U.S. Public Health - An Expatriate’s Perspective

July 15, 2014

As an American living in Europe, for me it was bitter amusement to observe, in the public debate over the Affordable Care Act, the contortions of the American Establishment to avoid, if possible, any form of public health care. Many would have preferred to go on forever as we have, despite the powerful economic and practical arguments in favor of the ACA (or a much stronger new law), mainly for the sake of not threatening the immense profits that now go to insurance and pharmaceutical companies, hospitals and clinics, and doctors and other health professionals. Another sad case of vested interests that pretend to speak for the public, and do their best to scare the voters with silly notions of a socialist menace.

In Europe, many think of the American approach as strange, perverse, or outdated, given that every country here has a national health system for which almost everyone is eligible. And this without much regard for one’s personal political convictions, left, right, or center. Public health coverage is taken for granted. It’s normal. I’ll give one example of a conservative politician who can’t explain U.S. intransigence in this matter: Nicholas Sarkozy, who is anything but a socialist.

Anyway, at the time I wrote a bit for one of the progressivist organizations whose petitions I generally sign - maybe it got tagged onto a petition they were presenting to a Congressional committee. Here it is, for what it’s worth.

Midwife with woman seated on a birthing chair, Germany, 16th C.

Universal Public Health Care – the perspective of an American living in Europe
August 2009

To the reader:

Anyone who can use my story or any part of it in any way, feel free, never mind the copyright notice. If I were a capable propagandist and had the time, I’d send it out to everyone who is concerned with this issue, pro or con. Beyond the e-mail addresses of the White House and the NY Times, I have no contacts. So please pass this on to whomever you think appropriate, edited as you see fit. So much hangs in the balance.

For the information of anyone who is in doubt about the benefits of universal public health care, let me say that in the fourteen years since I moved from the US to Italy, I have never had a serious complaint about the public health system in Italy – its availability, quality, or economy. And this in a country not known for efficiency. (Italians often remark that the health system is the only thing in the country that works.) I am not even an Italian citizen, but I have the same care as anyone else. I work free-lance, and do not earn a great deal, but my coverage is completely independent of my income level or how much I pay in taxes.

I have had every sort of medical care that I have required at little cost to me. My primary care physician is thorough and attentive and dedicated to his profession. If I didn’t like him I could choose another with very little fuss. I pay nothing to see him. He may refer me to a specialist, for whose examination I pay about €19, less for any follow-up visits. Besides my particular problems (e.g., orthopedic – herniated discs and other problems, or dermatological), this includes all the things that a man my age (58) should have done: annual urological and prostate exams, colonoscopy, sonograms of the carotid arteries, and so on. My wife (like all women) has all she needs, including pap tests and mammograms. Blood and urinalysis is paid depending on the tests have to be made, but what we patients pay is a fraction of the actual cost to the system. Some special tests, such as CAT scans, may cost more, but I’ve never paid more than €50 or so for anything.

Treatment for many chronic conditions is exempt from any such co-payments. For example, I was diagnosed with glaucoma about 18 years ago in NYC when I was 40 years old. In Italy the same determination was made and I was issued an exemption immediately. Since then I have not paid a penny for my annual checkups and visual field tests, or for biannual tests of ocular pressure. For a while I took eyedrops (beta blockers) for this condition, which cost me perhaps €12 for a year’s supply. A few years ago a new instrument, which measures the hardness of the cornea, came into use, and with this it was determined that I probably never had glaucoma, just hard corneas. But even without glaucoma I still have my exemption and continue the same checks as before; evidently they think it prudent to keep an eye on my eyes, and so do I. If they were more concerned about saving the health system’s money than about taking good care of me, they would have given me the boot.

Emergency care – in which one presents oneself at a hospital for any urgency – costs nothing, and is far quicker and more efficient than I have had at hospitals in New York City. For example, after a nasty fall while bicycling last year, I was getting X-rays and sonograms of the affected elbow and knee within 20 minutes of walking in the door, and my problem was of a very low priority.

The big item on my chart was an angioplasty four years ago, after some occasions of angina. I had the best possible care and it cost me nothing. And this was in a private clinic, one of many that participate in the public health system in providing health care. The system is “mixed” also in that anyone who wants to see a doctor privately is free to do so. Many doctors work within the public sector, but also have private practices on the side. The irony of this is that sometimes a private patient will have the exact same care as anyone else. Last year my father-in-law needed an angioplasty. With the irrational but unshakable conviction that private patients get better care, he went as a private patient to the same clinic that I had been to for my angioplasty. (He has some private insurance that paid perhaps 65% of his €20,000 bill for his operation and his brief stay.) He had the same cardiac surgeon and OR team as I did, and shared a hospital room just as I did. The biggest thing he got for his €7000 was menus (printed pseudo-elegantly in a cursive typeface) so he could choose what he’d eat and pretend he was in a classy restaurant. (And although his food wasn’t any-thing special, the hospital food here is better than in the US, even if you’d never choose it if you wanted to eat out.)

Let’s not forget medication. I take cardioaspirin, two kinds of blood-pressure regulators, and an anti-cholesterol drug. Every two months it costs me about €10 for a supply that otherwise would cost around €85. A few things are not covered, but they are usually inexpensive, such as antibiotics after oral surgery.

There is also, in the Italian health care system, a professional ethos wholly different from that prevailing in the U.S.. Doctors, nurses, and medical technicians all earn considerably more than the average worker here, but very few seem to be motivated mainly by the prospect of making a lot of money, as I have noticed with many U.S. physicians. (Although in the US I have usually been con-tent with their care, too many seemed to be in the profession in order to be very comfortable, well beyond a couple of hundred thousand a year.)

Compare this to my situation in the U.S.. I have been a photographer, artist, and art teacher over the years, and have usually worked free-lance or as a part-timer. Most notably I was an adjunct professor for the City University of New York for 15 years, but with no coverage whatsoever. Thus for many years I had no coverage at all, except for briefer periods when I worked as a technician in a series of photo-labs. Since there was always a waiting period of perhaps 3 months after starting a new job, the lack of any assurance of continued employment meant frequent interruptions of coverage in a field in which one was obliged to change jobs often. (Although it has little to do with health care, I was once laid off – by sheer coincidence – by an employer one week before I’d have been eligible for a week’s vacation with pay after a full year of satisfactory employment. That’s not just being cheap, it’s being a cheap bastard; excuse my language, but a weaker expression would be less than honest. I’m talking about you, John McPhee, you S.O.B..) Another lab simply offered no coverage, the owner saying he just couldn’t afford it, even though we were doing a good business. One of my colleagues there had suffered a heart attack and survived, but saddled with a debt of $50,000. He was earning at most $600 a week (ca. 1985) as a supervisor and was a good worker.

The only time I had satisfactory health coverage in the U.S. was during a period when I taught for the NYC public school system in the early ’90s, thanks to a strong union and a decent contract. If it had not been for that coverage, I very likely would not be alive today: at a routine dermatological exam I was found with a melanoma (early stage II), which – if it had been left untreated – probably would have developed in a year or two into something untreatable.

All those of you who oppose health care reform, haven’t you already heard dozens of stories like mine? I have nothing against the profit motive as such, but it shouldn’t come to dominate some-thing so crucial to the quality of life as health care. The private insurance business is in the position of controlling health care as currently arranged, and is motivated more by profit – as are many private health care providers – than by the goal of providing health services reasonably and equably. As such it is a superfluous middle-man, for all practical purposes a parasite with a vested interest in the status quo. It’s a bureaucracy more bloated than any in government, whose paper-pushing “services” add enormously to the cost of medical care, without adding any value. The average level of expenditure in the European Union is considerably less per capita than in the U.S., while providing everyone with a level of health care that is the equal of that in the U.S., and sometimes superior. A single-payer system would save great sums of money. It is in part a question of mere efficiency, a goal and virtue surely not anathema to private enterprise. Social Security and Medicare are administered rather well at far less cost than medical care under the present system. Doesn’t it make sense now more than ever to try to reform the system, when we have so many other equally urgent needs to revive industry and the economy, to revive public education and job training, and to develop new energy sources, just to name the most obvious? If the proposals – too modest in my opinion – of the Obama administration are calls for “socialized medicine”, you can have dog-eat-dog, winner-take-all free enterprise, and I’ll take this.

Perhaps it is not too off-topic to wonder how, in western Europe, with a standard of living comparable to that of the U.S., it is possible to pay for the public health system. On one hand it’s a complex question of income and expenditures, but on the other it’s a simple one of ink, black and red. In the U.S., there’s a very large portion of the GNP that goes to defense, a portion that dwarfs what is spent by European states for defense. This is the military-industrial complex Eisenhower – no dove – warned us about almost fifty years ago when leaving office as President. One might have thought that when the Cold War ended with the collapse of the Soviet bloc, we in the U.S. could have turned a few of our swords into plowshares. But it seems our economy is addicted to defense production. Too many jobs in too many congressional districts depend on DOD contracts for any law-maker to think very much of the good of the country in the long term. We are armed to the teeth, prepared for nuclear war or conventional war, but not very well adapted to meeting the political and military challenges of today, the threats of terrorism and “rogue” states included. The war in Iraq is a case in point – believing we could set everything right with the military options, we transformed a difficult situation into an atrocious one, alienating most of the world, inspiring unprecedented numbers of young men to enlist in Al Qaeda and other anti-American militias, getting a lot of people blown to pieces, and spending tons of money in the process. We would do well to establish what we really need for national security and cut out the pork. We have a massive industrial capacity that could be directed to many things more useful than weapons systems.

I’m astonished at the people lately who lash out at proposals for universal coverage as “Socialism” or worse. I’m afraid these people are ignorant of the facts, and are manipulated by reactionary news media, and by demagogues who are themselves unable to distinguish between a Sweden, an Italy, a Canada, or a France, and Stalinism. Are they equally opposed to the U.S. Postal Service, Social Security, highways, and school systems, all public financed and operated? It took me some time living in another country to fully appreciate this, but I’m afraid many Americans are terribly parochial and unsophisticated where politics is concerned, and have narrow and foolish notions of how life is elsewhere in the world.

Once I went into a store (B&H Photo) in New York City and said to a salesclerk that I was amazed that they could sell at such low prices. The clerk, an Orthodox Jew with a good sense of humor, answered, “Well, if you really want, you can pay more.” I laughed and said, “Thanks, but no, thanks.”

Would you pay more?

Allen Schill

Torino, Italy

Double scoliosis, X-ray, Allen Schill.