Adventures in Health Care, Latin Style

When I drag my injured leg into the clinic’s waiting room, I hold the door for a woman limping out who looks to be in much the same condition as me. No crutch, no visible cast or brace. Just a hurt leg and a desperate staggering stride. But she has just seen the doctor and wears a content though strained look on her face that she turns up to me as she passes.

“Gracias,” she says.

“De nada,” I reply.

Where I am is the Clínica Universitaria Colombia in Bogotá, two great towers of shining blue glass and steel that comprise one of the best medical centers in the city, and therefore the country. Bogotá is very much a bubble. It has all of the best of everything in Colombia, at least as far as goods and services go, but outside of the capital things change dramatically. Resources are stretched thinner. The polish and gleam of the minted international success story that is Bogotá fades to the reality of a country that is still very much on the long, winding and treacherous path of development.

But one thing that has been done more or less right in Colombia is the health care system. Everyone, in the capital and elsewhere, has access to the same system and interacts with it more or less in the same way. Even a foreigner can get on board, which is where today’s trip to the orthopedics office at Clínica Colombia comes in.

At the moment I’m in the country under a tourist visa (a situation I’m working to change, but which isn’t easy considering the intractable bureaucracy), and not working or volunteering under contract for any national company, so I’m not eligible to join the Entidades Promotoras de Salud system, or EPS. This is the system that almost every Colombian is a part of or interacts with in some way in order to get health care. Consider it the de facto national health care system, though not quite the same way as it exists in, say, the UK or Canada. It is supported by mandatory taxes paid by every worker (the ones who pay taxes anyway), but joining is not obligatory. If you have no employer or are part of no institution that provides or requires EPS membership, nobody is going to track you down and force you to pay for not having it. However, the benefits of membership far outweight the costs, so you will find few citizens of Colombia who do are not enrolled.

As a private citizen and a tourist, I am still perfectly free to pay particular, or out of pocket. For most Americans, paying out of pocket for medical expenses might raise alarm bells. The cost of medical treatment in our being-made-great-again country has skyrocketed so far above and beyond what might be considered reasonable that any thought of getting any kind of health care without some kind of insurance or coverage is daunting, to say the least. Even the simplest trip to the doctor’s office, for most people paying out of pocket, is going to cost an arm and a leg. Perhaps literally, for those without insurance or who lack the ability to pay.

In Colombia, this is no big deal. At least if you have a little money, or are coming from somewhere like the US with our fat green American dollars that more or less triple in value here. Treatment is still costly, but nowhere near what it might cost in back home, even relatively speaking. Take my trip to the orthopedist for example:

What happened was, I was on an extended trip through Ecuador and Perú. This was because of the aforementioned visa issues. I had to leave the country in order to “reset” my allotted ninety days in the country as a tourist, a common exercise among expats residing here without solid residency. During the trip, I injured my leg. I still have no idea how it happened. I was on an overnight bus trip from some place to another and woke up with a terrible pain and pressure in my left leg. At first I thought it was thrombosis, that I had a blood clot in my veins that was going to travel up to my heart or lungs and kill me. But after a while the pain began to subside and I was left with a kind of low-level chronic ache that persisted for days, then weeks, then months by the time I got back to Bogotá. Having a hurt leg is less than ideal if you’re traveling through a country like Perú where your main goal is to visit places in the Andes Mountains, see Machu Picchu, etc.

So when I got back and the pain still wasn’t going away, my girlfriend and her family pressured me at last to visit the doctor. My initial concern at the cost of seeing a specialist without health coverage of some kind was quieted soon after arriving at the appointment.

Let’s go back a bit. The year before, I was living in Colombia under a volunteer visa, then a work visa as an English teacher. As a condition of both contracts I was required to join the EPS system and pay a small portion of my monthly income for the privilege. I didn’t expect to need it, but like all insurance, it’s better to have it and not need it than the other way around.

As the months progressed, I began to learn about the wide variety and, to an American like me, shockingly low cost of receiving just about any kind of standard medical treatment under my EPS membership. I heard stories of other expats with similar coverage taking advantage of the system and getting just about every checkup or regular basic service that they could think of before their coverage expired. You could even get dental care, and not only teeth cleaning. They would fill cavities, do root canals, caps and crowns and braces and retainers and so forth. And all for almost nothing. A female friend said that, before she left the country, she was going to get every exam she possibly could while still covered, up to and including a prostate exam, even though she didn’t have one.

To be clear, you do still pay for each doctor’s visit. But under EPS, you pay little more than a token amount. This depends on what you are paying into the system, which depends on your tax rate, which depends on your income and what are known in Colombia as stratos, or your social/income/residential classification, but more on that later.

I decided to go in and get my teeth cleaned, just to give the system a trial run. I have several friends who routinely travel to places like Mexico or Nicaragua for dental and other medical treatment due to the astronomical costs and general unfriendliness of our great American health care system. Why should’t I do the same in Colombia?

Every official insitution in Colombia, whether government, health care, bank or otherwise, operates on a turn system. It’s an experience that is almost universal throughout the country. You walk into the office, say hello to the guard who checks your backpack or purse for anything dangerous or any large electronics to register (this is Colombia after all, things are on the upswing here but precautions must still be taken against the possibility of sudden violence or theft, neither of which is unexpected or surprises anyone when it happens), then walk to the electronic kiosk and take a number. Often you will make a selection regarding your type of visit so that the system can direct you to the appropriate agent. Then you sit down in one of the rows of bus-station-style plastic chairs mounted on long metal rods and wait your turn, watching the ubiquitous flat-screen TV with its slick over-produced videos and infographics promoting whatever organization it is you’ve come to visit today.

You might wait minutes, you might wait hours. The only certainty is that you will wait.

So I made an appointment with my EPS to get my teeth cleaned, which for most general procedures takes about a week. There is always the emergency room, or urgencias, but like all emergency rooms the wait will be tremendous and you will be up close and personal with a screaming, squalling, bleeding, crying, groaning mass of humanity from which there is no escape. And of course every EPS operates its own clinics (called IPS, or Instituciones Prestadoras de Servicios de Salud) so you have to take care to go the one operated by your provider.

Confused yet?

Another thing to note about EPS services is that there are a lot of them. Much like HMO’s in the US, each EPS has its own offices and clinics and doctors. When you make an appointment it will be to visit one of the IPS operated by your EPS. Everything is funded and regulated from the top by the government, but they outsource the actual provision of health care services to the various EPS. The EPS receives a certain amout of tax money based on enrollment, which is free and voluntary between services, giving them an incentive to provide higher quality services in order to keep their members and by extension their money.

When I arrived at my designated IPS for the dental appointment, I diligently took my number and sat down to wait. When my number appeared on the TV screen (which was displaying a polished infographic of a young girl playing with a puppy in a field of green grass and flowers) and was read out by the computerized announcer, I approached the desk to be served.

“Mi-les Bor-ke?” came the girl’s incredulous voice as I handed her my cédula, or identity card. In Spanish, miles means thousands, so whenever tell someone my name or hand them my ID here I grit my teeth for the inevitable laughter. I usually introduce myself by my middle name whenever possible, Arthur or Arturo, just to save me the embarassment.

“Si, soy yo.”

“Bueno, para una limpieza dental. Será doce mil pesos.”

“Cómo?” I reply with the same incredulity as she had for my name.

“Doce mil.”

Colombia’s national currency, the peso, is measured in thousands since it collapsed in the 1980’s during the chaotic years when the big cocaine cartels were at their height. Today, in 2018, one US dollar is equal to about 3,000 Colombian pesos. If anything was equal to the American “buck” here it would be 1,000 pesos. The Spanish equivalent word for buck is luca.

Throw that down at your next bar trivia night.

At my dental visit, the girl behind the desk was asking me for 12,000 pesos for the visit, or about four dollars. Imagine being asked to pay that out of pocket to get your teeth cleaned in the US. You can’t, can you? That’s because it wouldn’t happen. The last time I paid out of pocket there to get my teeth cleaned cost something like a hundred and fifty dollars. So after I scraped my jaw up off the floor, I paid my 12,000 pesos, went upstairs and had my teeth cleaned.

Another image many Americans have of Latin healthcare is that it takes place in some back alley shithole. Maybe you enter through a metal gate that creaks on its hinges into a dark room lit by a single bare lightbulb swinging overhead. You hear the sound of water dripping from somewhere. The “dentist,” a man wearing a greasy leather apron over dirty and sweatstained clothes, no gloves, no mask, directs you to an ancient rotten dental chair, some wrought iron monstrosity upholstered in old vinyl all cracked and spilling moldy foam. You see the spread of rusted steel tools on a bloodstained tray next to him and have to lean over to vomit and pass out. You might wake up later with clean teeth, or in a bathtub full of ice with an odd scar across the side of your abdomen. You might not wake up at all.

Medical offices in Colombia and indeed most of Latin America are nothing of the sort.

The one I walked into that day was surrounded by white walls, separated with walls of blue translucent glass, and full of what looked like brand new equipment and supplies, everything clean and sterile and smelling of good health, which is to say the smell of cleaners and bleach which permeates any hospital, or should at any rate. I had my teeth cleaned by a hygienist who attacked my mouth more than cared for it, but she did an excellent job and I walked out with all my expectations forever challenged. As it turned out, I had a cavity and had to go back a week later to have it filled. My dentist was knowledgable and careful and even spoke some English. Many Latin doctors visit the US or UK or other places in Europe to advance their training, attend conventions with their colleagues, and other such professional development, so quite a few acquire a working knowledge of at least basic English along the way.

And how much did it cost to have my cavity filled by this lovely woman? About 30,000 pesos. Ten dollars for a procedure that would have cost hundreds in the Land of the Free.

Fast forward back to the orthopedic office at Clínica Colombia. This is one of the better hospitals around, and I’m here to see a specialist, so I know it’s going to cost more than a few lucas. When the secretary calls my name, I take a deep breath and ask her how much it’s going to be. 150,000 pesos she tells me, or about fifty dollars. It’s a decent amount, but nowhere near what you would be asked to pay out of pocket in the US. Also you might not find out the cost until after the visit was complete and there was no backing out.

Once upon a time, in the US, I was on welfare. Not like cash payments every week for a lifestyle kind of welfare, but I was poor. I didn’t make a lot of money. I had decided to quit a stressful former job/career and move back home to finish school, which the aforementioned job had never quite allowed me the chance to do. I was going to school and working part-time, didn’t make a lot of money, and was old enough to be considered financially independent by the IRS. So I filled out the public benefits form and was awarded with $50/week or so in food stamps (which aren’t really stamps any more, but a plastic kind of debit card that they only take at grocery stores and some convenience stores) and enrollment in Medicaid, California’s version of the public low-income health care option.

Being on Medicaid at that time was a dream. The town I lived in had just opened up a big, shiny, brand new clinic which took all the welfare patients like me, as well as patients from other insurance companies. I went there several times during my welfare years for checkups, vaccine boosters, and to get a mole on my back checked out.  Apparently I am at high risk for skin cancer.

In all those visits, I never paid a dime. Of course, this was poverty health care. You take the appointments they give you and the doctors they give you (one of mine was still in training) and you can’t complain one way or the other. In that way it is very similar to the EPS system in Colombia. Of course, once you’ve been assigned a doctor then that person will not change, unless you or they change clinics.

My experience of the “public option” in California and that in Colombia bore striking similarities. Both were government-run and both functioned more or less the same. But the point is that they function. They work. Hassle-free (leaving the administrative part aside), low-cost, available health care for all. Of course, in California you have to be dirt poor by US standards to get it. And there is a similar service in Colombia for those who have little to no money at all.

In Colombia, society is divided. Not by race, like we have so elegantly accomplished in the US. Not by gender, although informally there are sharp dividing lines between the genders in a country where machismo still rules.

In Colombia, society is divided by class.

Officially, class is not the word used for the administrative stratification of Colombian society. The word is estratos, or strata. Imagine a cliffside, such as those revealed by millennia of erosion in the Grand Canyon. By looking over the rock face from top to bottom, you can see the different layers and types of rock deposited at different times  through geological history. The strata work much the same. For taxation purposes, you are taxed by stratum. But the easiest way to tell which estrato in which you live is to look at your utility bills. All cities in Colombia are divided by general income level of the barrio, or neighborhood. The very richest areas fall under the highest stratum, Estrato 6. The poorest are Estrato 1.

The very very poorest, such as campesino potato farmers living on hillsides in the country on dirt floors without electricity or running water, those people are Estrato 0. You must be truly destitute to fall under Estrato 0. These people qualify for a number of benefits, free health care being the first among them. And the services are incredible. You can get anything treated, from a cold to a cavity to gout, cancer or back pain, for no cost, in fantastic, state of the art facilities. Often doctors travel into the countryside to provide vaccination and basic care services for people who cannot reach the hospitals for one reason or another. Ask anyone here, and they’ll tell you that the services available to people living under Estrato 0 are top notch.

Of course, many other realities of life at such a level of desperate poverty can be brutal. This is Colombia, and there are still depths of poverty here that are today unheard of in the more developed nations. We have our poor and our sick and our huddled masses, but the kind of poverty that can be seen away from the richer and more touristy areas of Latin America must be seen to be believed. A more thorough discussion of that poverty is beyond the scope of this piece, but rest assured it beggars belief.

Back to the strata. Depending on your income, you will be assessed a certain amount for health care coverage every month. Again, it is not required to join the system, although most employers require it by law. But there are few people here who would willingly live without it, and the cost is exceedingly low, a fraction of a fraction of your income. That amount is leveraged through the EPS that you have elected to join. Some are better, some worse. A little bit of competition in the system is healthy to keep quality above a certain threshold.

At that point, you’re good to go. Should you require medical attention of any kind, whether routine care or sudden emergencies, your EPS is there for you. I won’t bore you with all the tedious details of administering the payments and documentation and everything else required to join, but considering the Latin passion for impenetrable bureaucracy, know that it is quite heavy. However, once you’re in, you’re in. Payments happen more or less automatically, on-site fees are low, and everything proceeds more or less how it should.

Now for those of you who are crying, “Damn their socialized medicine! Where’s the choice?” I have an answer for you. That answer is prepagadas. Prepagadas are prepaid health plans which anyone is welcome to purchase on top of their regular EPS obligations. Foreigners can even get a prepaid plan. They are 100% privately owned and operated, though of course they must operate under the same health standards and regulations that govern all health facilities in the country, at least in theory. Again, lest we forget, this is Colombia. Standards are not always enforced as strictly as they are legislated. And someone could always be paid off to look the other way. But it is generally known which places are better, which worse, which clinics and hospitals provide the best care and which will give you the bargain basement, in more ways than one.

The worst example of this is the plastic surgery clinics. Colombians are obsessed to the point of mania with their appearance, both men and women. I couldn’t count how many times I’ve walked into a peluquería for a haircut or peered into one from the street and seen all manner of women and men getting their hair styled, nails polished or feet scrubbed. The effect is more pronounced in big cities like Bogotá or Medellin, but in this country appearance is everything across the class spectrum.

But as far as plastic surgery goes, it seems that at least once every week or two I hear yet another horrific story about some botched nose job or breast enlargement or liposuction that went terribly wrong and the unlucky aspirant to greater beauty, most often a young woman, ends up dead or almost. The statistics of something like this happening are unbelievably high in a country where a not uncommon sweet sixteen present might be rhinoplasty or a boob job.

Of course this is still a small percentage of the population. There are large upper and middle classes, but the lower classes still account for the vast majority of the population. And those people have more immediate concerns than plastic surgery.

Let me close with a couple of positive notes.

First, the health system in Colombia reaches far beyond its borders. Take the example of one particular EPS, called Colsubsidio. Now, Colsubsidio does much more than just health care. They also provide credit services, operate a number of massive department stores, and also provide things like live theatrical music and entertainment and discounts on travel and hotels for their members. Besides EPS, Colsubsidio is also what is known here as a caja de compensación, or benefits provider for employees of certain companies and their families. Much like EPS, there are many cajas de compensación in Colombia, Colsubsidio just happens to be one of the largest.

A certain member of my girlfriend Lina’s large and extended family, also a member of Colsubsidio, happened to be traveling outside of Colombia in the United States. He injured his leg somehow (what is it with hurting legs while traveling?) and went to the hospital to have it treated. Not unaware of the realities of health care in the US, he went prepared to shell out a significant wad of cash for the visit. However during the interview, when the admitting nurse learned he had Colsubsidio, the whole thing got written off. He ended up paying the same token amount in adjusted dollars that he would have paid in Colombia. Giddy with relief, and no doubt with strong medication, he left the hospital a happy man.

Finally, there is the story of the birth of Lina’s young niece, Amelia. Lina’s brother, Felipe and his wife Andrea, already several months pregnant, were looking into options for where to have the baby and what it was going to cost. They had an EPS, but understandably wanted somewhere with the best possible facilities for the birth. They found a private hospital, but the cost for the procedure was going to run into the millions of pesos, or thousands of dollars.

As they were resigning themselves to this outrageous cost (health coming before economy, in this case), enter Lina’s sister Catalina. Catalina is a lawyer and an employee of MINDEFENSA, or the Colombian Ministry of Defense. As a government employee, she has what in the US would be considered something of a Cadillac health plan. Not only that, but she has the ability to enroll members of her own family to be covered under the plan. Normally the cost for the addition of extended family members is somewhat high, but they learned that Felipe and Andrea could be enrolled on a temporary basis to cover the birth.

When Amelia was born, everything took place in the clean, comfortable, highly professional offices of one of the best clinics in Bogotá. There were satiny pillows, excellent food, and top doctors and nurses attending to Andrea and her newborn daughter.

When they left the hospital, they paid around 50,000 pesos in total, less than twenty dollars.

Health care can be done right. It can be done well. And it can be done at a cost that everyone can afford. Even in a country like Colombia, where resources are limited and social classes are sharply divided. Where the past half-century and more has been marked by one of the worst and most intractable internal conflicts the world has ever seen.

But it comes at a cost. The political will to implement such a system must be present and overwhelming. People must be willing to give up a certain amount of control and personal choice in order to create a foundation which is more sustainable and more sustainable for the population in general. A wide majority must be willing to set aside some of their personal desires in order to have the needs of everyone met.

I believe this is possible in the United States. I believe that people across the sociopolitical spectrum are better and more generous than the polarized political narrative would have us think. I remember when Barack Obama and the democrats were struggling mightily against an intractable and hostile Congress and health insurance lobby to get even the most basic reforms to the national health care system passed into law. For a minute there we almost had a public option. A national health care system that, on some basic level, would be available to all at low cost, supported by taxpayer dollars.

But the scare tactics worked. The popular will failed to rise to get something more comprehensive and universal enacted for all. They told us that we would lose health care at our jobs because employers wouldn’t want to shoulder the extra tax burden. They told us that the services we had, those of us who were lucky enough to have them, would be cut back. They told us that the cost was unsustainable, and that we as a country just could not bear the burden of providing some kind of basic universal health care for everyone. This from a country that spends trillions of dollars a year on unpopular, unnecessary, and overall horrible wars in far away countries over vague and arcane “national interests” that seem to most people to have little or no bearing on their own lives.

What we got instead of the public option was a half-assed and mediocre reform to the existing system and the implementation of a bizarre “marketplace” for health plans that did little to reduce the overall cost of health care and remained unreachable for many, both in terms of cost and availability.

There is a valuable lesson to be learned from Colombia. The country is far behind the United States in many ways in terms of economic development, social mobility, and other such difficult to define areas. But there is unbelievable progress being made in terms of public health, and in other areas which I will explore here further in the future.

Maybe a little bit of socialism isn’t such a bad thing after all.

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