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Universal Health Care — A Modest Proposal

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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.

About Dan Miller

  • Clavos

    The fees you’re paying in Panama are attention-getting, Dan.

    $100 monthly premium; mine is $900 for a top-shelf PPO.

    $33 for an entire ER fee? My ER copay is $150.

    One feature we really need to consider in whatever plan(s) are eventually proposed (as they surely will be) is portability – if you change jobs or undertake any other lifestyle change, you take your insurance with you.

  • bliffle

    Tort reform is a distraction. You can remove it from your list. The overall cost of malpractice suits amounts to about 2% of medical cost. Yes, it’s gaudy, as some high-flying tort lawyer helicopters onto the courthouse lawn to make his plaintive plea to a jury and screw some doctor.

    But there are several countervailing arguments in favor of tort justice:

    (1) get rid of bad doctors. A small percentage of docs cause most lawsuits. The AMA simply won’t get rid of them. After all, the AMA is the doctors union.

    (2) most tort judgements are small, but the anti-tort folks play up the sensational ones.

    (3) in a Free Market system you can’t nullify a citizens right to pursue recompense for harm done to him.

    (4) Defensive diagnosis and testing may be a good thing. The road to successful diagnosis and treatment is not straight. Perhaps, in retrospect, it will be apparent, ex post facto, that some test was unfruitful, or some procedure was not necessary, but that’s true in most of our activities, anyhow. It’s not the job of the doctor to decide ahead of time what procedure is most economically efficacious. His job is to diagnose and treat. His goal is to do what is best for his patient, not what is best for some insurance company.

  • Clavos

    in a Free Market system you can’t nullify a citizens right to pursue recompense for harm done to him.

    But the recompense should be limited to actual fiscal damages.

    This should be true in all tort cases, not just medical.

  • Dan Miller

    Biffle,

    Just out of curiosity, where did you find that The overall cost of malpractice suits amounts to about 2% of medical cost? Also, just out of curiosity, what is included in the overall costs?

    Dan

  • Zedd

    Very informative Dan. Thanks.

    I am curious about what brought you to Panama and what the adjustment period was like. What are the pulls and what negatives would you warn Americans about.

  • Clavos

    Big awards don’t “put fear” into anybody; even the insurance companies know they can recoup the awards with higher premiums, and every doctor I know (and I know quite a few socially through my wife’s brother, who is one), bitches a lot about what they pay in premiums, but it’s really a cost of doing business, they still make a lot of money.

    The only group really affected, either positively or negatively, by large awards are the attorneys; at least, limiting awards would discourage a lot of the cases currently clogging the courts unnecessarily.

  • bliffle

    “But the recompense should be limited to actual fiscal damages.”

    So say some. But ‘punitive’ damages exist for a reason, namely to deter careless or malevolent acts upon another person. After all, we use punitive fines in traffic cases ($281 for violating the carpool lane!) and it works pretty good. If we only could sue for actual damages then the doctors strategy would incline him to be careless since it would only cost him if he got caught.

    Anyway, judges are generally antagonistic toward uninfluential little guys and hand out rather poor recompense, commonly discounting “actual fiscal” cost and dumping some part of the costs on the claimant, assuming, I guess, that he’s partly responsible for his own misfortune. Only high profile cases get the big awards. I’ve known two malpractice trial lawyers in my life. One was a flamboyant guy who sued the Mayo Clinic when they amputated the wrong leg on a young woman. He relentlessly smeared them and secured a gigantic settlement with a jury. Not that it gave the woman her leg back, but at least it made her life with no legs a little better, tho not as good as a one-legged life. And maybe it put enough fear into docs/nurses so they’ll check more carefully, although I was reading recently that they still make such egregious mistakes!

    The other guy was strictly a small-timer who secured small settlements for rather common mistakes that would usually barely cover the victims out-of-pocket expenses of a few thousand dollars, let alone lost work time and legal fees. Usually decided by judges, who are ultra-suspicious of claimants.

  • bliffle

    Panama is a very attractive retirement destination. I think they still have a favorable Retirado or Pensionada or whatever program favoring old people who can show a certain income per month. Costa Rica, by contrast, has ended their program.

  • bliffle

    I researched medical cost breakdowns several times in the past 30 years, starting with the old US Statistical Abstract at the public library. More recently I’ve done it with the WWW, probably using GAO or CBO or other such sources. I may have kept some source materials on a computer, maybe reports and URLs, but i’m loath to find them right now with so many projects to do. After awhile I just remember bottomline info. Anyone can google these things up, shouldn’t take more than a couple hours.

  • Dan Miller

    Zedd,

    After sailing around the Caribbean for half a dozen years and spending lots of time in various places, we wound up in Panama which we liked best. The adjustment period continues, but on the whole has been a pleasant experience. The fact that my wife speaks fluent Spanish helps, a lot. I’m learning, but my Spanish remains ungrammatical and my vocabulary limited.

    There is great diversity here, from several big cities (which I detest) to small towns and villages, and rural areas, in the mountains (which I love).

    The best advice anyone could give to someone considering relocating to any part of Panama, or indeed anywhere else, is go for an extended visit of several months. Here in the highlands, we have two seasons — wet (April-November) and dry (December – May). Some people visit during the dry season, move here, and find that they hate the rainy season. Others move to one area, decide that it isn’t for them and move; perhaps only a few miles. There are numerous micro climates, and they differ substantially.

    The other great advice is for people coming here to leave their perceptions at home, and accept Panama for what it is; it is not the United States, and the U.S. Constitution and laws don’t apply. This creates substantial frustration for many Gringos.

    I dislike stereotyping, but the people in rural areas here tend to be very gracious and welcoming, but you need to be able to communicate in Spanish.

    Just about everything is available here, except for good Jewish Rye Bread, for which I would gladly kill.

    Lest this post get too long, let me give you some internet links.

    Life in Potrerillos abajo, at about 2,000 feet above sea level. We are at about 3,200 feet AMSL. There is an interesting article comparing the Panamanian “resource driven culture” with that in the U.S.
    more general stuff categorized by topic
    Neuter and Spay clinic

    There are lots more, but this is a fair sample and only three URLs are permitted in a comment.

    One further thought: as I recall from one of your comments on a different thread, you have a teenage daughter. School can be a problem, since the local schools are not good; there are a few private schools for English speakers, but I don’t know much about them. Home schooling may be the best alternative. Some families on boats whom we met in the Caribbean used home schooling, and seeing the results, I became a big fan. It works, if the parents are willing to put in the time and effort.

    Maybe some day I will write something about an expat’s views of Panama.

    Dan

  • bliffle

    Ah yes, the schools. Friends of mine moved to Costa Rica for a few years and finally moved back to CA because they found the schools for their daughters to be very poor. Maybe this is a general problem in Central America. Good opportunity for an experienced educator, maybe. I knew a guy who did that in Mexico many years ago and he had a steady stream of US kids flooding into his school.

  • Zedd

    Dan,

    Thank you. It sounds lovely. I was hoping that you’d go on. I am looking forward to reading more from you in the hopefully not too distant future.

  • Clavos

    There have been American (and British) schools in Mexico for more than fifty years. I attended one of each in grade school.

    The granddaddy of them all is The American School in Mexico City, which even in the fifties was a K-12 with about 1500 kids enrolled; both American and other foreigners and upper class Mexicans. Most of the American kids left after eighth grade and were sent Stateside to boarding school. I went to a prep school in Massachusetts.

    They teach to the US curriculum and are fully accredited, so that children whose parents are transferred back to the States don’t lose ground.

    There are American schools in Mexico City (several), Guadalajara, Monterrey, and a number of smaller towns as well.

  • Clavos

    According to the US Department of State, in 1999, the population of Americans living in Mexico topped one million, and comprised 25% of all expatriate Americans worldwide.

    When I was born there (a Loooong time ago!), there were fewer than 20,000 in Mexico City, and another 5,000 or so in Guadalajara, with scattered smaller populations in the smaller towns.

  • Cindy D

    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… available to the most affluent will be available to all.

    But, it already is and has been in virtually every developed nation one can think of.

    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.

    This is your presumption, which is not supported by the facts.

    It also diminishes the availability of scarce resources for other worthy causes, such as education and the like.

    Another presumption. Also, not supported by the facts.

    This reads like an apology for the necessary evils of pure capitalism. Capitalism is so good and great and beneficial, that it’s not only necessary but it’s A-OK to let people die or suffer receive inadequate care, even though we can care for them. Greed is good.

  • Dan Miller

    Good morning, Clav

    I realize that Mexico has some very good schools. Jeanie (my wife) attended the University of Mexico in Mexico City for two years while she was in college, and thinks quite highly of it. While there, she lived with a Mexican family and that helped quite a lot with her Spanish language proficiency.

    The entire country of Panama, however, with a total population of just over three million, has less than a third of the population of Mexico City alone.

    I suspect that there may remain some good English language schools in Panama City, left over from when the U.S. had a big presence there. However, for folks living up here, in the highlands of Chiriqui Province, the closest English school(s) is (are) in David, about forty minutes away by car and longer by bus — quite a daily round trip. Recently, there has been some talk of establishing an English language Christian school in Boquete. Whether that will happen is unknown.

    The local schools generally teach by rote, and the teachers — while dedicated — are not the best trained in the world. The son of our farm manager, a bright young Indio (the least privileged population segment), just began attending university, from which he will be graduated with a teaching certificate after only one and one half years. I am very proud of him, and of his dad for providing such financial and other support as has been possible for him. The young man recently asked Jeanie to translate into English some Spanish phrases; his Spanish spelling was atrocious.

    For these and other reason, I think that for a family moving here with young kids, home schooling is the best bet.

    Dan

  • Dan Miller

    Cindy,

    You contend that superb health care purchased by the affluent without significant limit can be made available to all, without diminishing resources, and say that my contrary presumption is erroneous.

    If the money pot were infinitely deep, I would have to agree with you, provided that in addition to money an infinite supply of physicians and other health care resources were available.

    Unfortunately, funds and other resources devoted to X have to come from something else, which diminishes the resources available for “something else.”

    Perhaps things are done better in some “developed” countries; I haven’t studied the subject in depth, but have read that in many such countries health care is neither all that good nor all that available on a timely basis.

    Sure, the U.S. could institute something and denominate it “free, universal health care” in a flash. As we all know, increasing Governmental involvement consistently makes everything better, fairer, less expensive and generally superior. Or did I overlook something?

    Perhaps one avenue would be to extend the health care and benefits available to members of the Congress, the President, members of the Supreme Court, et al to everyone, for free. And why stop there? Those folks also have excellent pensions and get lots of perks. Why just them? Why not everybody? Obviously, those benefits are fair, just, reasonable and necessary, so why shouldn’t they be available to all, on the same terms?

    Perhaps you are correct about the free, universal health care provided in many other “developed” countries. If I can arrange junkets to undertake fact finding missions to those countries, at Government expense and with the perks provided to members of the Congress, I shall be happy to undertake an investigation (particularly in the most appealing of those countries) and provide a full report.

    Dan

  • Clavos

    Buenos dias Dan,

    The young man recently asked Jeanie to translate into English some Spanish phrases; his Spanish spelling was atrocious.

    That reflects VERY poorly on the rural Panamanian schools; as you know, unlike English, which is a very difficult language in terms of spelling conventions, Spanish is almost totally phonetic; spelling in Spanish is child’s play as long as one is literate.

    It’s a real tribute to the young man that he has overcome those kinds of odds and actually made it to university.

    When I was in grade school at the Colegio Americano (the American School), after completing the US curriculum I mentioned earlier, each day we had a Mexican teacher who came in to teach us Spanish grammar, Mexican history and geography, and (the only repetition from the English session) arithmetic. This lasted through the sixth grade, which at that time was the legal minimal education in Mexico. I still have my Certificado de Educación Primaria, issued by the Education Ministry, somewhere.

  • Clavos

    Dan sez,

    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… available to the most affluent will be available to all.

    Cindy replies,

    But, it already is and has been in virtually every developed nation one can think of.

    Not even in the USA, the most developed nation in the world, Cindy. You know that.

    In fact, in the USA right now not even certain elements of the middle class with insurance receive the “very best and most expensive healthcare.” You have to have an advocate who is quite sophisticated regarding medicine and willing to go to the mat for you in order to get that.

    I know this from several years’ of personal experience.

  • Dan Miller

    Clav,

    Spanish is almost totally phonetic; spelling in Spanish is child’s play as long as one is literate.

    True, but there are also a few problems, as you know far better than I. B and v are in many cases pronounced about the same and are therefore easily confused in spelling; that was one of the young man’s spelling problems. There were, of course, others.

    Dan

  • Cindy D

    Dan,

    Allow me to start you off with some information about the country the WHO rated #1 in 2001:

    France’s model healthcare system

    By the way, nothing is free Dan. That’s what taxes are for. It’s just a matter of what we want to spend our tax money on. Being alive is sort of a big priority for most people. I mean if you don’t wake up, how important are other things?

    You know, I often opine that we, as Americans, consider ourselves to be the best (hard to know how we decided this when we so often fail to actually examine those we compare ourselves to).

    Anyway, here is a reason why this is dangerous. If we are the best, then we don’t tend to look at how anyone else does anything at all. We thump along with our squarish shaped wheel or excuse some very foolish things we do, without noticing that there are other people sailing along on round wheels.

  • Cindy D

    I think we are in agreement Clav, about US healthcare.

    By virtually, I meant nearly every one except the U.S.A.

  • Clavos

    Cindy,

    According to your link, the French system does seem to be quite impressive, assuming the report is accurate and true (always a concern with material presented in an American news provider).

    It warrants further investigation.

  • Dan Miller

    Cindy,

    Interesting link, and I agree with Clavos’ comment. I do note that France doesn’t have much problem with medical malpractice claims, which probably helps. Additionally, the billing and payment procedures seem quite efficient. Also, the article notes that about 90% of the French have some form of private insurance to cover procedures not provided by the Government system.

    I don’t have the statistics to back it up, but I understand that physicians in Panama also are not as well compensated as those in the U.S., relative to the compensation of workers as a whole.

    The French system is certainly worth looking at.

    Dan

  • Cindy D

    A couple more links that are useful include:

    Physicians For A National Health System

    and,

    This link is to a bit of a PBS production called, “Sick Around the World”. Unfortunately, France was not included in this production. But, what I find interesting is Taiwan. Taiwan developed its system only very recently and they did so by studying the systems in other countries. Taiwan provides an example of the development of a fairly fresh healthcare system, culled from what were felt to be the best available.

    At the end of the 2 minute intro on Taiwan, Hongjen Chang, an official in charge of designing the system, says that they thought that America would (logically enough) have the best system. That was until they began to look. Very diplomatically, I think, Mr. Chang says that, well, America doesn’t really have a healthcare system, it’s a market. It’s what happens if you leave things to go as they will.

    Chang says they designed their system by “following the oxcart”. Chang: “The track of the previous cart is the teacher of the following cart.” So, you follow the cart that found a good route and you steer clear of the cart that got stuck. A very wise idea indeed.

  • Clavos

    Cindy,

    I’m familiar with PNHP, my brother in law (a physician) showed it to me about a year ago, but I’m not that impressed by their plan (which I’ve read carefully); I don’t think they’ve thought it through well enough; it raises more questions than it answers.

    BTW, I sent your link to him.

  • Dan Miller

    Here is a link to an interesting article on tort reform.

    In 2003 and 2005, Texas enacted substantial tort reforms and since then, some 7,000 M.D.s have flooded into Texas, many from Tennessee.

    Tort reform has allowed doctors and hospitals to cut costs and even increase the resources devoted to charity care. Take Christus Health, a nonprofit Catholic health system across the state. Thanks to tort reform, over the past four years Christus saved $100 million that it otherwise would have spent fending off bogus lawsuits or paying higher insurance premiums. Every dollar saved was reinvested in helping poor patients.

    Dan