My wife and I live on a small farm in a fairly remote, rural area of Panama, up in the mountains. This article is based on several years of observation of the health care system here. For people who have insurance and/or sufficient funds, health care is excellent, and in many respects superior to that in the U.S. It is also dramatically less expensive, and for that reason there has been some medical tourism. However, this article is not about that. It is about the health care provided to people who have neither private insurance nor much money.
The public health care system is available to all residents, Panamanian or not; an eighty year old Canadian friend who lives nearby lacked health insurance but needed a month of chemotherapy treatment; he received it at the public oncology hospital in Panama City. His total costs, including daily hospital visits, chemotherapy, a modest hotel room, transportation to and from the hospital, food, etc., came to less than $1,600. He survived, and is doing quite well.
Most people who are employed full time are covered by the Panamanian social security system. With very few exceptions, those who are not covered are not covered because the employer is breaking the law. The system is funded by employer payments (15.96% of salary) and employee payments (9.2% of salary). People who are self employed are not automatically covered by the social security system, but can be if they wish by paying a modest amount into the system. Unlike the system in the United States, health care is provided to all people covered by the system and to their immediate families, during their working years, as well as following retirement.
Within a twenty-five minute walk from our farm, there is a social security medical clinic in Potrerillos Arriba (population 1,165) which is open daily. The clinic is staffed by a nurse six days per week and, once or twice a week, by a physician as well. Care is provided to patients covered by the social security system at no charge, and is provided to others at minimal cost, roughly $3.00 for a routine visit. People perceived to have serious health problems are seen promptly, others have to wait a bit. If adequate care cannot be provided at the local clinic, the patient is transported, by ambulance if necessary, to the next level of care, in Dolega (population 1,843), roughly twenty minutes away. A physician is either there, or available at all times. Should care unavailable there be required, the patient is transported, by ambulance if necessary, to the social security hospital in the nearby large city, David (population 124,500), roughly twenty minutes away from Dolega. All of this is done without charge to those covered by the system and their families, and at very low cost to others. Some quite costly medical procedures, such as major organ transplants, are not available at the hospital in Dolega. Some procedures not available in David are available at a social security hospital in Panama City (population 708,738), a six hour bus ride away. The ambulance which is used to transport people to the clinic in Dolega and to the hospital in David is also used to transport people without transportation from their homes to the local clinic.
Care at the social security hospital in David is pretty good, but the families or friends of patients are expected to do their part by bringing food, changing bed linens, and doing other things of that sort normally done by hospital staff at private hospitals. Since extended families are common here, that is not so bad and obviously saves money. The public health care system here is basic, but is probably about as good as it can be with the resources available. To the best of my knowledge, there is nothing comparable in the United States.
The system here certainly has flaws: There are some very remote and sparsely populated areas where the closest clinic is hours away and bus transportation (very available and inexpensive in most parts of the country) is unavailable. Neither, to a great extent, is cellular telephone service. Those seriously ill and unable find a ride or to walk are out of luck. Recently, there was a scandal concerning tainted cough syrup distributed by the health clinics, which resulted in some deaths. Ingredients had been imported from China, and mislabeled; ethylene glycol had been used instead of glycerin. All medical care systems have deficiencies, but despite the occasional lapses, the system in Panama is pretty good.
There is another significant difference between health care in Panama and that in the United States: Malpractice litigation. Malpractice litigation has been one of the causes of increases in medical malpractice insurance. This is costly to physicians, hospitals and all other entities involved in health care. Consumers pay for it, whether directly, through their health insurance premiums, or indirectly, through those paid by their employers and passed along to their customers (although less visible, these costs are nevertheless borne by the consumer). A physician such as an obstetrician or gynecologist who has to pay a hundred thousand dollars or more each year for liability coverage obviously has to charge more per patient than a physician who does not. A pharmaceutical company subject to multi million dollar class litigation obviously has to charge more for medicine than one which is not. An additional problem is that physicians often feel compelled to subject patients to tests and various procedures which they deem of dubious utility, simply to minimize their exposure to malpractice claims. This is referred to as defensive medicine. According to a recent study in Pennsylvania, where there is no cap on jury awards,
more than 90 percent of physicians admit to defensive medicine, according to a 2005 study in the Journal of the American Medical Association:
* 43 percent used imaging technology when it wasn't necessary
* Over 50 percent referred patients to other specialists
* 70 percent of emergency physicians ordered additional diagnostic tests
* One third prescribed more medications than were necessary
* 60 percent used unwarranted invasive procedures (except neurosurgery)
* 42 percent have restricted their practices by eliminating procedures like trauma surgery and avoiding patients with complex medical issues.
In Panama, medical malpractice litigation is practically unheard of, and that is one of the reasons (there are others) why health care is comparatively inexpensive, for "rich" Gringos as well as for those who rely on the public health care system.
Although far from perfect, there are aspects of the system which the U.S. — with far more resources per capita than Panama — might consider emulating should universal health care become a reality:
1. Tort reform, involving realistic caps on civil liability for physicians and all others (some states have such caps, some do not), combined with a substantially improved system for resolving medical malpractice claims. I have not been able to find reliable statistics (an oxymoron?) on the savings to health care consumers which this would produce, but suspect that they would be significant. Some pain and suffering would obviously be experienced by the legal community — contingency fees are typically 33% and sometimes reach 50% of recoveries, and defending against a malpractice action is expensive as well.
2. Numerous local health clinics staffed by nurses, with physicians on call, strategically located and available to all at little or no cost, to provide care for those not seriously ill and for triage purposes, with a view toward providing a higher level of care should it be necessary. An ancillary benefit of this would be to relieve the overwhelming of hospital emergency rooms by people who do not require the level of care available there. This would reduce the long waits experienced by seriously ill or injured people at the emergency rooms. As a side note, a couple of years ago, I had to go to the emergency room at a private hospital in David because of an adverse reaction to two spider bites. There were few other emergency room patients, and I was seen immediately. The care was excellent, and the cost to me for everything, including about four hours in the emergency room, physician care, IVs, lab tests, etc., came to $33.00; fees in excess of those charged picked up by my medical insurance provider. My wife and I, both over sixty, together pay approximately $100.00 per month for medical insurance.
3. It has been said of the U.S. culture that there are four basic assumptions: 1) I like it 2) I want it, therefore 3) I need it, so 4) I am entitled to it. This is unfortunate. All economic resources are limited, and are rationed in one of two ways: by market pricing or by Government edict. The United States seems to prefer the market pricing system, and I personally think it works better than other forms of rationing. Food is an example. Those who can afford fillet mignon, caviar and champagne can pay for and enjoy them. Those who can't have to get along with less expensive food. The same is true of houses, automobiles, entertainment systems, and just about everything else.
Health care is an economic resource just like all others, and I simply cannot foresee a day when the very best and most expensive health care (or food, houses, automobiles or entertainment systems) available to the most affluent will be available to all. There must be limits on what is to be provided for "free", and some patients who could possibly survive for a brief period at a cost of several hundred thousand dollars would probably die were "free" universal health care along the lines suggested here to become the norm. That is a harsh fact of life; however, death is a part of life, and to the extent that allocating resources to postpone it briefly diminishes the care available to those who have a reasonable chance of survival, such allocation is harmful. It also diminishes the availability of scarce resources for other worthy causes, such as education and the like. In Oregon, several years ago, there was an attempt to "ration" Government provided health care based on the likelihood of success. Much disparaged, this attempt might be reconsidered. As a ten year cancer survivor myself, I cannot get insurance coverage for a cancer recurrence and quite possibly could not afford prolonged and expensive treatment (particularly in the United States) were that necessary to prolong my life. So be it.
Something is better than nothing, and I suspect that tort reform, examination of the local health clinics provided here in Panama, and reasonable limits on the nature of care to be provided "for free" might be useful to the U.S. in deciding on the nature and extent of the universal health care plan, if any, which is to be implemented.