Comparative Study of Health Systems: Germany and Spain How the Economic Crisis Has Affected Immigrant Access

to Care Tarra Theisen Summer Quarter 2013

I. ABSTRACT The question regarding access to healthcare as a basic human right has been a central topic of political debate in the United States, particularly in recent years. Healthcare policies in the US are constantly evolving, as is access for underserved populations and attitudes toward those requiring care. With this in mind, our group was intent on exploring the similarities and differences between the US and the two countries we visited this summer, Germany and Spain. Both countries healthcare policies are far different from those in our home country, and for this reason our research proved very interesting. Our group was interested in factors that affect healthcare access, both in terms of economic policies and other social issues, in the two new cultures we experienced. While governmental policies directly affect healthcare access, other factors such as unemployment, cultural differences, education, and mental health can limit ones access to basic needs. We approached this question from three different perspectives. Jane focused on the micro level of patient-doctor interaction and the possible effects of cultural differences. The understanding between patient and doctor is crucial in delivering effective quality of care, as well as expanding equal healthcare access for all. Cultural differences often influence and define the nature of interactions. With increasing globalization and immigrant population in the U.S., Germany, and Spain, strained interactions and cultural insensitivity can decrease healthcare access. Through the interviews with immigrants and natural citizens, Jane has worked to create a diverse narrative of cultural interactions, as well as the effect of education in both primary schooling and medical training on cultural sensitivity. Tarra focused on the more macro-level aspect of state policy and its varying impact on society, with a specific emphasis on policies involving immigrant populations. Within the economic community of the Eurozone, states with differing policies and approaches have experienced varying responses to the recent economic crisis. A cautious comparison of states universal healthcare systems and how service access has changed over the past decade (especially since 2007) illustrates both striking commonalities and differences with regard to unemployment benefits and health services afforded to immigrants. Theoretical and scholarly reading provided a foundation for the observations of and interactions with citizens and immigrants from varying socioeconomic statuses within Germany and Spain.

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Juliana focused on discovering the attitudes, both positive and negative, surrounding those who require health assistance of any kind. These groups of people ranged from refugees and immigrants to the homeless populations in each country, as well as unemployed youth and anyone experiencing poverty. This topic was interesting particularly in comparison to the US, where universal healthcare is a relatively new phenomenon and those receiving government assistance are often stigmatized. By interviewing both scholars and German/Spanish citizens as well as performing observational research and extensive background reading, Juliana has compiled some interesting findings regarding this issue. Through our multifaceted, interdisciplinary approach that incorporated students from backgrounds of both natural and social sciences, we achieved a relatively holistic sense of the healthcare situation in Germany and Spain. Our methodology mainly consisted of one-on-one, face-to-face interviews, structured and unstructured; observational research and ethnographic field notes; and analysis of secondary texts. We encountered some challenges along the way, and each group member has ideas of where the research could potentially lead in the future.

II. QUESTION In line with researching state policy and social benefits, my question focused on how the recent economic crisis has changed access and quality to healthcare services. How does a beneficiarys experience change when they are classified with immigrant and/or refugee standing? What tools is the government providing for state health systems, and what is the role of other voluntary nongovernmental organizations (NGOs)? With the institution of the Euro as the standard European currency in 2002, Germany and Spain entered into a new economic relationship with many countries in the Eurozone. One decade later, we are seeing how such a relationship affects other factors of society what types of changes are incurred and how such changes manifest into everyday experiences. My particular research question contributes to one overarching narrative of change that we have studied throughout our time abroad, focusing on social and artistic reflections of youth unemployment in the Eurozone. Social benefits and unemployment, structurally tied together via economic and political lines, generally tend to display an inverse relationship. In times of rising unemployment (among other things, inflation, etc.) social benefits are often among the first portions of the spending budget to be cut or reduced. Indeed, we see this occurring in the Spanish example with recent cuts in education, healthcare, and other social welfare benefits. Why have I chosen this question? I think it offers a different perspective on the effects positive and negative of globalization. As we try to delineate borders and boundaries (we are European, you are not), other methods of communication and movement serve to create a more fluid global

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community. Health is one topic in which we can see this trend. Though there are many issues and ideas that tie the world together (environment, global economy, war and violence, philosophical musings), health is perhaps one of the topics that has the ability to create connections and create change. Though we come from different political, economic and social backgrounds, I can arguably say that aiming to achieve a similar goal of healthcare for all. W.E.B. du Bois wrote of the peculiar indifference to the magnitude of human suffering that racial disparities in health reflect. Healthcare systems especially those operated by the state are one way that we can look into du Bois assertion and push for change. Thus, I am interested in seeing how such racial differences affect how people are perceived and how they are treated. Is health not something toward a universal right? Further, I appreciate that this topic allows me to engage in a more interdisciplinary approach to a posed research question, with historical, sociological, and ethnographic aspects to a global topic that is emerging as a field of social and technological interest. This has allowed me to interact with people via interviews, in addition to data gathered and life experiences learned. I have truly learned that on an aggregate scale, there is so much more to research than one would expect. Though I expected for an issue to be politicized, it is perhaps extremely so in terms of social welfare programs and this really has an impact on what kind of policies are approved and funded. The lesson that questions are often too broad proves true, leaving much room for further investigation.

III. BACKGROUND There are multiple factors influencing healthcare access and quality, including state policy in addition to cultural and socioeconomic backgrounds. Access to healthcare services further affects the wellbeing of a countrys inhabitants. As healthcare policies seek to reduce disparities in access and quality, there needs to be a close investigation of the factors that influence structural changes and effects in healthcare policies. Healthcare in general is a relevant topic in the discussion of youth unemployment because it is at the crux of the current crisis facing Europe. In addition to limited income for necessities such as food and shelter, unemployment can also lead to other social side effects. In times of economic distress, social welfare programs and healthcare services are often among the first options to be cut or limited by the government. The topic of healthcare access is also important to our generation of citizens and individuals. In the US, the ongoing battles of Social Security, Medicare/Medicaid, and universal health care have exacerbated the issue of care quality and affordability. In a more focused context, the Spanish state is one example of a society facing serious cuts in healthcare, education, and employment opportunities especially for youth.

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Healthcare spending cuts result in fewer doctors and less efficiency in healthcare spending, decreasing the access and quality of care offered by public systems. To look at my personal question of interest requires a brief survey of past healthcare and social welfare policies: a. Commonalities Both Germany and Spain offer some form of universal healthcare through state infrastructure and government funding. Universal is here defined as a healthcare system that is mandated and provided for through the state in some form.1 Though this is developing into a public-private industry, the notion of state-sponsored care suggests that healthcare is seen as a national social good that leadership should provide for its citizens. Both have enacted reforms over the past decade to state health systems, but the economic crisis has affected each state differently. b. Germany Germany actually hosts the oldest universal healthcare system in the world, dating back to 1883 under the Bismarck system. Today, the German system is comprised of both statutory health insurance (public) and private health insurance, with a partnership between the national and state (regional) levels. c. Spain Over the past two decades, Spain has arguably overseen one of the most regarded healthcare systems in the world. Especially praised for the commitment to universal access to basic health services (anyone within Spanish borders has the right to seek medical care, regardless of status, ethnicity, citizenship, etc.) The national health ministry is responsible for organizing the system, which most legislative and budgetary tasks are handled at the state (regional) level, similar to Germany. However, Spain has experienced more serious effects from the economic crisis, with soaring unemployment rates and tremendous cuts to social spending. Some argue that other states like Germany can be seen as a model for Spanish recovery in the future. One issue I found while researching this topic was how to define the concept of universal, especially as it proved to be more tenuous than I expected. When one says universal, it is implied that a good is offered to everyone universally, regardless of exclusionary factors. However, we must take point in noting that both Germany and Spain operate contributory social welfare plans. This means that the benefits you receive are somewhat dependent on how much you have contributed back to the state in terms of employment (income taxes). Until the enactment of the

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Spanish Royal Decree Law in September 2012, universal (i.e. non-exclusionary) benefits were offered to anyone within Spanish borders, regardless of background or citizenship. Now, illegal immigrants can legally be denied care.2 In most situations within both Germany and Spain, emergency procedures are still offered universally, in the name of human sanctity. People who are not eligible for the state system must therefore rely on voluntary medical care (as with the nurse in the Refugee Camp at Oranienplatz, Kreuzberg). Culturally, the notion of universal healthcare appears to be widely accepted within German and Spanish societies. Most of my interviewees noted that they agreed with the notion that healthcare should be seen as a given human right. Everyday citizens who usually were not too versed in numbers or statistics were surprised that we do not offer care services through the state in the US and that many go uninsured. Though we are for the purpose of this paper focusing on immigrant and refugee populations within Germany and Spain, we should also consider how our state systems in the US are including or excluding people within its borders. Theoretically, using the concept of convergence theory proved useful in guiding my analysis. Convergence Theory examines the relationship between cultural, social, political, and economic forces through the organization and output of national health systems, suggesting that the interplay of a variety of factors affects organizational and structural processes. A narrower look at such factors include the evolution of medical knowledge/technology, changing demography patterns, the growth of mass communication, and the pressure of rising public expectations. The latter two concerns involving mass communication and rising public expectations are especially prescient concerning the issue of healthcare access. Convergence Theory implies that a certain macro process in which a narrowing of system options takes place, compared with those theoretically possible, due to forces that generally lie beyond the control of particular national actors or institutions and to which more and more societies are being exposed. With the rise of mass communication (i.e. via the Internet, social networking sites like Facebook and Twitter, etc.) it is easier than ever to share information and to voice opinions. Discontent with state policies can be aired and shared at the click of a button, allowing for more people to get involved, as Carmen Haro discussed during the discussion of her work on new technologies and social revolution. Such a phenomenon was realized with the 15M movement in Spain a movement of social protest for state reforms and transparency. The White Tide branch of the movement focuses on recent cuts in health spending and services. Germany has faced similar problems regarding quality and consistency of care.

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This then raises the question: given the comparison between the German and Spanish healthcare systems, what will happen in the future? Will economic crisis draw these countries closer together or push them apart? How will the crisis affect future German/Spanish relations, given the ties already provided for (EYES Entrepreneurship and Youth Employment Strategy, which mobilizes resources from both state and union levels through the European Social Fund.) One analysis noted that, Increasingly confronted by similar kinds of health system problems, societies are also exposed to the same policy currents about effective health system management.3 The German model could be one avenue for Spain to explore, but it is more of an interchange. The analysis continues:
The most remarkable feature of healthcare system reform among the seventeen member countries [of the OECD] is the degree of emerging convergence. Whether intentionally or not, the reforms follow in the general direction of those pioneered in other countries.4

The question, then, remains: will structural differences and cultural influences bring different state together or push them further apart? Does the presence of an economic crisis change societal responses?

IV. RESEARCH METHODS (METHODOLOGY) The methodology of this research project consisted of three primary methods of data collection: close readings of texts (including scholarly articles and selections from academic journals), personal interviews (with both professionals and everyday citizens), and ethnographic observations of various settings. The data gathering process proved to be expansive and evolving, with one finding often leading to another (while also raising more questions). I relied on both quantitative and qualitative data. Quantitative data came from close readings of texts and scholarly articles. Qualitative data came from interviews and observations. Within an interview, I prepared questions beforehand and structured the conversation according to introductions facts/quantitative data (if given) opinion on the issue proposals for change. Close readings of texts provided a stable foundation on which to add observations and experiences. While some news articles provided a more quantitative approach, other scholarly articles often utilized facts and numbers to add to a narrative of social commentary. One article

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from the BioMedical Journal regarding austerity measures in Spain dedicated the latter quarter of its argument to personal testimonies from doctors and medical technicians. This assists my data collection in offering a story beyond just the facts and numbers, but inherently also displays a more distinct bias. The opinions collected and the facts utilized are completely based on the authors and authorial intent. For the purpose of laying the groundwork for field observation, it provided a good place to start. The opportunity to interview on-the-ground added a face to the statistics and scholarly reading done in preparation for our research. I enjoyed speaking to both professionals and experts in the field in addition to everyday citizens who, as one interviewee put it, experience life as its actually experienced. It was interesting to see how certain people would react to things I had previously researched for the trip. I once cited the tremendous health budget of Germany to the front desk clerk at Die Fabrik, Stefan. Though he acknowledged the issue he did not contest the amount; he felt that personally the state was doing a tremendous job in improving efficiency and cutting back costs as compared to ten or fifteen years ago. The strengths of this method include personal, unfiltered results, with the opportunity to engage with a subject on a very personal basis. This relationship also entails inherent weaknesses as well. A small number of interviewees limits my results and is more likely to be biased (dependent on who I choose to talk to and which questions I choose to ask). A more detailed analysis of my interviews and experiences may be found on my course blog. INTERVIEWS include ex-employee from the Berlin Job Center, Career Specialist at the University of Leon, quality care specialists MKG in Berlin, volunteer law services for immigrants in Berlin. The method of data collection that was most informative was the observational component. Though I gained invaluable insight from articles and interviews, I found that an ethnographic approach in which I do not have a direct influence on actions and events provided the most insight and perspective. OBSERVATIONS include Refugee Camp at Oranienplatz, Kreuzberg. One source also took care in cautioning a comparative study that may not utilize the same terms or units of comparison. Though similar in many respects, the German and Spanish systems are uniquely different in how state policies are realized on a day-to-day level. We must note this when conducting a research study for comparative purposes.

V. FINDINGS Though I hypothesized that economic crisis would correlate with cutbacks in social spending, I did not expect some of the more particular results. In Spain, I found that the spending varied widely by region. In Germany, I found tremendous discrimination against immigrants despite

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their strong and ever-efficient system. Through a comparison of these health systems, we can see where there is room for improvement and innovation for a global as well as local context. a. Health Systems: Germany Germany is often referred to as the model by which Spain should compare and seek to learn from. Though its healthcare and welfare systems are evolving every year, there is still room for improvement. Germanys health system has been plagued with rising costs, overcapacity, and inconsistent quality levels over the past ten years. In 2009, the total state healthcare budget came to 278 billion euros, equivalent to 11.6% of that years GDP. This budgetary amount ranks fourth in global spending, after only the US, Netherlands, and France. The total health expenditure per capita is 3,188 euros, which is 30% higher than the OECD (Organization for Economic Cooperation and Development) average of which both Spain and Germany are included. Since the latest health care reform in 2007, everyone who lives in Germany must be insured for at least hospital and out-patient medical treatment, but with the option between statutory or private care. About 87.5% of residents are covered by the statutory system while the other 12.5% opt for private health insurance. Proposed solutions include a focus on adequate, expedient, and cost-effective care with a more appropriate and fair allocation of resources. German quality-control organizations, like MKG Berlin that we had the opportunity to interview, base success on goal-oriented regulation guidelines that focus on transparency and improved record keeping systems. b. Health Systems: Spain Spain has historically been referenced as one of the top healthcare systems in the world. Lauded especially for their open access policy to health benefits, the Spanish state has worked to recreate a solid welfare infrastructure since the fall of the Franco regime. The economic crisis has unfortunately led to cuts in budgetary spending especially with regard to healthcare. Although the state spent 9.6% of GDP on healthcare in 2010, 26% derived from private sources. (Only 7% of health spending came from the national government in 2010, which is lower than the EU average spending amount of 7.6%). While the national level is responsible for determining aggregate structural policies and procedures, most of the actual delegation of funds is funneled down to the regional level. The seventeen regions of Spain - ranging from urban to rural, coastal to land-locked administer 90% of public healthcare funding that comes from the national government. This therefore leads to enormous disparities in access to care across varying regions. Budget Cuts & The Royal Decree: The health and social services budget was reduced by 13.65% in 2012, with very high cuts to public health and quality programs (45%). These

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cuts coincided with increased demands on the health system, in part reflecting the association between unemployment and poor mental health, but also because of a cut of 600 million euros in the dependency fund that supports elderly people and people with disabilities. A 3.1 billion euro cut is proposed for the remainder of the 2013 fiscal year.

An unusual law passed not by parliamentary debate but by royal decree directly affects immigrant access to state health systems. Royal Decree-law 16/2012, enacted in September 2012, excludes undocumented migrants from all but basic emergency care, prenatal care, and pediatric care, so ending the principle of free services at the point of delivery for all. This is perhaps the most dramatic effect of the crisis on the Spanish health system, as refugees can legally be excluded from social benefits if they do not have appropriate papers. c. Varying Perspectives: Role of the Immigrant Other Initial comparisons of the situations in Germany and Spain draw into question not only budgetary cuts for everyday citizens, but how such cuts affect an already limited access point for immigrants and refugees. In general, the immigrant experience of care accessibility is an inability to utilize routine treatment/checkups, with a higher likelihood of using emergency services. In both Germany and Spain, we encountered acts of conscious and unconscious discrimination against those who appeared to be different. To meet the goal of establishing residency, many immigrants find that they are caught in an unescapable cycle of unemployment/unregistered status. Structural barriers to inclusion include needing to learn German fluently before taking a citizenship test. At Turkyemspor, we saw how such discrimination against Turkish immigrants (or the image of such) could manifest itself in a sports setting. The emergence of the Neo-Nazi political party and racist lyrics in songs suggests that racism is still very pervasive in German culture, despite a noted attempt to connect and acknowledge a tarnished past. Within Spain, I also found that there was discrimination against those who appeared to be of different background. When shopping in a market at Valencia, I would often see men selling their wares on street blocks but would hurriedly pack up and run away when air of officials came by. This article notes that as the state health system is funded through VAT (a tax included in purchases), anyone who participates in the Spanish economy puts money into the system and should therefore have access to care. When one man without papers tried to seek medical assistance, he was turned away with the exception that he could come back for emergency care. This is similar to what we found in Germany at the refugee camp

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where health services are provided on a voluntary or emergency basis. Refugees are almost always unemployed as they are not allowed into the state system without papers and this is an issue that crosses national lines despite differences in state policy. Though I am quick to incite the bulwark notion of racism within these societies, I also acknowledge that this is an issue that is pervasive and in different forms. An ethical comparison of these two systems with specific regard to healthcare can therefore be based on a question of perspective. A so-called provider perspective focuses on a measure of costs and benefits for the healthcare provider, while a social perspective measures costs and benefits in relation to society as a whole. The latter example is how we can classify the American system: insurance is seen as an industry for profit, to offer a good (health protection) to the masses. Alternatively, more universal health systems utilize a social perspective in looking to minimize costs and maximize benefits for users. This is exactly what our group experienced in interviewing the MKG organization in Berlin noting that they look out for the patient in keeping costs low, a very different approach from the caustic and demoralizing American system. d. Public and Private Options Through our research methods and data collection, I found that there is the looming question of the public vs. private care debate. This is tricky as it is both a moral and an economic/political concern. The Dublin II regulation enacted at the EU level holds that the European country of arrival is responsible for offering asylum to refugees. Border states like Spain are overloaded with both legal and illegal immigrants and refugees and often travel elsewhere within the EU like Germany to find better opportunities. This is here where we find a notion of du Bois peculiar indifference, as no state wants to take on a larger financial burden during a period of economic crisis. Further, distinct cultural differences also work to the disadvantage of immigrant/refugee populations. Since 1988, there have been over 16,000 deaths at EU borders a bit ironic as our topic of focus, universal healthcare access and quality, is rooted in the notion of inclusion as opposed to the exclusion of other people who are of different background and nationality Limitations of the system become apparent at a philosophical level when universal public health providers become less attractive than the benefits of private care. We earlier discussed the notion of health as a national social good, a general idea behind the framework of universal healthcare. If such a national good is more or less put up for sale to the highest bidder through privatization, is it still seen as a national concern? What does state cutbacks in social health systems symbolize in the picture of national and even global standards of ethics?

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e. Impact of the Economic Crisis The economic crisis that hit global markets in 2007 has left varying impressions on state systems and budgetary outlooks. Though Germany and Spain are both part of the European Union and the Eurozone, differences in state health structure and funding have led to differing effects. In both states, the crisis has caused the exclusion of undocumented immigrants and the privatization of services (drawing the public vs. private debate). In Spain, health reforms have also led to decreasing levels of coverage, closures of clinics, shortened operating hours, and increasing copayments. In Germany, the crisis has had a smaller effect; focus is now placed on improving efficiency and transparency in general. The aforementioned budgetary cuts in recent fiscal planning has left many medical practitioners and professionals straining to make supply meet demand. Commenting on the effect of budgetary cuts, one general practitioner noted that
With the introduction of the cuts, last year they told me now you have to go back to your position of visiting patients rather than your technical position. I had not seen a patient in 20 years. I think these decisions are crazy. They have done this with me to save six months on a substitutionI am going to try my best, but I am aware that I am not competent to treat my patients properly. 5

Ultimately, the gaps left by structural and cultural changes are left to be filled by voluntary and non-governmental organizations. These organizations attempt to bridge the gap in providing for and defending basic needs and rights. Immigrant populations (both documented and undocumented) access these resources where they are available. The Sierra Pambley Foundation in Leon, for example, provides varying forms of support through Spanish language classes, technical training, and assistance transitioning into Spanish society. Similarly, Andre from the refugee consultation center for legal support in Berlin provides assistance to those seeking aid, employment, residency status, emotional support, etc. Our time spent at the Baltasar Garzon offices in Madrid further illustrates how NGOs and voluntary organizations attempt to offer aid and push for structural change. The La Caixa Foundation of Spain works to similarly provide aid, but also to undertake educational measures to dispel the fear/distaste of the immigrant menace in Spanish society. A report produced by the foundation in 2011 was the first of its kind to be released to the general public since the economic downfall in 2007. Though there is a belief that many immigrants and refugees do not contribute to the system while using the systems resources, this data illustrates that this is not quantitatively supported. Immigrant access and use of care remains proportionately low as compared to Spanish

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society at large. There is also a wide variation in health spending by region. A selection of graphs has been attached in the Appendix for reference. The work of voluntary organizations abroad parallels the efforts of citizens at home as well. This article discusses how Americans are working outside of the system to assist immigrants crossing the border from Mexico. f. Social & Artistic Responses How are youth in particular responding to the economic crisis? Through various forms of artistic and social expression, we have found that unemployment can be seen as an opportunity to provide social commentary. As in our discussion of Convergence Theory, the rising usability of social media to create connections is intermingling with the use of art to express discontent. Aleix Salos work, for example, utilizes comic art to provide dissenting commentary on state policies in the Eurozone (Euro Nightmare). Aaron Rux, low-cost film movement, Xabi Tolosa, unemployed academic who used unemployment to his personal benefit. Other movements including the Marea Blanca branch of the 15M collective and flashmobs at unemployment centers allow for a sense of solidarity to grow out of a hard economic time. Marea Blanca organizes popular demonstrations that defend public health against cutbacks and the allure of privatization. Here Comes the Sun flashmob at Spanish unemployment center. This video showcases the power of community resolve and inspired action during difficult times. Though it is a step in the right direction, I was unable to find information on how immigrants and refugees themselves protest and engage (if they do). Was unable to find information from immigrant/refugee groups directly, but offers room for further research. Ultimately, social responses to the structural issues of unemployment and reducing social benefits budgets can be seen as an attempt to challenge institutional policies for the sake of social change. I argue that this will continue to be a point of convergence for societies across the globe.

VI. CONCLUSION As a whole, our group has learned that though more research and data is needed and the future is uncertain, the recent economic crisis has impacted policies regarding healthcare and social welfare programs within Germany and Spain. Interestingly, the public and private healthcare divide poses an important question regarding the ethics of having both programs available. It will be crucial to observe any structural changes in the future and how these public and private

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changes might affect healthcare access for disadvantaged populations. The relationship between Germany and Spain through the Eurozone crisis is an interesting factor as much Spanish debt is owed to the Germans, who are also providing jobs for Spaniards who seek employment. On a micro level, there seems to be a growing movement toward cultural sensitivity and improving healthcare access and quality. However, disadvantaged minorities, both immigrants and refugees alike, do not feel included in the national healthcare system both structurally and culturally, despite both Germany and Spains universal healthcare system. Julianas research suggests that Spaniards are more accepting of disadvantaged populations. This may be attributed to the fact that there is a higher percentage of immigrants in Spain compared to Germany. However, more data is needed to provide a substantive conclusion. Budgetary cuts will continue to reduce healthcare quality and access, and policies change constantly. In the coming years, will the economic divide between Germany and Spain widen or narrow, and how will this in turn affect healthcare policies and the publics opinion of those on social welfare? While the future is uncertain, we will need to pay close attention to how policies will impact healthcare access and quality, beyond what is outlined in texts and statistics.

Our research has highlighted the porous nature of borders and the growing importance of transnational systems and identities. It has been one decade since the institution of the Eurozone, which has tied Western Europe together in a relationship economically and politically bound. This has led to an interplay of cultures, who must balance essentially in political and social aims as well. Their economies are linked with countries with differing interests, trades, etc. Public opinion and political institutions interact and influence each other/healthcare system outcomes. Importance of both public opinion AND political institutions. Immigrants inability to access routine treatment and checkup appointments, more likely to use emergency services: what does this say about universal healthcare as it is understood today? During economic/political upheaval? Back to du Bois point about racial indifference Question of transitioning from African to German or Spanish? Creating new national identities? Integration vs. acculturation Not including unemployment benefits question for future study and analysis VII. REFERENCES BMJ Austerity Measures.f2363, n.d.

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Castle, Stephen. German Finance Minister Puts Focus on Unemployment. The New York Times, May 9, 2013, sec. Business Day. http://www.nytimes.com/2013/05/10/business/global/germanfinance-minister-puts-focus-on-unemployment.html. Comparative Medical System.pdf, n.d. Disability_and_Social_Inclusion.pdf, n.d. El PP de Madrid No Privatiza La Sanidad Pblica, Estimula La Sana Competencia, Dice Su Portavoz. Pblico.es, January 7, 2013. http://www.publico.es/448483/el-pp-de-madrid-noprivatiza-la-sanidad-publica-estimula-la-sana-competencia-dice-su-portavoz. El Privilegio de Los Que Tenemos Papeles. Eldiario.es. Accessed July 22, 2013. http://www.eldiario.es/desalambre/privilegio-papeles-inmigrantes_0_144186037.html. Focus on Spanish Society-1.pdf, n.d. Germany Health System PPT.pdf, n.d. Germany Health System.pdf, n.d. Gestin Sanitaria Privada: Costes, Perspectivas y Conclusiones. Eldiario.es. Accessed July 22, 2013. http://www.eldiario.es/agendapublica/blog/Gestion-sanitaria-privada-perspectivasconclusiones_6_88251180.html. Higgins, Andrew. E.U. Is Pressed to Reconsider Cuts as Economic Cure. The New York Times, April 26, 2013, sec. World / Europe. http://www.nytimes.com/2013/04/27/world/europe/eu-ispressed-to-reconsider-cuts-as-economic-cure.html. Immigration and the Welfare State in Spain.pdf, n.d. List of Cuts, n.d. http://wiki.15m.cc/wiki/Recortes. Pas, Ediciones El. 6.700 millones menos para sanidad. EL PAS, February 16, 2013. http://sociedad.elpais.com/sociedad/2013/02/16/actualidad/1361029181_888112.html. . La puerta giratoria entre la sanidad pblica y la privada. EL PAS, January 12, 2013. http://ccaa.elpais.com/ccaa/2013/01/12/madrid/1357981624_795106.html. Rabin, Roni Caryn, and Reed Abelson. Health Plan Cost for New Yorkers Set to Fall 50%. The New York Times, July 16, 2013, sec. Health. http://www.nytimes.com/2013/07/17/health/healthplan-cost-for-new-yorkers-set-to-fall-50.html. This World (BBC 2012) - The Great Spanish Crash (VOS). Dailymotion. Accessed July 22, 2013. http://www.dailymotion.com/video/xwqhgp_this-world-bbc-2012-the-great-spanish-crashvos_news. Traynor, Ian. Unemployment of Europes Young People Soars by 50%. The Guardian, April 16, 2012, sec. Business. http://www.guardian.co.uk/business/2012/apr/16/european-youthunemployment-soars. Understanding Racial-ethnic Disparties in Health; Sociological Contributions.pdf, n.d. VIDEO: Here Comes the Sun Flashmob in Madrid Unemployment Office Goes Viral. Latino Rebels. Accessed July 22, 2013. http://www.latinorebels.com/2013/02/20/video-here-comes-thesun-flashmob-in-madrid-unemployment-office-goes-viral/. White Tide, n.d. http://wiki.15m.cc/wiki/Marea_Blanca. yoSi Sanidad Universal, n.d. http://yosisanidaduniversal.net/portada.php.

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VIII. CULTURAL SENSITIVITY This is the self-reflective component. Retrospectively, discuss the process of the research project. What were the surprises? What did you discover about personal and cultural biases? Consider why this project is of personal interest to you as well as why others (local and global communities) should care to know more about the topic. Consider any struggles you encountered while doing your research. Discuss what you learned about yourself and also within the context of the research/larger groups. I was surprised that it actually stuck with me as an experience. Though our project for this course may have come to a close, I find myself more open to talking with strangers about their experiences and where they come from. Spanish couple on the plane even shook my hand as we deplaned. I discovered that personal and cultural biases are oftentimes engrained in a persons behavior and worldview. Sometimes, it is not an outright bias that can be identified but rather takes time to look into and analyze anothers point of view. This project is of personal interest to me as an international studies major with a focus on Global Health. Again, I feel that health is one topic that can bring people to the tableMajor obstacles include political aims, economic preferences (especially of the pharmaceutical industry), the issue of universal healthcare and insurance industries. As convergence theory suggests, each system is unique in its past and the influences upon structural policies but perhaps there is room in the future to come together. IX. APPENDIX a. Graphical Representations

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b. Interview Transcriptions & Notes For our last assignment, we were asked to venture out into the real world and seek out three different types of people to talk to. It was a bit offsetting approaching strangers at first especially as I speak very little Spanish but once I made an introduction it turned out better than I expected! I have never before really attempted to engage strangers in a serious conversation, and I had hesitations that many would blow me off or walk away. I realized however that throughout a day there are many opportunities to talk to people in line at the grocery store, your neighbor on the train, going to class, etc. Societally it seems like we have almost trained ourselves to look past another or to pretend like they dont exist when we walk down the street. Though I dont think I will be able to approach every stranger I ever meet, this exercise proved interesting and exceeded my expectations. I began my conversations as suggested, which turned out something like:

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Hi, I'm Tarra! I am a student from the University of Washington in Seattle and I am on a program focusing on youth unemployment in Germany and Spain related to the economic crisis. Specifically, I am researching the impact of such change on state health care and social welfare systems. Have you personally felt an impact (positive or negative) in accessing state health resources? Are you (or if you know another person who is) unemployed? If so, how do you feel this has impacted your (their) access to health resources? 1. Youth (i.e. high school or college student age) I met Maria while waiting for an interview in the Language Center last week. I took a seat next to her and we started chatting as she wanted to practice her English. When I explained my project regarding state health systems, I was surprised to find that she did not really have an opinion on the topic. She noted that she thought the job market was definitely difficult, but that cuts should be expected across the board. She said her parents paid for private care when public care was not available. As an aside, I think this is interesting because I feel that we have met many youth who are very engaged with the issue those we have had talks with, the 15M movement, social activist groups like the Baltasar Garzon Foundation, etc. Perhaps for youth who are still growing into a social and political consciousness, topics like these produce participants on either end of the spectrum either very involved and oriented, or somewhat apathetic and ambivalent on an issue that some may not directly understand. This is a parallel I would offer to make for youth in the United States. Though I have friends who are involved politically and socially, I would argue that many including myself do not feel prepared or engaged to deal with many politicized social issues. 2. Family (parents with kids) I had an opportunity to speak to a couple (early 30s) while on the beach in Valencia. I didn't catch their names, but they were very friendly and were interested in knowing about our studies here in Spain. Ileana was on hand to translate. This couple recently had their first child one year ago, born in a hospital but mainly cared for through private care. The mother explained that for some specialties like OBs, eye doctors, dermatologists, etc. the quality you would have at a public facility is not the best. She said that she once had to wait for 3 days to get in to see a doctor when she first became pregnant - after that, the couple found a private clinic. Both of the parents hold jobs and are thus not unemployed, but when I inquired if they knew of someone who was, the mother replied that her younger brother had just graduated from University and was still searching for work. "It has been hard for him because he has had to

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move back in with our parents...he cannot support himself." I got the impression that there is little to no unemployment insurance/benefits (as compared to that Harts 4 system in Germany). 3. Older generation (50+) On Thursday before we departed for Valencia on the train, I went to Corte Ingles for some snacks and goodies. While in line at the checkout, I was standing next to an elderly woman and her son Ana and Miguel. I smiled and attempted to ask how she was doing (in Spanish), which she got a huge kick out of! Luckily her son spoke English as he is currently studying at University in Madrid. Our congenial conversation turned into a very interesting discussion as we were held up in the checkout line. I explained my research topic and asked what her opinions were. She noted that yes, definitely, things have changed but really I have been alive for decades so I like to think Ive seen it all! Essentially, Miguel explained that he comes home to Leon when he has time off from school, to take care of his mother. Doctors appointments, prescriptions, helping around the house that kind of stuff. We also go to a private clinic for her dermatologist, and the paperwork can get confusing so I try to take care of that for her. I think that this situation is the most that I can relate to, personally. As an American with parents of the baby boom era, I realize that our social security and welfare systems may not hold as we take care of more and more elderly. Though waiting and red tape can always be frustrating, it is of a different nature with regard to health and a person's wellbeing. I feel that this is something that every nation should deal with - whether via a healthy and supported state infrastructure or via competition between private firms offering quality care. All in all, though some conversations were more fruitful than others, I found that generally people still have a sense of hope and security in state-run institutions. Though I was not able to hone in on the unemployment aspect of my research, the interviews suggest that more people are looking to private doctors when a public one is not available. Cuts to the state health care system have included reducing hours (meaning more patients/hour for doctors, or some patients being turned away). **As an aside, I should note that Spain is notable for it's "open-access" policy in that anyone within Spain can reportedly access health care services. Regarding the issue of immigrants, especially those from Italy and North Africa, this standard is not being honored completely. This article notes that as the state health system is funded through VAT (a tax included in purchases), anyone who participates in the Spanish economy puts money into the system and should therefore have access to care. When one man without papers tried to seek medical assistance, he was turned away with the exception that he could come back for emergency care.

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This is similar to what we found in Germany at the refugee camp - where health services are provided on a voluntary or emergency basis. Refugees are almost always unemployed as they are not "allowed" into the state system without papers - and this is an issue that crosses national lines despite differences in state policy.

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