1007/s10198-019-01141-3

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