Caja, a Model Health System?

August 21, 2009

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First in a Three-Part Series on Health Care in CostaRica

 

As the healthcare debate swirls through thechambers of the United States Congress, in town hall meetings, on main streetand in boardrooms throughout that country, medical experts in Costa Rica havewatched from the sidelines with heads shaking.

It’s been more than 65 years since this smallcountry of 4.6 million people introduced a public health care system. Spending $6,000less per capita than the United States on health today, Costa Rica boasts alonger life expectancy and an infant mortality rate nearly equal to that of theU.S.

With a reputation for high quality and lowprices, the country has even fashioned an industry out of health care,attracting hundreds of visitors each year who take advantage of medicaltourism.

“What we don’t understand is how we are ableto work with this,” said Rosa Climent, medical director of the Costa RicanSocial Security System, pointing to a chart that shows employers pay 9.25percent and workers pay 5.50 percent of their salaries into the system, whichcovers “all our health needs. And how the U.S. pays so much more and doesn’tcover its citizens.”

Not only do Costa Ricans have an 86.8percent coverage rate, but the public health system serves residents who livemiles from cities.

“How does a small country with a medium investmentlike ours achieve full coverage for all of its citizens?” asked Climent. “It’sa big accomplishment.”

Like any institution, the Social Security Systemin Costa Rica (the Caja) has its faults – long wait times and bureaucratic hurdles– but most Costa Ricans agree that their North American neighbor can learn somethingfrom the system that serves their country.

TheBirth of the Caja

Costa Rica’s Social Security System was bornin 1941 under then-President Rafael Angel Calderón Guardia, a European-educatedCosta Rican physician, who modeled it after a program in Chile.

Staunchly opposed by doctors, employers andpharmacists at the time, coverage gradually expanded and – at each step – was metby complaints that it would eliminate private medicine and related businesses.

In 1943, the Caja became an autonomous organization,operating on income generated by workers and their employers.

Today, the central government contributes onlyenough to provide for the 17 percent of people who live below the poverty line.

Challenged by a 1995 World Bank report, theCaja’s most recent campaign has been to flush rural hospitals and clinics withenough staff to make coming to San José for treatment unnecessary.

Health officials set up 1,000 clinics throughoutthe country, calling them Basic Teams for Integral Health Attention (EBAIS), andtasked them with enhancing prevention methods and expanding primary care.

“What we are trying to ensure is that the capitalcity doesn’t absorb all the services or all the technology that our countryhas,” Climent said. “We are working on equipping our provinces with the besttechnology so that people who need health services don’t have to come to SanJosé.”

But the Caja has long been only one arm ofthe Costa Rican medical system. A private option existed many decades before a publicprogram was offered, and it continues still. The private option primarilyserves the wealthy and upper middle class.

For those who can pay for the added coverage,the National Insurance Institute also provides private health insurance for roughly$800 a year, depending on age and medical condition. It will cover minorailments and surgeries (depending on the plan) and allows patients to avoid thewait that comes with attention by the Caja.

Additional health insurance companies areexpected to break into the Costa Rican market in the near future, due to theCentral American Free Trade Agreement with the United States (CAFTA).

TheWait Time

Every country – from the corporate-dominatedhealth care in the United States to the social programs of Canada and England –is confronted with the challenge of limiting demand.

“It’s almost an art form,” said Daniel Wikler,an international health professor at Harvard University and a consultant forthe World Health Organization. “With the limited number of spots there are, youhave to find a way of deterring people from making an appointment with doctors.”

Even the insured in the United States, someof whom pay as much as $800 monthly for health coverage, are encouraged to stayaway from medical services through higher co-pays.

“To say someone is insured in the United Statesdoes not mean a whole lot,” Wikler said. “Most people are shocked to get a billfor $60,000 and a note from their insurance company informing them that thetype of service they received is not covered. In fact,most of the people whofile for bankruptcy in the United States are insured.”

The public system in Costa Rica limits demandwith long wait times.

To get an appointment with a doctor, patientsline up outside of medical clinics at sunrise and – if they are lucky – theyget an appointment within a few weeks.

Non-emergency services can keep some patientsin hospitals for upwards of a month. When asked about the long wait periods, Climentshrugged it off, saying that people could plan ahead for needed healthservices.

“For someone suffering from a heartcondition, it may take one day to receive attention,” Climent said. “Butfollow-up appointments can be scheduled in advance.”

Yet, Edwin Ramírez, who’s been waiting 35days for a hip replacement, knows better. Ramírez hasn’t left the fifth floorof Hospital Calderón Guardia since he first got a bed there in mid-July.

“I can’t leave or I’ll lose my spot,” he said,as he walked to a small seating area at the end of the hall. “From myperspective, the system is broken.”

The 37-year-old advertising executive passesthe time by reading books and sending text messages, but he admitted that it feelslike prison.

“It’s a lot of waiting,” he said.

Ramírez had the same surgery done on hisother hip two years ago. At that time, he came into the hospital, had thesurgery and left only days later.

“Two years ago, the population was less,” hesaid. “But now there are more people, more immigrants and more (seniors) in theirlater years. Costa Rica doesn’t have the infrastructure to support them.”

Added to the wait time and sleepless nightsis the stress of wondering whether he still will have a job at the end of theprocess.

His roommate, 51-year-old Urtecho Campos,who had been in the hospital a combined 42 days waiting for surgery, said heworries about keeping his job, also.

“Thankfully, my children are all grown,” hesaid. “But imagine a parent who has young kids, who is struggling to pay the rent,who has other bills. I have lost a lot of income on this already.”

What frustrates Campos more than waitingis the idea that his tax dollars are being wasted on downtime in the hospital.

“It’s very disorganized, administratively,”he said. “Other people could be in this bed – maybe people who need it more. “Justdo my surgery and get me out of here,” he said.

MaintainingSolidarity

While most people interviewed voiced frustrationat wait periods and long delays, they agreed they wouldn’t trade their system forthe one in the United States.

“It’s a good system, it’s just broken,”said Ramírez. “We need to pay more into the Caja for more doctors and beds.”

But, it’s also important to keep theprivate option, he said.

Danilo González, a doctor who runs a privatepractice in Escazú, but who spent 15 years serving in public hospitals, agreed.

“Anyone – anyone – can receivecare in Costa Rica, and they’ll receive the best care available in the country,”he said. “In the United States, (what happens) if you don’t have insurance andcan’t pay? Out the door. You are left to die in the streets.”

Climent, director of the day-to-dayoperation of Costa Rica’s Social Security System, said she almost was turnedaway from the door when she sought emergency services for her daughter in theUnited States. She said her family wasn’t allowed to see a doctor at a hospitalin Florida before presenting $600.

“In our system, the people who earn the most,pay the most, and the people who earn less, pay less,” she said. “But everyonehas the right to the same services. The people who earn more pay more so thateveryone has access to healthcare.”

And what is the most significant obstacle toadoping a similar system in the U.S.? “They don’t have the same commitment tosolidarity,” Climent said. “We have a culture of solidarity in our country inwhich people with more economic means take care of those with less.”

And, while Costa Rica may provide a modelfor the U.S., President Barack Obama already has rejected the idea of ahealthcare system based on the Canadian system, similar to that of Costa Rica.

Earlier this month, Obama said, “I’ve saidthat the Canadian model works for Canada. It would not work for the UnitedStates, in part simply because we’ve evolved differently.

So, we’ve got to develop a uniquely Americanapproach to this problem.”

 

The Current U.S. Health System

Healthcare is offered through theworkplace, with workers paying a portion and their employers paying anotherportion. For those over 65 or on welfare, the government provides insurance formedical services. A significant flaw in the system is lack of coverage forpeople between jobs, or are in positions where employers don’t offer insurance.Private insurance premiums (not through an employer) can run as much as $800per month for a young, healthy man or woman. Health insurance companies arealso known to refuse coverage for expensive medical procedures and forpreexisting conditions, leaving the insured with bills that could take alifetime to pay off.

 

The Costa Rican Health System

Consumers in Costa Rica can choosebetween the public system – known as the Costa Rican Social Security System(Caja) – or elect to go to a private doctor, or both. In order to compete withthe public system, private practices keep their rates low and a simple check-upwould cost between $50 and $60. Yet, all workers are required to pay a portionof their salaries (roughly 5.5 percent) to the Social Security System, whetherthey use it or not. Though public, the Caja is still touted for its highquality, the latest technology and doctors who split their time between the twosectors. Complaints include long-wait times and alleged instances offavoritism.

 

What’s Proposed for the U.S.

U.S. President Barack Obama has proposedreforms that would include a reduction in healthcare costs for businesses andgovernments, protection for families from bankruptcy due to healthcare costsand maintenance of coverage when a person changes or loses a job, among otherproposals. He’s looking to establish a government-sponsored health insurance programsimilar to Medicare that would be an option for all citizens, regardless ofage.

 

HealthCoverage Among

CentralAmerican Countries in 2007

 

Population

Percent Without Coverage

Percent Without Access

to Health Services

Costa Rica 4

4,618,012

13.2 percent

0

El Salvador

7,104,999

84.2 percent

41.7 percent

Guatemala

13,611,646

81.7 percent

20.1 percent

Honduras

7,690,040

82. percent

30.1 percent

 

Nicaragua

6,091,158

92.3 percent

27.9 percent

Panama

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