Subsequently published at the Francis L. Holland Blog and the Public Option Health Care Now blog.
Because of chronic depression and diagnosed bipolar illness, I have been an intense medical consumer for the last 24 years in three countries, including my native USA; France and Brazil. I've also traveled through seventeen countries and had opportunities to discuss medical care with many different people, including two weeks as a medical translator in Nicaragua.
Every day from Brazil, as I watch the health care debate going on in the United States, I mentally compare the US health care “market” with the Government health systems I experienced in France for thirty months (2001 -2003), and now in Brazil for the last five years.
In this article I offer statistical evidence and then first-hand experience to show readers how awful the US health care "market" is compared to what other countries offer. Although many people here are happy with their health care, few of them know what they could get overseas for a quarter of the price.
Too many people who pontificate about the terrors of "socialist" health care and the deficient care in other countries versus the wonderful care in the United States simply have never been outside the United States and therefore, frankly, have no idea what they're talking about.
They are like childless men who would nonetheless describe the experience of pregnancy and delivery in great detail, comparing hospitals to midwives. They simply have no idea what they're talking about from personal experience and probably will never bother to confuse their ideological certainty with actual statistical evidence. So, they offer their opinions and profer any half-baked "proof" they can muster to show that they know something about which they are actually utterly ignorant (like the 67% white male US Supreme Court that determines when women can get family planning care and how and why.)
Such opinions offered by laymen would be considered "hearsay" and therefore inadmissable as evidence in courts of law, and they certainly would not qualify under the Federal Rules of Evidence as "expert opinions", or as any opinions at all.
The [Federal] Rules - especially Rule 702 - place appropriate limits on the admissibility of purportedly scientific evidence by assigning to the trial judge the task of ensuring that an expert's testimony both rests on a reliable foundation and is relevant to the task at hand. The reliability standard is established by Rule 702's requirement that an expert's testimony pertain to "scientific . . . knowledge," since the adjective "scientific" implies a grounding in science's methods and procedures, while the word "knowledge" connotes a body of known facts or of ideas inferred from such facts or accepted as true on good grounds. The Rule's requirement that the testimony "assist the trier of fact to understand the evidence or to determine a fact in issue" goes primarily to relevance by demanding a valid scientific connection to the pertinent inquiry as a precondition to admissibility. Pp. 9-12. DAUBERT v. MERRELL DOW PHARMACEUTICALS
And yet many talking heads and professional lobbyists' pontifications are having a weightier role in our health care debate than actual statistics from reliable and neutral sources, or first hand accounts from people with personal and unbiased experience.
There are all too many paid hacks who oppose public option medical care, prefering to argue motivated by their investments, their lobbying fees and/or their own "free market" ideologies and the baseless fears, instead of looking at the experience and statistics from other countries and interviewing people from overseas to see what their actual experiences have been. Or they argue against public option medical care for patients based on the negative effect that public option medical care could have on insurance companies! Pardon me, but I couldn't care less whether my access to effective health care hurts somebody else's stock portfolio.
Television is full of pontificators, but has any reader of this article actually seen ANYONE on television from a foreign country describing how their health care system works and how it compares to ours?
If they have, it will surprise me and I would love to hear about it in the comments. It would normally be considered unpatriotic to tell the real truth about this, the truth being so sad and maddening, but I'm going to do so here anyway, based on personal experience, in the hopes that the USA can someday (if President Obama has the manhood) improve to the point where we can be proud of our overall health care even when we tell the truth about it.
I will acknowledge that there are many people who are happy with their health care in the USA, but I would also observe that (1) most of them have had no opportunity to compare it with what is available overseas for a quarter of the price, and (2) anyone can find fresh salmon in a supermarket if they are willing to pay forty-five dollars a pound for it. Those who can't pay that are the ones who either go without or eat sardines with a fork from an oval can.
I'm getting to the actual comparison, but I must also observe that in the USA there are far too many conservative and media talking heads who prefer to offer excuses (without supporting statistics) for the fact that the infant mortality rate in the USA is twenty percent higher than that of Cuba, instead of looking at what Cuba is doing and trying to learn from it.
The USA infant mortality rate is actually almost three times higher, if you compare Blacks in the American South to Latin Americans in Cuba. Yes, "We have the best health care in the world in the USA," but for some reason there are 32 countries in the world with infant mortality rates lower than ours. Actually, the truth may be worse. The CIA's World Fact Book says there are 45 countries in the world with less infant mortality (death in the first year of life) than the United States.
Nicholas D. Kristof of the New York Times observed,
Babies are less likely to survive in America, with a health care system that we think is the best in the world, than in impoverished and autocratic Cuba. According to the latest C.I.A. World Factbook, Cuba is one of 41 countries that have better infant mortality rates than the U.S.
Let's suppose that we refuse to believe Cuba's infant mortality rate as mere Communist propaganda. That still doesn't explain why 32 to 40 other countries still have less infant deaths than the United States. Is this a worldwide conspiracy to bake statistics in order to make the USA look bad - including help from our own CIA Factbook? It is worth noting that many websites look for ways to discredit the Communist success of Cuba with infant mortality, but they offer no excuses for the other three dozen countries that do better than the United States does.
After eight years of presidential advocacy for the "rights of the unborn," you would think that children actually born in the United States would be healthier, rather falling farther behind children in other countries where abortion is perfectly legal.
So, let's take a moment to compare US health care with that of Brazil, which many Americans associate only stereotypically with tree-dwelling monkeys, Rio de Janeiro prostitutes, the Amazon and the drug trade:
Public health care in Brazil is a constitutional right. Even though I am not covered in Brazil by any private insurance, and only by Brazil’s public option health care, ("Systema Única de Saude" or "SUS", which means "Unitary Health System"), the public care available to me here is better than the private care that was available to me in the United States, even when I worked as a managing attorney for a five-office legal consortium.
I will not even bother to compare the USA to France, where I lived for thirty months, since that would be like comparing the ski slopes in Bermuda to the ones in Vail, Colorado.
Instead, I’ll just compare in bullet points the differences between two alternatives:
- The USA's “free market” and
- Brazil's public option “system”, which I call a "system" in all seriousness, since the USA has a health care “market”, but lacks a health care “system”.
(A "system" includes a series of integrated parts that interact to create a whole, yet no one would argue that the USA's health care includes everyone in a "system" or that what parts there are are integrated or that they create a whole (unless it's a whole mess), or that its accessibility behavior is predictable in any particular case.)
Some people venerate the "free markets" but markets are notoriously chaotic and unreliable, as everyone's 401k plans are now showing, and as the sub-prime mortgage market, and trading in derivatives have taught over the last two years.
If a diabetic's medical care and blood sugar swung for two years as the real estate, money market and bank stocks have, the diabetic would be in a casket right now, six feet under the grass in a cemetary.
And yet our American access to medicical care is based on just such a "free market," with insurance companies no more reliable than CNN stock prognosticators and snake oil salesmen.
So let’s compare Brazil’s public option care to the US’s private market medical chaos:
- First of all, US private interests, including medical schools, the AMA, insurance companies and pharmaceutical interests have so smothered the “free market” with pro-industry federal regulations that , for example, Americans cannot import drugs from overseas that are made by the same companies but cost 75-80% less at Brazilian pharmacies;
- US medical schools are not increasing the number of medical school graduates relative to the number we will need if there are 15% more people with medical insurance, requiring regular checkups. The monopoly market is assuring that the supply of doctors will not meet the demand, and therefore prices will increase when new insureds enter the market. Medical schools and the AMA control the number of doctors trained, but they clearly are not acting in the public interest.
- In contrast: “The number of graduates from U.S. medical schools has remained roughly constant at about 16,000 a year since the 1980’s. But the number of new doctors has fallen as a percentage of the population. The population rose by 50 million from 1980 to 2000, according to the census.” NYT, 2009
- In the United States, an increase in the number of doctors trained “would be welcome news to the Association of American Medical Colleges, which is calling for a 30 percent rise in admissions. According to a 2008 report co-written by Edward Salsberg, director of the Center for Workforce Studies with the medical association, the gap between supply and demand for doctors could be 125,000 to 159,000 by 2025, if the training of doctors fails to keep pace with population growth and a rising need for specialists catering to the aging demographic.” New York Times
- Brazil has opened many new medical schools, and has even seen a need to block the opening of new schools to maintain their quality. According to Brazil’s National Institute for Educational Research, the number of medical schools increased from 98 in 1998 to 123 in 2004, which means that more doctors are available, it’s easier to get appointments and it’s harder for doctors to charge outrageous fees. Odontologia.Com.br
- Meanwhile, the US is number 23 in terms of practicing physicians per thousand population, among OECD countries . OECD Statistics
- No wonder we can’t get an appointment in the USA with a doctor! The number of doctors is stagnant while the population increases and ages!
- It is hard to justify the claim that the USA has "the best medical care in the world,' unless we acknowledge that we simply have the most expensive medical care for the 85% of the country that has any access to medical care at all, while we have among the worst care for those 15% without any sort of medical insurance. And that's why we're somewhere beneath little old Cuba in infant mortality. (I once asked one of my Cuban political asylum clients what was the nature of the persecution he experienced when he was in Cuba. He told me indignantly that the Castro government cut off children's free milk allotments when they reached the age of ten!)
- I was born in New Bedford, Massachusetts which, last I heard, had one Public Health Service medical center and one mental health center for the 100,000 population. For two years, my sister worked there as a General Practitioner physician and personally delivered all of the babies in the city that were not delivered by private practice doctors. When she left the Public Health Service she said that one of her greatest frustrations was that patients for whom she painstakingly identified their illnesses could not afford the medication that would make them better. Meanwhile, private practice doctors refused to cover for her, so she worked seven days a week delivering babies at all hours of the day and night.
- Compare that to Brazil's public option services, where medications are available, for free, at each public health clinic and hospital. It's true that the US has the Public Health Service, but it would need to be massively expanded, its services increased, and a national system of VA like hospitals included, available to everyone, to even begin to compare with what Brazil offers to each member of the population, regardless of income. Every Brazilian city has one or more hospitals that delivers babies free of charge, with no $30,000 hospital bill awaiting the new mother as she brings her baby home.
- Now, I compare my experiences in the United States to those I've had in Brazil: I live in a Brazilian city of 100,000 population that has one free Government medical center per neighborhood. There are so many free neighborhood health centers that lifetime residents of this city literally cannot count them all. But I can say, having visited some of them and used their many services, that within a ten minute walk from my home, there are two free medical centers; a free adolescent mental health center; two free adult psychological centers; and a free full-service hospital; all with free pharmacies; plus a free-standing Government pharmacy where no medicines dispensed cost more than five dollars per month.
- The free medical centers provide dental care as well, including fillings, dentures, cleaning and other basic care. It doesn’t take a genius to predict that more free medical centers, hospitals, and free pharmacies closer to where people live will help increase accessibility and improve outcomes.
- Based on personal experience, I know it is possible to visit a dentist here with no appointment in various areas of the country. Moreover, you can get a root canal or crown here for half of the monthly minimum wage, and many dentists will accept post-dated checks, and IOU’s for their services. When my step-daughter broke a large piece off of her front tooth, a dentist fixed the tooth impeccably, with no evidence that it had ever been broken, and he charged us one fifteenth of the monthly minimum wage for the service. Is there ANY service you can receive from a US dentist for 1/15 of the monthly minimum wage?
- My wife had two moles which she was afraid might be precancerous. At a private clinic, we saw a dermatologist who charged us one fifth of the monthly minimum wage for a consultation. He said he did not believe the moles were cancerous and his fee would be one half of the monthly minimum wage to sample and test the cells. Instead, we went to a local public hospital where a doctor sampled the moles, sent them for testing and pronounced them noncancerous, all at no cost whatsoever. We discovered that it would cost two thirds of the monthly minimum wage to tests the moles through the private doctor. Even though the moles were not cancerous or precancerous, the Government doctor offered to remove them and did so, as elective surgery. It took about three months to complete this round of services, but the Government services were entirely free of charge.
- Brazil has excellent private hospitals and is well-known for medical tourists traveling here for plastic surgery, because it is so much quicker and less expensive here than in the United States. "Changing the "Face of Cosmetic Surgery, Brazil Leads the 'Plástica' Revolution." Obviously, it would not be possible for Brazil to be an international center of private market cosmetic surgery unless their medical schools trained a lot of doctors.
- Brazil's public option doctors work for a (moderate) salary, which makes it possible to have so many clinics without creating trillions of dollars of government debt. In fact, Brazil has a positive foreign exchange right now and low federal debt, in spite of national public option health care.
- It is not as well-known that dentistry tourism is also very cost effective and pleasant in Brazil. “The most popular and well-known place that Americans go to get inexpensive but quality dentistry is Los Algodones, Mexico, which is just over the border from Yuma, Ariz. However, Costa Rica is among the top five countries where Americans seek dental work. The other hot spots are Argentina, Brazil, and Malaysia,” says AARP.ORG.
- In fact, one of the major holes in the French national health care is that it doesn’t cover dental work except extractions and reconstruction after serious accidents. In comparison, Brasil’s public option covers fillings, cleanings and dentures. But the real savings are to be had at private dentistry clinics in Brazil, where even people earning minimum wage can afford to wear braces on their teeth. When I left the United States in 2000, I had a desperate need for a crown. A dentist gave me an appointment a week away and charged me $250.00 for a temporary crown that soon fell out. In France, a dentist offered to provide the crown for the equivalent of two thousand dollars. Four years after the need for the crown became apparent, I found an excellent dentist in Brazil who installed a crown for the equivalent of one hundred and twenty-five dollars. A root canal on another tooth cost me another one hundred and twenty-five dollars. And because dentists and dental office time are far more plentiful in Brazil, I was able to have the entire process finished within one week, with the initial cleaning and ex-rays done on the very same day on which I first contacted this dentist.
- Because there are more dentists in Brazil per one thousand patients and far more competition, it is possible to see a dentist and receive complete or significant care immediately. Even wealthy people cannot access care as easily in the United States.
- There are plenty of stories on Brazilian television about people who were harmed by long lines and callous doctors. This occurs without doubt, but remember that these are complaints about free medical care and not about insured care whose premiums gobble up a fifth of their salaries, as is so common in the United States.
As I said above, I suffer from chronic depression and diagnosed bipolar disorder. I know what it is to need medical care and have a lot of experience trying to find it. Under no circumstances would I want to trade the access to health care that I have now under the Brazilian Government's public option for the access I had when I worked in the United States as a managing attorney and had private market HMO care, as well as other various makeshift non-profit or quasi-public options.
If you have suffered as I have trying to access consistent and acessible mental health care in the United States, I urge you to move to the South of France or Brazil, where medical care is more easily accessed and the climate might do wonders for you. If it doesn't work, you can always return to the United States. You already know what that's like.