Brazilian Public Option Health Care Beats USA "Market" Hands Down
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 I 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. 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 free market cosmetic surgery unless their medical schools trained a lot of doctors.
- It is possible for Brazil to provide free medical care, regardless of income, to a population that is far less wealthy overall than that of the United States, because 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.
- I have a childhood friend who is the chief psychiatrist for mental health services in one of the largest cities of Brazil. He is not wealthy, but wealth is not why he entered the medical field. He entered psychiatry to help people with their psychiatric problems and not because he wanted a three car garage and a Mercedes for each of his three daughters.
- For those who pass the medical school entrance test with the highest scores, medical school is free at the federal universities in each state, and the federal universities have the highest status and reputation for quality. Although graduates are not required to work in the public system when they graduate, they also are not required to repay hundreds of thousands of dollars in loans that would force them to work in private practice. Indeed, the entrepreneurship of medicine in the United States starts on the day when students begin medical school with the knowledge that they will invest hundreds of thousands of dollars in the (not entirely certain hopes) of receiving a significant return on their investment. In Brazil many doctors are educated for free through the federal universities, and so they are not compelled, as doctors are in the United States, to get a high "return on their investment" just to keep from defaulting on their exhorbitant student loans.
- 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 Peter Greenberg in an article at AARP.ORG.
- Parenthetically, one of the major holes in the French national health care system 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, which are available at regular health clinics, because, believe it or not, teeth, gums and the mouth are part of the human body. Just as the whole person can die from an infection in the foot, the whole body can die starting from an infection in one tooth. "Twelve-year-old Deamonte Driver died of a toothache Sunday. A routine, $80 tooth extraction might have saved him." WaPost
- The real dental 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 US dentist "did me a favor" and 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.
- Did I mention that Brazilian private market doctors who charge for an initial consult must also provide a second check-up "return" visit for free, and they must schedule that free visit on the day when they conduct the initial paid appointment? Have you ever heard of such a thing in the United States? Since it sounds like it can't be true, why not research it on the Internet, or come and see for yourself?
- 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 on the day of the first visit. Brazilian private practice dentists must provide commendable service so that patients will return and recommend these services to their friends. At a private practice Brazilian dentist's office, an X-ray costs one twelth of the Brazilian monthly minimum wage, but it's free at the public option office. Even wealthy people cannot access care as quickly and easily in the United States' "free market" as they could from private practice dentists in Brazil.
- There are plenty of stories on Brazilian television about people who were harmed by long lines and callous doctors. This occurs without a doubt, both in the free market "insured" care and the public option care. While one story tells about lack of doctors in a city's public system, another tells about lack of pediatricians in a private HMO. My psychiatrist friend tells me that Brazil's private insurance is much like that of the United States: when your medical need is so expensive that you can't possibly pay for it yourself, that's when you discover that your insurance company doesn't want to pay for it either.
- Brazil's public option makes no distinction between limits of care offered for bodily and mental illnesses. There are no limits for either, to the extent that the Government has the necessary resources. In fact, they have special units called CAPS (Centers for PsychoSocial Attention) which have special sub-units for ambulatory adults, day-patient adults, inpatient adults; and children and adolescents. I know of three of these various units in the city where I live.
- Abortion is illegal in Brazil, both in the public option system and through private insurance and when self-paid. It's simply illegal. When women put poison in their vaginas or otherwise try and self abort and are successul and//or fail, and then have to go to the hospital, nurses are reportedly unsympathetic.
- In Brazil the Government encourages the use of condoms and contraceptives for those who need them. During Carnaval and other large parties, Government workers give them out from a booth on the street, but condoms and birth control pills are also available for free at health clinics.
- When I asked my wife if birth control pills were available for free at Government health posts, she said, "At Government health posts EVERYTHING is free. In fact, if anyone asks you for money you can report them to the police." This is why I think President Obama's plan to obligate people to buy insurance would be bureaucratic, unrealistic, unnecessary and assinine, particularly for clients who live under bridges. ("Sorry, Mr. President.)
Brazil's infant mortality rate, at 23 per thousand, is about four times that of the United States generally but only 33% higher than that of Blacks in the Deep South of the United States. The infant mortality rate in the USA is increasing. One that points to reasons for the high rate in Brazil may also be relevant to the increasing rate in the United States:"The diseases leading to the fatal outcome - for example perinatal conditions - constitute the immediate (or proximate) causes of death. Their occurrence is ultimately determined by macro-level social, economic and cultural factors - such as income, education and land tenure - which constitute the distal determinants of mortality. These factors influence the occurrence of the immediate causes of death by affecting intermediate-level determinants, either by increasing exposure to risk factors (for example, poor nutrition during pregnancy, etc) or by decreasing access to protective factors (for example, antenatal and delivery care, etc)." Infant Mortality Due to Perinatal Causes in Brazil.
There is also a relatively high rate of maternal death in childbirth, probably (anecdotally) in part because public hospitals are overloaded and so nurses and doctors fail to notice and appropriately respond to symptoms of complications that threaten the lives of mother and infant.
As I said above, I suffer from chronic depression and diagnosed bipolar disorder. (Because of the seriousness of bipolar illness, the French public system payed 100% of medical care and medications related to the illness, with no co-pays. Meanwhile, in the United States, because the illness is in a part of the body that is found above the shoulders, US insurance companies may refuse some or all of the expenses, after a month or so, even if one has "good insurance". France and Brazil have no maximum number of times that a patient can visit a psychologist or psychiatrist, while the US may limit the visits to ten times per year, and still charge a copay. The United States has yet to recognize that "chronic" means all the time, and that serious chronic illnesses untreated tend to get worse and become more expensive for the individual, family, community and society.)
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.