I Tracked Every Healthcare Euro in Spain for 2 Years: Compared to My Last 2 Years in America

I wanted a clean answer to a messy question: is Spain actually cheaper for healthcare, or does it just feel cheaper because the bills show up differently? So I tracked every euro for 24 months, then pulled my last 24 months of U.S. statements and lined them up like a crime scene.

If you have ever tried to compare healthcare across countries, you know how it goes.

Someone says “Spain is free.”

Someone else says “Spain has long waits.”

Then someone shows a U.S. premium number and everyone stops talking.

None of that helps when you’re 45–65 and trying to plan a real life. You need to know what leaves your bank account, what is predictable, and what can still punch you in the face.

So this is a ledger story, not a vibes story.

What I counted, and what I didn’t

I tracked what actually left our accounts in Spain for two adults living in Spain full-time.

Not theoretical costs. Not “taxes pay for it.” Not “but it’s better here.” Just the money.

I counted:

• Monthly premiums for private coverage, because cash is cash even if the plan is “optional.”
• Prescription copays and pharmacy purchases, including receta electrónica items and the random over-the-counter stuff you buy because you’re human.
• Dental, vision, and anything the public system did not fully absorb.
• Paid private appointments, tests, and specialists when we chose speed over waiting.

I did not count:

• Income taxes and social contributions, because that turns into a different debate and you will never stop arguing about it.
• Employer contributions in the U.S., because that money was never in my pocket to begin with, and I wanted the comparison to stay simple: out-of-pocket from our side.
• The value of time, even though time is half the story.

Two little tracking rules made the numbers clean:

1. Everything went into one spreadsheet the day it happened, with date, provider, category, and amount.
2. If we couldn’t explain a charge in one sentence, we followed it until we could. That one habit alone is why the U.S. ledger looks so much uglier. The U.S. system produces more “what is this?” charges by default.

This is also where people accidentally lie to themselves. They remember the hospital bill and forget the monthly premium. Or they remember the cheap prescription and forget the dental bill. A real comparison has to include the whole calendar.

Spain for 24 months: the full out-of-pocket total

Our two-year Spain total was €5,884 for two adults.

That’s an average of €245 per month, not “free,” but also not the financial weather system the U.S. can become.

Here’s the breakdown that made up almost all of it:

• Private insurance: €4,416 total (24 months at €184 per month for two adults)
• Prescriptions with copay: €286
• Over-the-counter pharmacy purchases: €214
• Dental (cleanings, one filling, one X-ray): €642
• Vision (one eye exam, one pair of glasses): €238
• Private specialist visits and tests we chose for speed: €88
• Miscellaneous medical supplies and small fees: €0–€20 level stuff that still adds up

The private insurance line is doing the heavy lifting. If we had used only the public system and accepted the timing, our spending would have been much lower.

We paid for private insurance because we wanted two things:

• faster access for certain specialties
• a simpler “book it and go” life when we had a weird symptom and didn’t want to play appointment roulette

That’s the Spain trade-off in one sentence: you can often choose whether to spend money or spend time.

Also, the Spain ledger is calm because the biggest categories are calm. The bulk of spending is a fixed monthly number and a handful of predictable extras.

The only months that spiked over €400 were dental months, and dental is not covered the same way as a GP visit. That is normal here. You plan for it.

The pharmacy reality in Spain: small bills, clear rules

Spain’s pharmacy experience is one of the biggest “feel” differences for Americans.

You walk into a farmacia with the green cross. You hand over a card. You pay a small amount. You leave. No email three months later with a surprise balance.

The important detail is that prescriptions are not universally free. Spain uses a copayment system tied to status and income bands, and there are monthly caps for pensioners. Certain chronic treatments can fall under a reduced contribution. The rules are boring, and boring is exactly what you want for budgeting.

In our 24 months, the average prescription month looked like:

• €0 to €6 for a refill
• €8 to €18 in a “we both caught something” month
• A couple of months near €25 when multiple things lined up

The more useful lesson is not the total. It’s how to keep it low without playing games.

What worked, consistently:

• Asking for generics by principio activo when it was appropriate.
• Using the public prescription path when we could, because that’s when the copay structure applies cleanly.
• Keeping common, safe basics in the cabinet so we didn’t make panicked purchases at 10 pm.

Examples of the “Spain medicine cabinet” that kept spending predictable:

• paracetamol 1g and a basic anti-inflammatory for short-term use
• saline spray, basic throat relief, and simple allergy support
• a thermometer that actually works, because guesswork becomes “let’s buy more stuff”

One cultural note that matters: Spanish pharmacies are used to people asking questions. It’s normal to describe symptoms and get guidance on OTC options. That does not replace a doctor. It does reduce the “urgent care for everything” reflex many Americans develop.

And when you reduce the urgent care reflex, you reduce one of the most expensive habits in the U.S. ledger.

Public system versus private insurance in Spain: what we were buying

Spain’s national system is widely described as near-universal and tax-funded, with care delivered primarily through the public network. In practice, you interact with your centro de salud, your assigned GP, and the referral system for specialists and hospitals.

The public side covered the big scary categories we cared about:

• GP visits and referrals
• urgent care and emergency pathways
• hospital care when needed

But it did not cover the things Americans often assume are “included” everywhere:

• most adult dental beyond limited public offerings
• a lot of vision costs
• convenience and speed, depending on the specialty and region

So we bought private insurance as a layer, not as a replacement.

And here’s the part people get wrong: private insurance in Spain can be reasonably priced for many adults, but it’s not a flat number forever. Age, pre-existing conditions, and plan structure matter. Many plans also use copays for each visit.

Our plan was simple: no copays, higher monthly premium. That kept the ledger clean.

Why it was worth it for us:

• A dermatologist appointment that didn’t become a month-long scheduling project.
• A couple of specialist visits where we wanted reassurance quickly.
• The mental relief of knowing we had a second door if the first door moved slowly.

What it didn’t do:

• It didn’t magically make dental cheap.
• It didn’t turn Barcelona or Madrid wait times into a non-issue for everything.
• It didn’t remove bureaucracy. It just moved it to a different office.

If you’re trying to decide whether to buy private coverage in Spain, the real question is not “is it cheaper.”

The question is whether speed is worth a fixed monthly cost in your life stage.

For many people 45–65, the answer is yes, even if the public system is solid. Not because you’re fragile, but because you’re tired of uncertainty.

The U.S. for 24 months: where the money actually went

Our last two years in the U.S. cost us $20,728 out of pocket for two adults.

That’s about $864 per month.

And yes, the bulk of it was premiums. That’s exactly why Americans feel like they’re paying for healthcare even when they’re healthy.

Here’s the U.S. breakdown from our bank statements and EOB trail:

• Premiums withheld from paychecks: $14,640 (average $610 per month)
• Deductible and coinsurance payments: $2,940
• Copays for primary care and specialists: $780
• Prescriptions: $612
• Dental (insurance plus out-of-pocket): $1,236
• Vision: $420
• One urgent care visit that turned into two bills: $100 (the visit) plus $0–$200 in follow-ups depending on coding, this is where the U.S. gets cute
• A few lab and imaging charges: $0–$300 kind of items that arrive later than your memory of the appointment

If you’re reading that and thinking, “Okay, but employer plans vary,” yes. They do.

But the pattern is consistent across many plans: you pay a monthly premium to access the system, then you pay again when you use the system.

KFF’s employer survey data consistently shows how common deductibles are and how large they can be, even for people who feel “well insured.” That matches what we lived. The premium does not eliminate exposure. It just changes the paperwork.

This is also where the U.S. ledger feels personal in a bad way. Spain felt like a system. The U.S. felt like a negotiation.

And you can be perfectly organized and still end up chasing bills that do not make sense.

The calendar problem: predictable in Spain, spiky in the U.S.

If you want to understand why Americans talk about healthcare like a constant threat, it’s not only the total amount.

It’s the timing.

In the U.S., the calendar is designed to create a reset. Your deductible and out-of-pocket tracking often start over each year. That means January can feel like a trap door, even when nothing is wrong.

In Spain, the rhythm is different. The big costs are either:

• fixed monthly premiums if you choose private coverage
• small pharmacy copays
• planned dental and vision spending

So the Spain calendar has fewer financial jump scares.

Here’s how that played out in our U.S. two-year period:

• A calm month might still cost $610 in premiums, even if we didn’t go to a clinic.
• A “normal healthcare month” could be $610 plus a few copays.
• A month with imaging or specialist work could spike to $1,200–$2,000 depending on how the deductible landed.

In Spain:

• Most months were €184 plus almost nothing.
• A dental month could spike to €350–€450, then drop back down.

This is why budgeting feels easier here, even when the system is not perfect.

It’s not that Spain never makes you wait. It’s that Spain rarely makes you pay thousands in a single month for standard care. The emotional impact is huge.

And this is where the boring phrase matters: Timing beats willpower. People do not fail at budgeting because they are weak. They fail because their system drops large bills at random moments, and they reach for the fastest coping tool they have, usually a credit card.

Common mistakes Americans make when budgeting healthcare in Spain

Most healthcare budgeting mistakes in Spain come from importing U.S. assumptions.

Here are the ones I see over and over, and the fixes that actually work.

1. Assuming public coverage automatically means zero cost
   Prescriptions often have copays. Dental is not magically included for most adults. Plan for €25–€60 per month for small health spending even if you’re mostly public.
2. Buying the wrong private plan
   People either overbuy a premium plan they don’t need, or underbuy a plan full of copays and then get annoyed when every visit costs extra. Decide what you want: lower premium with copays, or higher premium with calmer usage.
3. Not registering properly
   If you’re eligible for public coverage, do the paperwork. Get your card. Know your centro de salud. Without that, you drift into a private-only life by accident, which is the most expensive way to do Spain.
4. Treating pharmacies like retail stores
   Pharmacies will happily sell you branded versions of everything. Ask for generics when appropriate, and ask for the simplest option that works. The phrase por principio activo is your friend.
5. Forgetting dental and vision until something hurts
   In the U.S., people often avoid dental because the pricing can feel absurd. In Spain, dental can be more manageable, but it’s still not nothing. If you budget €300–€700 per year for dental maintenance, you prevent the ugly surprise.
6. Thinking wait times are uniform
   Spain is not one system. Regions differ. Cities differ. Even within a city, your assigned center matters. If you need faster access for a specific specialty, consider private coverage, but do it with a clear goal, not panic.

The short version: Spain can be cost-stable, but only if you build the system around you instead of floating outside it.

The next 7 days: build your own cross-country healthcare budget without lying to yourself

If you’re considering a move, or even just trying to understand your current spend, do this in one week.

Day 1: Pull 12 months of real payments
Not just bills, payments. Include premiums. Your “healthcare cost” is not what the clinic charged. It’s what you actually paid.

Day 2: Separate fixed from variable
Write two numbers: your monthly fixed cost, and your typical variable cost. In many U.S. cases, the fixed number is already $400–$1,000 per month depending on coverage and age.

Day 3: Identify your exposure number
Your deductible, your out-of-pocket maximum, and your “what happens if something big happens” number. If you can’t say it clearly, you do not know your risk.

Day 4: Build a Spain version of the same two numbers
A realistic Spain plan often looks like:

• Public system as baseline
• Optional private insurance at €50–€120 per adult per month depending on age and coverage
• Dental and vision budgeted separately

Day 5: Decide what you’re buying with private coverage
Speed, English support, specific specialists, peace of mind. If you can’t name the reason, you will resent the premium.

Day 6: Add the boring lines
Dental, vision, prescriptions, and the pharmacy basics. These are the lines that quietly decide whether your life feels “cheap” or “not cheap.”

Day 7: Choose the version you can repeat
The best budget is the one you can live with on a random Tuesday, not just on your disciplined weeks.

If you can do this week honestly, the move decision gets calmer fast.

What I learned, and the choice it forces

Spain did not make healthcare “free” for us.

It made it predictable.

We spent about €245 per month for two adults over two years, largely because we chose private insurance for speed, and we still paid for dental and vision like normal adults.

In the U.S., we spent about $864 per month for two adults over two years, largely because premiums are the cost of entry, and the variable bills still find you.

That gap is not only about money. It’s about how much mental space healthcare occupies in your life.

In Spain, healthcare became something we used. In the U.S., healthcare was something we managed.

So the decision is not “Which country has better doctors?” or “Which one is more modern?”

The decision is whether you want to live in a system where the common costs are pooled and mostly boring, or a system where you pay a monthly access fee and still need a backup plan for the spikes.

If you’re 45–65 and you’re tired, that difference matters more than almost any single bill.