lack of funding The General Reciprocity of Civil Servants MUFACE already shows strains in healthcare, a serious situation for specialties such as Oncology, and has driven civil servants toward private healthcare. If MUFACE were to falter due to financial trouble, the state would save less than the current €890 million annual relief, and the private sector would feel a heavy impact: 19 provinces face a serious risk of hospital closures, mainly Castilla-La Mancha, Extremadura and Castilla y León. Waiting lists would grow substantially: external consultations could rise by 266 percent, with surgical waits up to 115 percent.
This finding appears in the report Administrative mutualism: Selection of mutualists and a forecasting model of future scenarios. Created within the framework of the Chair of Sustainable and Responsible Health at the Complutense University of Madrid and backed by the Spanish Private Health Alliance ASPE, the comprehensive report was unveiled this week at an event hosted by the Madrid Ministry of Commerce and Tourism. The event featured remarks from the Dean, María Francisca Blasco López.
With data from MUFACE
The document defines administrative reciprocity as a coverage mechanism for the Special Social Security Regime that includes MUFACE, the General Judicial Reciprocity MUGEJU, and the Armed Forces Social Institute ISFAS. It presents an in-depth look at MUFACE, the sole partner that contributed data for the report, from statistics to policy recommendations.
This is the second study issued by the Complutense University Chair for Sustainable and Responsible Health in 2022, with ASPE support for actions in the health sector. The director Ana Rosado indicated that the document offers abundant and granular information at a critical moment when it is essential to understand mutual communities.
MUFACE reached nearly 1.5 million associates in 2022; about 70% were owners and 30% beneficiaries
Industry leaders, including Herminia Rodríguez of the private healthcare employers association, express concern that providers face tighter margins and questions about whether services can be maintained within mutual societies. This has raised concerns about care quality, especially in Oncology.
The first MUFACE figure shows almost 1.5 million associates in 2022, with the balance of ownership at 70% and beneficiaries at 30%. Over the last decade, the total has declined by 5.1%, even as the number of shareholders grew by 5.5% between 2013 and 2022. The decrease in associates is largely due to a 23% drop in beneficiaries.
The most mutualistic provinces
Geographically, Madrid leads with 16% of mutualist presence, followed by Barcelona, Valencia, Seville and Malaga. The provinces with the smallest share are Álava, Soria, Ceuta, Melilla and Teruel.
Associate members are 55% women and 45% men, with an average age of 57.2
Looking at the member profile, women account for 55% and men 45%. The average age among owners stands at 57.2 years, a rise of three years over the study period 2013–2022.
Beneficiaries
Retired associates increased by 9.2 percentage points over the last decade, rising from 29.1% in 2013 to 38.3% in 2022. The number of beneficiaries per associate member dropped from 0.59 in 2013 to 0.43 in 2022. Most owners belong to Group A officers.
Associate members can choose each year between public or private care. The share opting for private care stands at 72.9%, while those choosing public care are also at 72.9%? A note: the report shows competing trends with ISFAS and MUGEJU leaning toward public care.
Despite deteriorating public health indicators and longer waiting lists noted in MUFACE circles, the proportion favoring private care declined by 9.2 percentage points in the last decade. In 2013, private care accounted for 81.9%; by 2022 it stood at 72.9%.
Founding
On financing, health expenditure in 2023 for public systems is estimated at 1,608 euros per person. MUFACE’s weighted premium is 1,014 euros, creating a gap of 594 euros per member annually. If this gap were applied to all mutualists MUFACE, MUGEJU and ISFAS, the mutualist model would still generate significant state savings.
Public health spending rose 54.3% from 2014 to 2023, while MUFACE premiums increased 31.4%
The report notes that public health spending surged by 54.3% in 2014–2023, whereas MUFACE premiums rose by 31.4%, a difference of 22.9 percentage points. Insurers only passed about half of the premium increases to large hospital groups in recent years.
What if MUFACE disappears?
The report outlines one path forward and two hypothetical scenarios. If MUFACE vanishes or persists, substantial changes would be needed. Experts warn that population aging and rising chronic disease burden press on the system.
The consensus is that the model cannot be sustained as is and would require replacement within two years at most. Insurance companies and unions have urged a rapid solution, as mutuals may lack the capacity for extra financing.
Bankruptcy
In the first scenario, the insurance industry could halt billing in the event of bankruptcy. Administrative reciprocity premiums totaled over 1.7 billion euros in 2022, representing roughly 14% of the sector’s turnover.
If MUFACE disappears, private hospitals in 19 provinces face a serious risk of closure
Private hospital providers would cease billing for about 1,000 million euros, roughly 8% of sector revenue. If MUFACE ends, about 2,041 inpatient beds would sit empty in private hospitals nationwide.
The impact would vary by province, but 19 provinces overall face a serious risk of private hospital closures, with Castilla-La Mancha, Extremadura and Castilla y León at the forefront.
Public collapse
What happens to public health if mutuals disappear? The report argues that civil servants currently receiving benefits through MUFACE would need private system coverage. This shift would impose a substantial economic burden, reflecting the current premium gap and ongoing private options.
Infrastructure would need about 3,975 additional hospital beds nationwide, equating to roughly a 3.8% capacity increase. It could be especially challenging in Madrid, Seville, Valencia, Barcelona, Cadiz and Malaga.
Waiting lists in the public system would rise significantly: outpatient queues could grow by 266%, while surgical wait times could climb by 115%.
Fewer oncologists
Accessibility and care quality indicators point to a visible decline in services due to underfunding. There would likely be fewer hospitals and oncology centers, slower emergency services, and reduced specialist availability in some locations.
Longer intervention times and slower updating of medical records hinder care
Wait times would lengthen, with slower processing for approvals and delayed electronic medical record updates affecting timely treatment.
Insurers
The mutualist profile varies by insurer. Asisa, Adeslas and DKV participate in the current agreement. DKV tends to house the youngest member base and the most beneficiaries per associate, with a higher share of women and active associates, primarily Groups A1 and A2.
Asisa records an older member profile with more retirees and fewer beneficiaries. SegurCaixa Adeslas enrolls the largest number of regular associates for care and sits between Asisa and DKV in several metrics.