Who are those who take out private health insurance in Spain? What makes them do it? What consequences could it have for the future of the public health system? How could we reverse this situation? These questions are of decisive importance for the maintenance of a universal public health system, which is capable of facing with equity and efficiency the challenges that the 21st century brings to public health. But before looking for answers to these questions, allow me a comment on the importance of the role that public health plays in supporting liberal democracy and the social market economy, which is the economic system enshrined by the Constitution. Public health is a fundamental piece of what we could call the social contract , the glue of Spanish democracy. In the Moncloa Accords signed in October 1997 and in the 1978 Constitution, a social contract was formalized: the left accepted that the market economy could be a good system for creating wealth, in exchange for the right supporting a new State. social that had public health as one of its four fundamental pillars. The General Health Law of April 1986, promoted by the remembered Minister Ernest Lluch, changed the genome of the system: from “beneficence” to “universality” of the public health service. To what extent does our national health system Is health today complying with these principles of universality? The Economic and Social Council of Spain (CES), which I have the honor of presiding over, has recently published a report on The health system: current situation and prospects for the future. In addition to its recognized technical quality, it combines the fact that its diagnosis and proposals are the result of dialogue and agreement between the sixty councilors who represent the large union and business organizations and other sectors of the Spanish economy such as agriculture, fishing, consumers and the social economy. The Report exhaustively and rigorously analyzes all dimensions of the system. Given the limitation of space, I want to highlight two warning signs that public health is showing: the appearance of an inverse care effect and the risk that waiting lists are causing the middle classes to flee from the public system. The policy of Investment cuts in public health, due to the austerity of the last decade, have left lasting scars on universal access. These scars are the result of four biases that have appeared in the system: age, gender, place and social class. The former mean that the elderly are unjustifiably excluded from trials, treatments, diagnoses and suffer from rationing of services due to age. Gender biases operate in the same sense as age biases to the detriment of women. Place biases in access arise from living in small towns, villages and rural towns. Class bias operates in the sense that the poorer you are, the less benefits you receive from the system. The result of these scars produced by austerity is the appearance of a reverse care effect: those who need health care the most are those who receive the least health care. But perhaps the most decisive warning sign for the future of the public system are the long waiting lists. In the CES report they appear as the main reason for contracting private health insurance. The people who do it belong to a certain segment of the population: upper-middle income level, university education, and intermediate ages. They flee from waiting lists. Why is it important to stop and reverse this flight of the middle classes from public healthcare? Because they are the segment of the population that has the greatest capacity to exercise their voice to denounce the deterioration, as well as to pressure for its improvement. If they leave the public system, valuable information about its functioning will be lost, while internal pressure to stop its deterioration will decrease. We risk returning to a system based on charity, not universality. This perverse effect of the flight of citizens from fundamental public services (it also occurs in education) was accurately identified and explained by Albert O. Hirschman , the economist of the second half of the last century most cited by non-economists. In a small and thought-provoking book (like all of yours!) titled Exit, Voice and Loyalty. Responses to the deterioration of companies, organizations and States (1970; Spanish edition, 1977, FCE) Hirschman saw that the “exit” of citizens from public services (or customers in the case of companies) makes organizations lose a valuable information mechanism about what is going wrong and an internal force of pressure to reverse the deterioration. Hence, it is recommended that those responsible for States and companies favor the exercise of the voice of users who are dissatisfied. The advantage of voice over exit is that it strengthens loyalty to the system and forces its improvement. According to this approach, the priority task of those responsible for public health should be to implement short-term shock actions that reduce waiting lists; and, in the medium and long term, carry out more effective planning and management of human and material resources to retain the middle classes in the system. Public health is one of the great achievements of democracy. It continues to maintain a high reputation and broad social support. In comparison with other national systems it continues to fare well. But we must pay attention to these warning signs. Not only because of a question of equity in access to good health but because a healthy population is economically more innovative and productive. Furthermore, the deterioration of public health would also affect support for democracy and the legitimacy of the market economy system. It must be remembered that article 1 of the Constitution says that “Spain is constituted as a social and democratic State governed by the rule of law.” The order of the adjectives is not indifferent: first it is social and then democratic. And public health is a fundamental pillar of our social State.