board annual increases unrelated to merit,
The mean waiting time for a prostectomy is 62
days; for hip replacement surgery, 123 days.115
performance, or patient satisfaction.123
Some health services that U.S. citizens take
As a result, Spain has fewer physicians and
for granted are almost totally unavailable. For
fewer nurses per capita than most European
example, rehabilitation, convalescence, and
countries and the United States. The lack of
primary care physicians is particularly acute.124
care for those with terminal illness are usually
left to the patient's relatives. There are very few
Even so, Spaniards are generally happy
public nursing and retirement homes, and few
with their system. Nearly 60 percent describe
hospices and convalescence homes.116
their system as good, the second highest favor-
ability rating in Europe. (France was first.)125
As with most other national health care sys-
tems, the waiting lists and quality problems
Accordingly, health care reform does not rank
have led to the development of a growing pri-
high on the average Spaniard's political agen-
vate insurance alternative. About 12 percent of
da. One observer described health care as
the population currently has private health
"conspicuous by its absence as a major issue"
in recent elections.126 Only about 46 percent of
insurance. (This amounts to double coverage
since opting out of the government system is
Spaniards describe the need for reform as
not allowed.117) In larger cities such as Madrid
"urgent," while 35 percent see reform as "desir-
able." And Spaniards are less inclined toward
and Barcelona, the number of privately insured
market-based reforms than most other
reaches as high as 25 percent. Overall, private
European countries. Only 42 percent of
insurance payments account for 21 percent of
total health care exenditures.118 More com-
Spaniards believe that it should be easier for
patients to spend their own money on health
monly, Spaniards pay for care outside of the
care, and only 58 percent believe that giving
national health care system out of pocket. In
patients more control over spending will
fact, nearly 24 percent of health care spending
improve quality. However, Spaniards do want
in Spain is out of pocket, more than any
more choice of doctors and hospitals, and
European country except Greece and Switzer-
land, and even more than the United States.119
they want the government to do a better job of
dealing with waiting lists.127
Here again, a two-tier system has devel-
oped, with the wealthy able to buy their way
around the defects of the national health care
Japan
system, and the poor consigned to substan-
dard services.120
There are also shortages of modern medical
Japan has a universal health insurance sys-
Spain has fewer
technologies. Spain has one-third as many
tem centered primarily around mandatory,
MRI units per million people as the United
employment-based insurance. On the surface,
physicians and
States, just over one-third as many CT units,
Japan's national health insurance program
fewer nurses per
and fewer lithotripters.121 Again, there is wide
defies easy description, comprising some
capita than most
2,000 private insurers and more than 3,000
variation by region. For example, two regions,
government units. However, in a broader
Ceuta and Melilla, do not have a single MRI
European
unit.122 The regional variation is important
sense, the system encompasses four principal
countries and the
insurance schemes.
because Spaniards face bureaucratic barriers in
The Employee Health Insurance Program
trying to go to another region for treatment.
United States.
requires companies with 700 or more
All hospital-based physicians and approx-
The lack of
employees to provide workers with health
imately 75 percent of all other physicians are
primary care
insurance from among some 1,800 "society-
considered quasicivil servants and are paid a
managed insurance" plans. Nearly 85 percent
salary rather than receiving payment based
physicians is
of these plans cover a single company and
on services provided. Compensation is based
particularly
can be thought of as similar to the self-insur-
on years of practice or the attainment of cer-
acute.
ance plans operated by many large U.S com-
tain professional credentials, with across-the-
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