The Independent Authority for Fiscal Responsibility (Airef) has put forth significant proposals aimed at restructuring the Mutualidad General de Funcionarios Civiles del Estado (Muface), advocating for voluntary participation in mutual healthcare services and the progressive incorporation of new civil servants into the public health system.

These recommendations were presented during a recent analysis of administrative mutualism expenditures, amid ongoing challenges in attracting insurers willing to provide services at government-specified rates.

Cristina Herrero, president of Airef, articulated two primary proposals.

The first suggests converting the mandatory participation in the mutual system to a voluntary one, with prior consultation of beneficiaries.

Currently, civil servants must select between public and private healthcare, yet if they choose public care, they remain part of the mutualism framework, with continued contributions from both the state and the individual.

Herrero indicated that allowing a departure from mutualism when opting for the national health system could streamline expenditures and yield savings.

Airef's second recommendation is to facilitate a gradual integration of new mutualists into the national health system.

This aligns with preferences expressed by certain beneficiary groups, such as teachers, who predominantly opt for public services, particularly among younger employees.

While currently only 24% of mutualists select the national health system, this percentage rises to 70% for severe medical conditions.

Herrero noted that such an integration would not be immediate and must consider enhancing the nation's healthcare capacity and addressing existing waitlist challenges.

These findings are part of Airef's first phase of public spending analysis known as a 'Spending Review' for the period 2022-2026, which includes evaluations commissioned by central or regional governments.

The analysis principally focused on healthcare provision under Muface and support mechanisms for small and medium enterprises (SMEs) funded by the Recovery Plan.

The proposal for integrating new civil servants into the public health structure is regarded as a structural initiative aimed at increasing system efficiency, similar to the suggested transition from obligatory to voluntary mutual participation.

Herrero elaborated that if a civil servant opts out of mutualism, it would eliminate both state contributions and individual payments.

In the interim, Airef suggests implementing measures to enhance the effectiveness and efficiency of mutualism, including improvements in health information systems, such as digital medical records, and optimizing pharmaceutical spending, as private centers can charge up to six times more than public providers.

Recent developments related to Muface reveal that no insurance companies were willing to continue their participation in the upcoming 2025-2027 agreement due to adverse financial conditions.

Previous providers, including Adeslas, Asisa, and DKV, experienced aggregate losses close to 600 million euros under the prior contract.

In response to objections from insurers and pressure from labor unions to preserve mutualism, the government engaged in complex negotiations, increasing the budget for the upcoming contract to 4.81 billion euros, a 41.2% rise from previous allocations.

Following these negotiations, Adeslas and Asisa have agreed to participate in the bidding process, while DKV declined.

Muface operates under the authority of the Ministry for Digital Transformation and Public Function, providing health services to around 1.5 million beneficiaries, including civil servants and their relatives.

Participants pay a monthly fee that covers part of the overall cost, with the state covering the remainder.

Other mutualities include Isfas, serving military and civil guard personnel, and Mugeju, catering to judges, prosecutors, and judicial officials.

Airef's recommendations also extend to these mutualities.

Labor union representatives, particularly from CSIF, have expressed staunch opposition to any reductions in the mutualism model, citing its effective service delivery over decades.

They emphasized the need to ensure continued care continuity in an upcoming meeting of the General Council of Muface.

In addition to recommendations on mutualism, Airef evaluated support mechanisms for SMEs, endorsing their performance, particularly regarding guarantees and risk capital bolstered by European funds.

The authority noted that the guarantee system has been performing satisfactorily, as evidenced by the ratio of 3.1 euros in loans for every euro refinanced by Cersa, positively impacting employment and business sustainability.

Recommendations include improved coordination among institutions and enhanced tracking of national and regional aid initiatives.

Regarding risk capital, Airef highlighted the potential of multi-window mechanisms for specialized assistance, proposing enhancements in coordination.

Specific instruments like ICO-Axis are noted for their sustained positive impacts on access to bank credit, while supports from Enisa, focused on innovation projects, show favorable but sporadic results requiring further assessment.