As the healthcare debate swirls through the chambers of the United States Congress, in town hall meetings, on main street and in boardrooms throughout that country, medical experts in Costa Rica have watched from the sidelines with heads shaking.

Waiting for Parts and Service: Edwin Ramírez, right, patiently waits for his turn in the operating room for hip replacement surgery at Calderón Guardia Hospital in San José. He has occupied a hospital bed for more than a month. “I can't leave or I'll lose my spot,” he says.

Whitney Martin | Tico Times

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

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

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

Not only do Costa Ricans have an 86.8 percent coverage rate, but the public health system ser ves residents who live miles from cities.

“How does a small country with a medium investment like ours achieve full cover age for all of its citizens?” asked Climent. “It's a big accomplishment.”

Like any institution, the Social Security System in 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 something from the system that serves their country.

The Birth of the Caja

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

Staunchly opposed by doctors, employers and pharmacists at the time, coverage gradually expanded and – at each step – was met by 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 only enough to provide for the 17 percent of people who live below the poverty line.

Challenged by a 1995 World Bank report, the Caja's most recent campaign has been to flush rural hospitals and clinics with enough staff to make coming to San José for treatment unnecessary.

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

“What we are trying to ensure is that the capital city doesn't absorb all the services or all the technology that our country has,” Climent said. “We are working on equipping our provinces with the best technology so that people who need health services don't have to come to San José.”

But the Caja has long been only one arm of the Costa Rican medical system. A private option existed many decades before a public program was offered, and it continues still. The private option primarily serves 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 minor ailments and surgeries (depending on the plan) and allows patients to avoid the wait that comes with attention by the Caja.

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

The Wait Time

Every country – from the corporate-dominated health 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 for the World Health Organization. “With the limited number of spots there are, you have to find a way of deterring people from making an appointment with doctors.”

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

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

The public system in Costa Rica limits demand with long wait times.

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

Non-emergency services can keep some patients in hospitals for upwards of a month.

When asked about the long wait periods, Climent shrugged it off, saying that people could plan ahead for needed health services.

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

Yet, Edwin Ramírez, who's been waiting 35 days for a hip replacement, knows better.

Ramírez hasn't left the fifth floor of 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 my perspective, the system is broken.”

The 37-year-old advertising executive passes the time by reading books and sending text messages, but he admitted that it feels like prison.

“It's a lot of waiting,” he said.

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

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

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

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

“Thankfully, my children are all grown,” he said. “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 waiting is 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.

“Just do my surgery and get me out of here,” he said.

Maintaining Solidarity

While most people interviewed voiced frustration at wait periods and long delays, they agreed they wouldn't trade their system for the 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 the private option, he said.

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

“Anyone – anyone – can receive care 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 and can't pay? Out the door. You are left to die in the streets.”

Climent, director of the day-to-day operation of Costa Rica's Social Security System, said she almost was turned away from the door when she sought emergency services for her daughter in the United States. She said her family wasn't allowed to see a doctor at a hospital in 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 everyone has the right to the same services. The people who earn more pay more so that everyone has access to healthcare.”

And what is the most significant obstacle to adoping a similar system in the U.S. ?

“They don't have the same commitment to solidarity,” Climent said. “We have a culture of solidarity in our country in which people with more economic means take care of those with less.”

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

Earlier this month, Obama said, “I've said that the Canadian model works for Canada. It would not work for the United States, in part simply because we've evolved differently. So, we've got to develop a uniquely American approach to this problem.”

Next Week: Private Health Care