From Panama, a Different Perspective on Health Care

President Obama has promised to reveal some details of ObamaCare II today. It will be different in some respects from ObamaCare I, which more Americans now oppose than support. Which is cool, and I enjoyed this cartoon. In the meantime, I have a few modest suggestions. None were a part of ObamaCare I, and I am willing to bet that none will be included in the new draft.

My wife and I have lived in Panamá for about seven years. Health care is good and inexpensive; it is not perfect, and problems exist due to the topography and population distribution in Panamá as well as the limited funds available. The population of Panamá is about three and a half million, and there are many rural areas, some of them very remote.

I. "Free" health care for all

Here, there is "free" health care for all full-time employees and their immediate families, including a spouse and unmarried minor children. They and their employers pay for it through the social security system. Health care is provided during their working years as well as after retirement, when they also receive modest retirement payments.

All full-time employees are required by law to participate and to pay approximately 9.2 percent of their salary in social security fees; their employers are required to pay approximately 15.96 percent of salary. The amount which our one full-time employee pays, and which we pay on his behalf, totals $52.21 per month -- only part of which goes for health care. People who are self-employed are not automatically covered by the social security system, but they can be by paying a modest amount into the system.

The system gives beneficiaries and their immediate families access without further charge to medical care at local health clinics and, if appropriate, at social security hospitals. The smallest clinics are staffed by nurses with a physician on call. The larger ones are staffed by physicians as well as nurses. Even in the rural area where we live, frequent bus service is available within a ten-minute walk. It takes the bus another ten minutes to reach the nearest clinic, located in a small village (population 1,165). An ambulance is available if necessary. The clinic provides immediate care and triage. If necessary treatment is not available there, the patient is transported, by ambulance if appropriate, to a facility with the equipment and personnel to deal with the problem. Sometimes this means transport to the social security hospital in the city of David (population 124,500), roughly twenty-five miles away. Rarely, it requires transport to the principal social security hospital in the city of Panamá (population 708,738), roughly two hundred and fifty miles away.

Medical care at the social security hospitals is 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. This is a cultural thing -- since extended families are common here, it is not a significant problem and obviously saves money.

A slightly modified program in the United States would take tremendous pressure off the expensive emergency rooms in hospitals full of costly equipment and with specialists immediately available or on call. It would also greatly diminish the waiting time for patients who actually need immediate emergency care. I have no idea how much money would be saved, but I believe it would be substantial.

Some medications are also provided, without charge, by the social security clinics and hospitals. Some are not available there and have to be purchased. However, most medicine available in the United States is also available in Panamá, at far less cost. One medication I have occasionally used for many years now costs in excess of $100.00 in the United States. The identical medication costs less than $10.00 here. All elderly citizens (women over fifty-five and men over sixty), as well as elderly non-citizens with legal permanent resident status, are required by law to be given substantial discounts on any medical services and prescription medications for which they pay, as well as on various other things.

II. Inexpensive health care for everyone else

The same care provided to social security beneficiaries is available to everyone else at minimal cost. For example, a routine doctor visit at a social security clinic costs $3.00. An elderly (mid-eighties) uninsured Canadian friend was diagnosed a few years ago with cancer; he required a month of outpatient chemotherapy. His total costs, including transportation to and from Panamá City, a modest hotel room, food, taxis, daily visits to the oncology hospital, and all other associated costs totaled less than $1,600. That is not a typographical error. He recovered and leads a normal and productive life running a small business. I required surgery a few days ago to remove and biopsy some suspicious lesions on my head and forehead. The surgeon, whose English is excellent, works at a small but quite adequate hospital in nearby David associated with neither the social security system nor with our health insurance company. The surgery was done under a general anesthetic and took just over an hour. Following surgery, I spent about two hours in bed at the hospital to recover. The total cost for everything including the biopsy was $450.

Private health insurance is available here at reasonable cost. In Washington, D.C., I paid over $1,000 per month in the late 1990s. We pay less than one-tenth of that here. That includes cancer coverage for my wife; since I had cancer surgery and radiation therapy in the United States in 1998, I am not eligible for cancer coverage here. I am sixty-eight years old, and my wife will soon be sixty-five. The rates increase slightly as one ages.

III. Factors which keep costs low

One factor which helps to keep medical costs (and therefore health insurance premiums) to a minimum is that very few medical malpractice suits are brought -- litigiousness is not a Panamanian thing. Hence, physicians and other medical personnel are not burdened with obscene malpractice insurance premiums and trial lawyers do not get rich by bringing or threatening malpractice suits. This also reduces the incidence of defensive medicine, necessary to obviate many malpractice claims but unnecessary for the well-being of patients. The tests deemed medically (rather than legally) necessary are done -- inexpensively and quickly.

An excellent surgeon who operated on me for cancer in the United States in 1998 later ceased the practice of medicine and became an attorney specializing in medical malpractice litigation. He will not take a case unless his medical background leads him to conclude that the claim is meritorious and his experience as an attorney leads him to expect that it will generate legal fees of at least $100,000. No matter how meritorious the case may be, he is very unlikely to take it in a jurisdiction where jury awards are low. With reasonable caps in all jurisdictions, some malpractice attorneys in high jury award states might need to find another specialty or move to another jurisdiction with more victims.

The trial lawyers' associations, which traditionally support Democratic Party proposals, oppose such caps and that is one of the reasons why ObamaCare does not call for them. In an unusually candid statement, Howard Dean said:

The reason tort reform is not in the [health care] bill is because the people who wrote it did not want to take on the trial lawyers in addition to everybody else they were taking on. And that’s the plain and simple truth.

In 2003, Texas imposed substantial caps on medical malpractice awards, and the resulting influx of physicians from jurisdictions lacking such caps was surprisingly great. The United States should give serious consideration to placing reasonable caps on medical malpractice recoveries. As a recovering attorney, I have nothing against lawyers earning a good living. However, there are less socially harmful ways to do it.