The debate over a public health care option in the United States is difficult to follow for the millions of global citizens that already enjoy some form of public health care coverage. A country that is perceived to be one of the most powerful in the world does not have a solution for the 15% (more than 45 million) of its own citizens who are denied health coverage or can’t afford it. A 2009 Harvard study found that one person dies every 12 minutes in the country due to lack of access to health care. In the land of opportunity, medical debt is the principal cause of personal bankruptcy, and in many cases, the person subscribed to private health insurance.

In the U.S. financial advisors recommend emergency savings accounts with thousands of dollars to cover unpreventable accidents. In many countries this is considered unnecessary, lending to a ‘live in the moment mentality’. It may sound careless, but what if an extensive hospital stay for a broken leg and orthopedic surgery didn’t cost you a cent? Would it free up your list of financial priorities? Make life a little bit easier?

Living in Costa Rica has introduced me to a new system of healthcare based on helping the majority, no matter their socio-economic status. The U.S. is in a great position to learn from the successes and failures of countries like Costa Rica that have taken the step toward public healthcare before us.

Here is just one example of what life is like with a two-tiered health care system.

Costa Rican Healthcare Setup

In Costa Rica, the health care system was placed under the control of the government social security program (or the ‘Caja’) in 1973, a move that was not without opposition. From then on, all employers were required to pay 9.25% of each employee’s salary to supplement their own healthcare payments of 5.5%, regardless of income level. Today, additional laws have been put in place for employers to insure part time workers, resulting in an estimated 86.8% of the population being covered by the Caja system. Of the remaining populace, all must be offered healthcare by law, though about half will receive government subsidiaries for being below the poverty level, and the other half would receive a bill for their care.

Within the public system there are 30 hospitals and 250 clinics throughout the country. Each insured person is assigned a specific public clinic for normal procedures and a hospital for more serious conditions or emergency care.

Pay to healthcare professionals is based on a teamwork system where their outcome dictates the clinic or hospital’s yearly funding. The idea is to promote quality of care as better health outcomes and efficiency are rewarded. They also save costs by staffing a high number of mid-range medical professionals, especially in rural areas, rather than doctors who require higher salaries and more costly education.

Medicine is purchased from international suppliers in bulk to resell at low prices. A specific department determines how much is spent on what with the goal of attending to the largest percent of the population. However, there have been several cases in which patients won lawsuits against the Caja to obtain funding for expensive drugs or treatment for rare conditions.

Costa Rica also offers a private healthcare option that is available at affordable prices due to the public competition and is provided by the National Insurance Institute (INS), a government insurance monopoly. This option runs for about $800 per year and is used mainly by the upper-middle and upper classes. Subscribers have access to over 200 affiliated doctors, hospitals, labs, and pharmacies in the private sector, including Clinica Biblica and Clinica Catolica, two hospitals affiliated with U.S. hospitals. The quality of care is perceived to be higher than the public option with less wait time, though patients must pay upfront for their care before applying for refunds.

The Patient Reality

Dealing with the Costa Rican public healthcare system is a lesson in humility for patients and visitors alike. While one might compare this to U.S. healthcare for the non-insured, keep in mind that 86% of Costa Ricans subscribe to this system and employers are required to subsidize it for their employees. This is my personal experience with public healthcare in Costa Rica, as a visitor:

On a trip to the beach, my boyfriend Luis broke his arm playing football. We were told there is only one ambulance in the Jaco region and that it would be quicker to drive him to a private clinic to get X-rays. A quick check up, two X-rays and $140 later it was confirmed that he had a distal fracture in his right humerus at a sharp 70 degree angle. They put his arm in a sling and sent us an hour north to the closest public hospital in Puntarenas.

In Puntarenas he was seen immediately by a general practitioner to analyze the situation and put on the appropriate waiting list. An hour later waiting with another orthopedic patient, a doctor told Luis it was the orthopedic specialist’s day off. After further stabilizing the arm, he said we’d have to go to San Jose to Hospital Mexico and they would likely have to operate. Despite fainting two times in the office, Luis was told that the ambulance would probably take 45 minutes to get there and he’d be better off if we could drive him.

After a 2 ½ hour drive, I dropped Luis off at the emergency room in Hospital Mexico. However, because of his local address in San Jose, he would have to go to a different hospital 15 minutes away: Hospital San Juan de Dios. The ambulance was in Alajuela, so we had to drive him to the 3rd emergency room of the day. By the time a doctor was able to see Luis, after providing all of his personal details for the 3rd time that day despite their centralized information database, it was 11:30 p.m. – 10 ½ hours after the accident.

Culture Clash

A smiling doctor called me into the emergency room where bleeding bodies filled the hallways on gurneys parked along the wall. He said Luis would have to stay overnight because he needed surgery once they found the necessary materials, which might not happen for four days. At that point, Luis was sitting up on a padded table instead of a bed, with no pillow and couldn’t lie down because it would pull on his bandaged arm.

Despite my protests, the doctor said if we take him out of the hospital, he would lose his spot on the surgery list. As it was way past visitor hours, I wasn’t allowed to return with his things and a pillow and would have to come back the next day between 6 and 7 p.m. for emergency room visiting hours.

For the next 20 days, my life, while rotating around hospital schedules, was spent trapped in visitor waiting lines and arguing with nurses and guards about lost visitor cards and smuggled snacks. The visiting hours had been reduced to one due to an outbreak of Clostridium difficile that claimed seven lives on the 5th floor (which we could oddly never find). Each patient could only have one visitor at a time, which proved difficult when Luis’s mom came to visit from Guanacaste for more than a week.

The doctors only passed by once a day at 6 a.m. to see patients but avoided questions as skillfully as the nurses, telling Luis that they were waiting on more tests or that there weren’t materials for surgery. Consulting orthopedic doctors in the states, I was forewarned of possible complications like muscle atrophy or the bone resetting incorrectly due to the extended lack of medical attention. The question of taking him out of San Juan and sending him to a private hospital for several thousand dollars tore at us. Promises that his surgery would happen soon made us keep him there, but as estimated dates came and went, our frustration was at an all time high.

By day 10, I had dug up contact information for the director and ex-director of the hospital and the president of the Caja and sent a very worried e-mail claiming negligence on the part of the hospital and referred to the poor treatment that my boyfriend was receiving. That same day an orthopedic surgeon arrived during visiting hours with my printed e-mail in hand demanding to know who wrote it. Ten days after Luis’s internment, this doctor finally told us that they are still waiting results from an CAT scan, nuclear medicine tests and bone density scan to rule out the possibility that the fracture was caused by bone cancer.

The word “Cancer” is powerful enough to shut anyone up – for a moment at least. The fact that they were being thorough in their care does not explain why test results that take one day to obtain in the U.S. were delayed more than a week and a half. It does not make up for 10 days of inconsistent excuses about a lack of materials or lost exam results delaying his surgery – which had us unrightfully turn our frustration to the Caja system. It does not make up for indifferent nurses who would ignore yells for help from the patients sharing Luis’s ward.

On one of his first mornings in the orthopedic ward, a nurse shooed Luis’s mom away as she helped him take off his hospital shirt, insisting he is too old to need help maneuvering his unset broken arm. These were the same nurses that refused to show him his medical files despite a Patient Code of Right’s directly stating his right to see them, and who made mistakes like hooking up a patient in critical condition to an empty tank of oxygen overnight.

The Silver Lining

On day 18, Luis was finally sent to the surgery ward. He was operated on by the chief of orthopedics due to the abnormal situation in which the fracture occurred. The operation went flawlessly and a 6 inch metal plate was placed with 4 pins in his arm. He regained full mobility in his hand and six months later, has overcome most of the atrophy that occurred during his 20 days of hospitalization. He will still set off metal detectors and won’t be throwing footballs anytime soon, but after 4 months out of work, he didn’t pay one cent and, as a government employee, received 100% of his salary.

A month after the surgery he was placed in physical therapy through the Caja, but after two tries, opted to stay with his personal therapist who he had been seeing several weeks prior. At $24 a visit, this was a better option than working with medical students who twice asked him how far he could rotate his foot.

Conclusions

Costa Ricans base the success of their health care system on a general mentality of solidarity. Everyone antes up their portion to cover those who fall ill or injured. The rich pay more than the poor, but everyone gets the same quality of care. Since health care is a right, the lower and middle classes can enjoy a level of security in living paycheck to paycheck without fear of financial problems brought on by an accident or unforeseen illness. As a result, Costa Rica has one of the highest life expectancies in the world at 77.58 years, despite its status as a third world country.

After my experience and many similar stories of subpar care from other patients, it is obvious that the nation cuts corners on health care to maintain affordability. The basis of the system does the best that it can with the resources available, but the management and execution fall short. At one point when a pregnant lady fainted in the waiting room, a mid-level administrator ran out of an office and yelled at a doctor to call the emergency room to attend to her because it is not his department. Her ignorant directions were ignored, and the doctor was met by a round of applause from visitors fed up with the system.

In closing, I believe that healthcare should be a right bestowed on all citizens despite their income or current health. Offering preventative medicine to the lower class will offset expensive medical procedures in the future. The existence of a low cost public option has had far reaching positive influences, and its presence serves as a check on private health care prices, while at the same time the better quality and speed of care are plenty to justify a price difference.

With the high level of medical education and modern health facilities in the states, we have the hope and possibility of staffing public hospitals with more qualified health care workers. There may still be a discrepancy in how quickly such a system can attend to its populace versus private health care, but as long as the quality is there, those who would otherwise face 6-digit health care bills might find that they too have a little patience in them.

Our current situation puts the nation’s health in the hands of a profit motivated health insurance industry. In our system, preventative health care is seen as a cut to the bottom line. Taking profit out of the insurance system is the only way to put priorities back into place and make care more affordable for those without insurance. For the rest of us who have the luxury of acting on the belief that health is invaluable, may we rest assured that we have more than one option.

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Filed under: Living on December 16th, 2009