What happens when you restrict access to the public health care system for immigrants?

February 19, 2019

By Dolores Jiménez-Rubio and Judit Vall Castelló

There has been increasing recent debate on whether and to what extent certain sectors of the immigrant population, for example undocumented immigrant and mobile EU workers, should get access to welfare benefits and public services. This political debate has not been fully informed by academic research. Our latest paper – which is part of work package 5 of the REMINDER project – explores a reform that was introduced in Spain in 2012 and that imposed restrictions in access to health services for the undocumented immigrant population in order to shed light on this issue.

After four years of economic downturn, the Spanish government introduced a law that changed the nature of the health care system in the country, turning a universal health care system into a targeted one. In April 2012, several aspects of the health system were redefined, including the beneficiaries, the universal nature of the system, the gratuity of all services and other cost containment measures (Gallo & Gené-Badia, 2013). The 2012 law specifically linked entitlement to contribution to the system, thus excluding a large group of undocumented immigrants from receiving health care. Emergency, maternity and child care were the only services which undocumented immigrants were able to access on the same terms as Spanish nationals. At the same time, the government announced alternative health care plans for undocumented immigrants, which have since proven to be unaffordable and even more expensive than existing private insurance plans in Spain (Nuño-Solinís, 2016).

Several reports have documented the existence of obstacles to health service access by population groups that, in theory, are unaffected by the law, such as children, and in some cases even impediments to access to emergency care by undocumented immigrants (Nuño-Solinís, 2016). The new reform has also been accompanied by substantial confusion about the terms of the restrictions, not only among the targeted population but also among doctors and other stakeholders in the system.

In our paper, we focus on the impact of this reform on health care utilisation, satisfaction and self-reported health status. We first compare the impact of the reform on undocumented immigrants vis-à-vis Spanish nationals. Secondly, in view of the fact that some regions refused to apply the new regulation, we compare the health care outcomes of undocumented immigrants across regions. Finally, we compare access to the health care system by region and by immigrant status, before and after the reform.

Our results highlight important reductions in planned care by undocumented immigrants which do not seem to be fully compensated by higher emergency care use by this population. In addition, the findings reflect a sharp decrease in levels of satisfaction with the emergency services which since the reform constitute the only health resource available to undocumented immigrants. These results suggest that restrictions on access to health care can have major health and well-being effects on those affected by the restrictions. With the reported sharp drop in planned care which includes regular screening tests for early detection of diseases as well as treatment of existing diseases, the incidence of diseases and the associated mortality will most probably increase for this population. Furthermore, there could be spillover effects to other parts of the population, such as the native population, if contagious diseases are also rising due to the lack of adequate treatment.

These results are important, especially in the context of discussions currently taking place in various countries on restricting access to health care services for certain sub-groups of the population or in the case of the EU limiting access to healthcare and other public services for EU mobile workers.

You can read the paper here.


About the authors

Dolores Jiménez Rubio is Associate Professor Department of Applied Economics at the University of Granada, Spain.

Judit Vall is Assistant Professor Department of Economics at the University of Barcelona, Spain.


Gallo, P., Gené-Badia, J. (2013). Cuts drive health system reforms in Spain. Health Policy, 113(1), 1-7.

Nuño-Solinís, R. (2016). Working Paper: Spatial dimension of solidarity: from local to transnational acts & practices. Case study description on health. Available online from

Latest Tweets

Unable to load Tweets

Signup to our newsletter

Enter your email address to get the latest news direct to your inbox