Main findings of this study
In general, the percentage of people who made any medical consultation increased in 2014 with respect to 2009, in both the native and immigrant populations. Those results were due to consultations with family physicians and with public specialist physicians, since no significant differences were observed between the first and second period in the frequency of consultations with a private specialist.
In both 2009 and 2014, after adjustment for the demographic and socioeconomic variables and for the indicators of need for care, no significant differences were observed between the immigrant and native populations in the frequency of consultation with any type of physician. No were significant differences between the two populations seen in the frequency of consultation with a family physician or a public specialist physician. Only consultation with a private specialist was found to be lower in the immigrant than in the native population in both periods.
What is already known on this topic
A previous study using data from the National Health Surveys of 2006–07 and 2011–12, which aimed to evaluate the impact of the 2008 economic crisis on the use of healthcare services in Spain, observed that the use of healthcare services was no worse in the second than in the first period in either the native population or the immigrant population . The authors of the study noted that, given that the data corresponded to the period 2001–12, their investigation did not permit evaluation of the impact of the measure implemented by the Spanish government in 2012, which restricted the use of health services in undocumented immigrants. Various authors have pointed out the need to analyze the possible impact that this measure could have on the care of the immigrant population [15, 16]. The results of the present study, which used data on health services use in 2009 and 2014, show that restriction of universal health coverage has not reduced the frequency of use of health services in the in the entire population residing in Spain, natives and immigrants. Besides, the frequency of consultation with any type of physician was higher in 2014 than in 2009, an increase that was greater in the immigrant population.
According to some authors, the regional governments did not apply the measure implemented by the central government, and this could be reason for the findings in the immigrant population [17, 18]. Nevertheless, the native-born population knows better than immigrants how the healthcare system works, and this knowledge may help them to avoid entering the health system through the family physician. This could explain why the increased frequency of physician consultations in the native population was seen only for visits with public specialist physicians.
What this study adds
There are probably various reasons for the increased frequency of physician consultation. One possible explanation could be an increase in the frequency of health problems. The findings of this investigation show that the percentage of subjects with negative self-reported health and of those with some long-term disease was higher in 2014 than in 2009, both in the native and immigrant populations. However, this reported increase by respondents is implausible from the biological point of view, at least as regards physical health problems. Furthermore, it is contrary to the trend seen for other health indicators such as life expectancy, which showed a continuous increase in Spain between 2009 and 2014 . In contrast, some studies have shown an increased frequency of mental health problems in the years following the 2008 crisis [20, 21]. The estimates of the European Health Surveys used in this study also reflect this increase. The percentage of persons who reported some mental health problem in 2009 was 6% in the native population and 2% in the immigrant population, while the figures for 2014 were 7 and 4%, respectively . However, given that the increase was small, it is improbable that such an increase could explain the higher frequency of physician consultations observed.
Most studies on health services use in Spain have found a greater frequency of physician consultation in the native than in the immigrant population . Our findings are similar, both for 2009 and 2014. However, after adjusting for the different sociodemographic and need-for-care variables, no statistically significant differences were seen in the frequency of physician consultations between the immigrant and native populations, except for consultations with private specialists. This result suggests that the frequency of physician consultations may have increased for reasons other than the presence of health problems in the two study populations. For example, a large part of the reported increase in the frequency of both health problems and physician consultations in both populations could be a reflection of an increase in other social needs. Nor should we rule out a change in physicians’ clinical practice as responsible for this increase, especially in the case of the increased frequency of consultations with public specialist physicians. In fact, the information system of specialized physician care shows an increase in the number of consultations with public specialists per person and year .
The findings of the present study have great relevance. In principle, one might think that austerity policies and restrictions of access to the health system necessarily lead to a lower frequency of use of the health system. Such a thing does not have to happen, as evidenced in our study. However, from an ethical and political point of view, the achievement and maintenance of social objectives such as the human right to health care must be evaluated before the concrete results that derive from the application of those rights. Therefore, this result cannot hide that the measure adopted by the Spanish Government meant a restriction on a specific human right.
Limitations of the study
The European Health Surveys used in this study allowed us to identify the pattern in health services use by the immigrant population in Spain before and after the measure implemented by the Spanish Government in 2012. The large amount of information offered by these surveys made it possible to control in the analyses for different variables related to the use of services. It is possible that the people most affected by this measure remained outside the sampling frame of these surveys. However, the same findings are observed in the analyses performed with data from clinical information systems in primary care. Specifically, the crude analysis shows that the frequency of consultations with primary care physicians in the immigrant population is lower than that of the native-born population .
In the analyzed databases it was not possible to identify the immigrants affected by the restriction on the use of health services, so the analysis we included the entire immigrant population. It is unlikely that the significant increase observed in the frequency of consultations was due exclusively to immigrants who maintained their right to health care. Perhaps, due to the fact that the regional governments did not apply the measure implemented by the central government, all immigrants contributed to this increase.
About a quarter of the selected subjects did not respond to the survey. However, there was no difference in the response rate between native and immigrant populations. On the other hand, the measures of self-perceived health problems used in health surveys may not reflect the burden of disease in the immigrant and native populations in the same way. However, data from clinical information systems in primary care show similar results: lower frequency of health problems in the immigrant than in the native population . Likewise, it is possible that the measure implemented by the government in 2012 particularly affected the economically active population aged 16 to 64, whereas the present study included those aged 16 to 74 in order to increase the number of subjects analysed. Nonetheless, we performed the analyses with the sample of subjects aged 16–64 years, and the point estimates were similar.
The migrant population may have changed substantiallybetween 2009 and 2014 and this to some extent could have biasedthe results. However, such a thing did not happen if its place of origin is evaluated. The percentage of foreign population in Spain from Central and South America, Africa and Asia was, respectively, 37.7, 16.5 and 5.0% in 2009 and 38.5, 17.4 and 6.1% in 2014 . However, in 2014 the proportion of the immigrant population with a low level of education was higher than in 2009. Given that subjects with a lower level of education have a higher frequency of health problems and therefore a higher frequency of use of health services, it cannot be ruled out that the increase in the frequency of doctor visits in the immigrant population may be due to this fact.
Finally, our study evaluates with 2014 data the possible effect of a measure implemented in 2012. It will be of great value to check if the pattern in the frequency of consultations to the doctor has changed, based on the information provided by the new European Health Survey in Spain, whose data has been collected throughout 2019. Mainly, because in 2018 the new Central Government repealed the measure that restricted access to the health system to undocumented immigrants.