I moved to New Delhi a year and a half ago from New York for a new job with a newspaper. When I arrived in India's capital, I figured if I was going to live in the country, I might as well get used to the food, the water and the bacteria that doesn't seem to bother too many natives. I ordered juices, ate cold salads and drank the un-bottled water that restaurants bring customers for free. But I learned the hard way there are better methods for adjusting your body to the new climate. Less than two weeks into my time there, I found myself vomiting at the foot of a 12th century monument, the Qutb Minar.
I had anticipated getting sick in India. Since I had elevated carelessness to the level of doctrine, I had almost guaranteed it. But it was something I hadn't prepared for. I had no idea how to navigate the Indian healthcare system. How would I find a doctor? What if I had to go to the hospital? How different from the American system would it be?
What I hadn't anticipated was that India's treatment would turn out to be so good. And cheap. Unless you happen to be one of the hundreds of millions of Indians who are poor and don't live in a major metropolitan area. The Indian healthcare system is an anarchic hodgepodge, with little insurance, little regulation and a range of services offered by hundreds of government-run, trust-run and corporate hospitals. The care it produced for me was fast, effective, courteous and cheaper than American medicine, even when adjusted for the lower cost of living. But that was the care it produced for me, a middle-class woman in the big city. As America considers healthcare reform, the Indian system is a testament to both the triumphs and the pitfalls of letting the free market heal people.
At first I fought the suggestion to visit a doctor with my stomach bug. I rested and didn't eat much for a few days, hoping it would disappear on its own, like stomach bugs tend to do. I thought that making an appointment, and waiting to see a doctor, and getting ahold of any medication in India, would take more time than just getting better on my own. After all, it took almost 17 hours of phone calls and store visits, and two instances of crying hysterically to customer service reps, for my cellphone to work. If just getting a basic telephone connection was so much effort, I didn't want to think about what a visit to the doctor would be like. But after the third day of diarrhea, and continued inability to eat anything without being hit with an overwhelming wave of nausea, I caved. "OK, let's call a doctor," I told my friends who were taking care of me.
It was about 9:30 in the morning. My friend, who works for an outsourcing firm, called a gastroenterologist -- not a general practitioner but a specialist -- and set up an appointment for 10 a.m. We drove to the hospital, a mile away. It looked brand-new; the floors were shiny and everything glistened. The staff was courteous and the whole place was quiet. The doctor called me in at 10:02. He diagnosed the problem as a bacterial one, gave me a list of what to eat and prescribed a course of antibiotics. The pharmacy counter where I could pick up the drugs was just outside his office. The cost to see the doctor? $6. The pharmacy bill was about $1. Total cost, $7, with no insurance company involvement whatsoever.
Before I left New York, I had spent $20 just on a copay to visit a doctor and get a blood test done, another $20 copay to pick up the test results, and a third $20 installment for a tetanus shot. That was $60, plus whatever my insurance company paid, just so I could get a clean bill of health.
A couple of weeks after my first encounter with an Indian doctor, I had another bout of stomach problems. This time, it was probably a glass of watermelon juice that did me in, and the next morning, I couldn't even keep water down. We called the same doctor on his cellphone, and he prescribed the same antibiotic. When I threw that back up, we called him again, and he said to try a more powerful anti-vomiting drug. We called the pharmacy, which delivered the drugs for free.
It worked, for the most part, but when nausea was still bothering me a few days later, I paid another $4 visit to the doctor. He told me to go to a lab down the street from his hospital and have a blood test and stool sample done. I went in without an appointment and walked out 20 minutes -- and $20 -- later. That afternoon, I picked up the results and read them to my doctor over the phone. The liver function test came back a little high, so he said to take it easy and go back two weeks later for the same tests. I did, and the levels were almost down to normal. The phone calls were free.
Even emergency care in India seems to work along the same lines. The same friend who first called a doctor for me had been in a horrific car accident about eight months before I arrived. He was taking a right turn at 2 in the morning when a truck came from the opposite side, ran into his car and just kept going. His femur was broken like a twig, as were his collarbone and wrist. His lip was split and his nose was hanging off his face.
Two months and a few surgeries later, he walked out of the hospital. He walks now without any aid and has had no major complications. The total bill, paid by his Indian insurance company, was less than $10,000. A similar accident in the U.S. would run up a $200,000 bill and bankrupt almost anyone who didn't have health insurance.
How is this accomplished? Largely through supply and demand. Almost 25,000 doctors graduate from India's medical schools every year. Because there is so much competition, doctors and hospitals are forced to keep their prices low to get patients. Residents, who go to medical school straight from high school, only make the equivalent of a few hundred dollars a month. An average surgeon's salary would be around $8,000 per month. The take-home pay to fix a hip fracture, for example, might run between $100 to $300, out of the $1,000 fee to the patient, says orthopedic surgeon M.S. Phaneesha. At his hospital in Bangalore, he says, there are 20 orthopedic surgeons alone on staff. For 1,600 beds, the hospitals employs around 700 doctors full-time; 300 of them are surgeons. In the U.S., by comparison, a first-year resident might take home around $2,500 each month, and the average surgeon more than $20,000 per month. A hip fracture would cost a patient around $30,000, of which the surgeon's charge is $5,000. Even general practitioners in America earn on average more than $100,000 a year.
Another factor in India's costs is the tiered system of beds that most hospitals employ. One night in a general ward at the private Artemis Health Institute in a New Delhi suburb, for example, costs around $20 per night. One night in a single room, or a deluxe, or a suite, though, will cost you between $100 to $200. Services are similarly tiered. A general ward patient at Artemis would only pay $2 for an X-ray, while single-room patients would pay more. There are so many hospitals, says Artemis' chief operating officer Jose Verghese, that rates at the lower end stay low.
Unsurprisingly, for the urban middle class, says Ajay Mahal, who teaches international health economics at Harvard University's School of Public Health, finding medical care isn't a major problem. Referrals through friends and family work as a check on quality. And in general, those in the middle class, like my friends, are connected enough to find the best private doctors.
But this type of care isn't available to all Indians, since the average income in the country is still around $65 per month, and more than 300 million Indians out of a population of 1.2 billion still live on less than $1 per day. The poorest residents, just as they do in the U.S., often skip out on expensive treatments, and visit doctors only in serious situations. They do have access to free top-tier government hospitals for serious medical conditions. The national government and some state governments are trying out models to cover medical costs for its poorer residents, such as paying for certain surgical procedures or providing yearly vouchers that cover around $600 in expenses, to mixed results. Only 8 to 9 percent of Indians even have private health insurance, so most expenses are paid in cash, by the patient.
And about those doctors: Only a handful are from reputable institutions, explains Mahal. Quality of care varies throughout India, and is a big concern in smaller towns, where the more questionable institutes are based. But it is also a concern in the big cities. The sheer number of doctors is one of the main downward pressures on healthcare prices, but it's a good thing I had the name of a good doctor and didn't wander in off the street to the offices of a poorly trained M.D.
In some ways, the Indian system is like the U.S. system before the spread of private insurance -- that extra layer of bureaucracy is still not a major factor in Indian healthcare costs. Private insurance costs help explain why the U.S. spends a greater percentage of its GDP on healthcare than the European democracies. The Indian system of health insurance also works differently, in a way that holds down costs. Those Indians who do have private insurance pay their bills out of pocket -- to doctors who don't charge much because of all the competition -- and then get reimbursed. The insurance companies aren't the ones setting the rates or acting as the middle man.
In other ways, the Indian system is like the current U.S. system, except writ very cheap and very large. Just as in the U.S., healthcare is better the bigger the town, the bigger the wallet. It is out of reach for the poorest segments of both populations because of simple economics. Both governments have partial safety nets -- though public costs are a far smaller percentage of GDP in India and a smaller portion of all healthcare spending.
There are also some differences that seem largely due to culture. A tiered system of care might be untenable in the U.S., where more patients have insurance and everyone expects the best available care. There is also a different expectation and feel to the actual doctor visits. Raj Sringari, the surgeon who treated my friend, and who also practiced in the U.K. for seven years, says the Indian doctor-patient relationship is an extension of a culture built around social visits. "If you want to see a doctor, he is available from 9 in the morning till late in the evening. A patient can walk in, and if the doctor is free, he is happy to see you."
Still, it is remarkable that the healthcare system of the world's most powerful country has anything at all in common with the healthcare system of an emerging industrial nation, and so little in common with the systems of the other Western democracies.
By the way, in July, I moved back to the United States. I bought travel health insurance from Tata-AIG, which is available to anyone who has spent at least six months in India. I'm covered for three months, up to $200,000 in expenses. I paid $100 for it. When it expires, I will likely get health insurance from Blue Cross. It will cost more than $500 per month.
A moderate Democratic senator who voted to allow debate over a health care bill says he might not support the bill in its next hurdle in the Senate.
Sen. Ben Nelson of Nebraska says he has serious problems with the bill. He says he wants tougher restrictions on what services taxpayers pay for.
The Nebraska Democrat says he wants an overhaul of the nation's health care system but still needs to be convinced that the Senate bill is the right path to that goal.
On Saturday night, Democrats mustered the minimum 60 votes needed to advance the Senate bill to debate after the Thanksgiving break. After that debate, the bill faces another vote that requires 60 senators in support.
Nelson appeared Sunday on ABC's "This Week."
Invoking the name of Edward M. Kennedy, Democrats united Saturday night to push historic health care legislation past a key Senate hurdle over the opposition of Republicans eager to inflict a punishing defeat on President Barack Obama. There was not a vote to spare.
The 60-39 vote cleared the way for a bruising, full-scale debate beginning after Thanksgiving on the legislation, which is designed to extend coverage to roughly 31 million who lack it, crack down on insurance company practices that deny or dilute benefits and curtail the growth of spending on medical care nationally.
The spectator galleries were full for the unusual Saturday night showdown, and applause broke out briefly when the vote was announced. In a measure of the significance of the moment, senators sat quietly in their seats, standing only when they were called upon to vote.
Republican Sen. George Voinovich of Ohio missed the vote.
In the final minutes of a daylong debate, Majority Leader Harry Reid, D-Nev., accused Republicans of trying to stifle a debate the nation needed.
"Imagine if, instead of debating whether to abolish slavery, instead of debating whether giving women and minorities the right to vote, those who disagreed had muted discussion and killed any vote," he said.
The Republican leader, Sen. Mitch McConnell of Kentucky, said the vote was anything but procedural -- casting it as a referendum on the bill itself, which he said would raise taxes, cut Medicare and create a "massive and unsustainable debt."
For all the drama, the result of the Saturday night showdown had been sealed a few hours earlier, when two final Democratic holdouts, Sens. Mary Landrieu of Louisiana and Blanche Lincoln of Arkansas, announced they would join in clearing the way for a full debate.
"It is clear to me that doing nothing is not an option," said Landrieu, who won $100 million in the legislation to help her state pay the costs of health care for the poor.
Lincoln, who faces a tough re-election next year, said the evening vote will "mark the beginning of consideration of this bill by the U.S. Senate, not the end."
Both stressed they were not committing in advance to vote for the bill that ultimately emerges from next month's debate. Even so, their announcements marked a major victory for Reid and the White House in a year-end drive to enact the most sweeping changes to the nation's health care system in a half-century or more.
The legislation would require most Americans to carry insurance and provide subsidies to those who couldn't afford it. Large companies could incur costs if they did not provide coverage to their workforce. The insurance industry would come under significant new regulation under the bill, which would first ease and then ban the practice of denying coverage on the basis of pre-existing medical conditions.
Congressional budget analysts put the legislation's cost at $979 billion over a decade and said it would reduce deficits over the same period while extending coverage to 94 percent of the eligible population.
It's done: Senate Democrats gathered 60 votes and got their healthcare reform bill through the first test it will face.
All 60 members of the Senate's Democratic caucus stuck together for this vote, a cloture motion that opens debate on the legislation. Similarly, all 39 of the Republicans who voted opposed the motion. Sen. George Voinovich, R-Ohio, was the lone senator not voting.
Actual debate on the bill won't begin until after Thanksgiving, and it won't be easy. Already, two members of the Democratic caucus -- Sens. Joe Lieberman and Blanche Lincoln -- have threatened to support a Republican filibuster if it includes a public option, and more could follow.
Later Saturday night, the Senate Democrats' healthcare reform bill will pass its first test. Majority Leader Harry Reid officially has the 60 votes needed to win on a cloture motion that will open debate on the legislation. The last two members of the Democratic caucus to announce their intentions, Sens. Mary Landrieu of Louisiana and Blanche Lincoln of Arkansas, both said Saturday that they'll be voting with their party.
But this is just one procedural vote. The more daunting hurdle of the cloture vote to break a filibuster and hold an up-or-down vote on the bill itself still lies ahead, and there Reid may have serious trouble, especially if a plan to create a government-run insurance provider -- the public option -- remains in it.
Sen. Joe Lieberman, I-Conn., who is a member of the Democratic caucus, has already said he'll vote to filibuster a bill that contains any form of the public option. (He is voting for cloture tonight, but not, he says, the next time around.) And on Saturday, Lincoln too threatened to support a filibuster of the legislation if it includes the public option.
Both will be tough nuts for Reid to crack. Lieberman's not up for re-election next year, and has already been taunting liberals by saying he's not afraid of possible retribution. Lincoln, on the other hand, is up for re-election -- and that's the problem. She's seriously vulnerable, and is looking at polling numbers that seem to indicate voting with her party to support a public plan would only put her in a more precarious position.
Earlier this week, Senate Democrats finally unveiled their healthcare reform legislation. Despite all the squabbling that's gone on over the public option the bill does, like its House counterpart, contain a plan for a government-run insurance provider. However, there are a number of important differences between the two proposals. Assuming Senator Majority Leader Harry Reid musters together the 60 votes necessary to get his version through the Senate, there are going to be a number of points that negotiators will need to work out in committee. Here are some of the most important differences between the bills.
Public Option: Will states be allowed to “opt out”?
Both bills include the creation of a government-run insurance provider to compete with private insurers. However, the Senate version would allow states to opt out of the public plan.
Abortion: The Stupak Legacy
To garner much-needed support from anti-abortion Democrats, House Speaker Nancy Pelosi (D-CA) allowed them to attach the infamous Stupak-Pitts amendment to her chamber's version of the bill. The provision would bar women who are receiving federal subsidies for their insurance from purchasing plans that cover elective abortions. It would also bar the public plan from offering abortion coverage. The Senate version takes a more moderate approach: Those receiving federal subsidies could buy insurance that covers abortion -- but insurers would have to place federal money in separate accounts and could only use private dollars to cover the procedure. The public plan could also offer abortion coverage, as long as it segregated federal subsidies in the same way.
Cost: The difference a year makes
According to the Congressional Budget Office, the House bill would cost about $1.052 trillion and reduce the deficit by $138 billion. The CBO predicts that the Senate bill would cost $849 billion, while cutting $130 billion from the deficit. This difference is largely due to the fact that many major provisions in the Senate proposal would not go into effect until 2014 -- a year later than in the House bill.
Coverage: Universal? Not quite
For decades, the Democrats talked of providing universal healthcare. These bills come closer, but neither quite reaches that goal. Both, however, will significantly reduce the number of uninsured. Today, 83 percent of non-elderly legal residents have health insurance. (The elderly are covered by Medicare.) Under the House bill, 96 percent of that population would be covered by 2016. The Senate's legislation would expand coverage to 94 percent. Still, about 18 million people would remain uninsured under the House's proposal, as would about 23 million in the Senate's.
Paying the bills: What gets taxed
Under the House bill, much of the money to pay for the reforms would be raised through a 5.4 percent surtax on high-income people -- that is, individuals making more than $500,000 a year or couples with annual incomes in excess of $1 million. The Senate version, on the other hand, would impose a different series of new taxes including: A 40 percent tax on “Cadillac health plans” (employer-sponsored group plans with premiums of over $8,500 for individuals or over $23,000 for families); the introduction of annual fees for health care companies; an increase in Medicare payroll taxes from 1.45 percent to 1.95 percent for those earning more than $250,000 a year and the implementation of the so-called "Botox tax," which is a five percent tax on elective cosmetic medical procedures.
Employer mandates: Do companies need to offer health insurance?
The House bill stipulates that employers with payrolls of more than $500,000 must offer health coverage or pay a federal tax. The Senate version does not explicitly require employers to provide coverage; however, companies with 50 or more full-time employees would have to pay a penalty of $750 per employee if they fail to offer coverage and if any of their employees obtain federally subsidized care via the new health insurance exchanges.
Friday, Senate Democratic leaders agreed to include the Wyden amendment in their healthcare proposal. Under this provision, employers would have one of two options. Companies could offer their employees a single plan and give all eligible workers the option of accepting a voucher to independently purchase their own insurance. Alternatively, an employer could offer two or more health care plans, provided that at least one has a premium that costs no more than the average premium of the two least expensive health plans in the local exchange. The House bill includes no comparable language.
Individual mandates: Penalties for remaining uninsured
Both bills require most Americans to maintain a minimum level of health insurance. However, the penalties for not doing so are much stiffer in the House bill: Those who failed to acquire insurance would pay a tax equal to 2.5 percent of their gross income of over $9,350 for individuals or $18,700 for couples. Under Reid’s legislation, the penalties would start at $95 per person in 2014 and gradually go up to $750 a head in 2016.
Insurance Exchanges: State-based or national
Both bills would create some sort of health insurance exchange, a marketplace where individuals and small companies can shop for insurance and compare benefits and prices. The exchanges would put individuals into large risk pools, which are intended to provide them with leverage to purchase insurance at a lower cost. The House bill would create a national exchange, although states could petition to run their own exchanges as well. Under the Senate proposal, states would form their own exchanges. This, however, could prove problematic, as it is unclear whether state exchanges would be able to attract a sufficient number of enrollees to push for lower premiums.
Illegal Immigrants
The House bill would allow illegal immigrants to buy insurance from the exchanges, but would not allow them to obtain federal subsidies. The Senate version prohibits illegal immigrants from purchasing insurance from these exchanges, even if they could pay for their own coverage in full. This could have the effect of preventing illegal immigrants from buying individual insurance altogether.
Immediately after reading about the new cervical cancer screening guidelines, which recommend delaying pap smears and having them less often, a friend sent me an e-mail reading: "I mean, should this month's headlines be summed up as, 'New medical guidelines recommend that women get a lot less healthcare than they used to?'" Indeed, this advice comes on the heels of the U.S. Preventive Services Task Force's controversial new guidelines that bump the suggested age for mammograms up to 50. The American College of Obstetricians and Gynecologists, which issued the new pap smear guidelines, says the proximity of both news items is strictly coincidental and that its new position has been in development for quite some time.
Some skepticism on women's part about these relaxed standards makes sense after years of repeatedly being pinned with pink ribbons, lectured about the importance of yearly paps and hit over the head with pamphlets about the lifesaving HPV vaccine. That's especially true for those of us who know women -- some in their 20s and 30s -- with breast or cervical cancer. As my friend wrote, it feels a bit like the overarching message is: "Chill out, chicks! It's just cancer!" Yeah, and it'll just kill you!
That these new guidelines come amid a contentious healthcare debate has also raised paranoia that this is part of an effort to lower healthcare costs -- at the expense of women's health. The impossible-to-avoid Sarah Palin took to Facebook late Thursday to air her worries about this shift in the wisdom about pap smears: "There are many questions unanswered for me, but one which immediately comes to mind is whether costs have anything to do with these recommendations," she wrote. "The current health care debate elicits great concern because of its introduction of socialized medicine in America and the inevitable rationed care." Many other Republicans have jumped on the "rationing" bandwagon as well. (Yeah, now they care about women's healthcare!) Judy Norsigian, executive director of the Boston Women's Health Book Collective (aka Our Bodies Ourselves), told me that "we have a discourse at the moment that is dominated by right-wing rhetoric that the Democrats are all about denying healthcare services."
The truth is that Kathleen Sebelius, secretary of health and human services, insists that the breast cancer screening guidelines will not change "what services are covered by the federal government." (Also, insurance companies claim they won't change mammogram coverage and, as David Dayen points out on FireDogLake, "the procedure is mandated at [age 40] in 49 of the 50 states.") The Obama administration has yet to address the new standards for cervical cancer screening -- but medical opinion on the benefits and risks of pap smears is far less contentious than when it comes to the mammogram debate (which has been going on for decades).
Cindy Pearson, executive director of the National Women's Health Network, an independent consumer-advocacy group, told me that the suggested pap smear routine "is not at all about cost-cutting," but instead "improving women's health." Most women's bodies are able to fight off the virus that causes cervical cancer -- but, when a doctor does detect infection through a test for the virus or the appearance of "disturbed cells" on the surface of the cervix, they typically provide treatment that very well might be unnecessary. This isn't just an issue of experiencing bothersome "cramping, discomfort and missing some work" after having the abnormal cells removed, she says -- "what's actually happening is it's weakening the cervix in some women so that they can't support a pregnancy full-term."
My question for her was why doctors haven't instead adjusted their response to the discovery of the virus' presence -- was it in the interest of avoiding malpractice suits? She explained that the medical community operates under the mantra of "if you see it, you treat it." Essentially, the new cervical cancer screening guidelines reduce the likelihood of a doctor seeing it, so as to avoid their treating something likely to clear up on it's own. "Sometimes there are cases when you say, 'Watch and wait,'" she says, "but almost no one does it."
It just goes to show that you have to be your own advocate when it comes to navigating the healthcare system. As Mary Elizabeth Williams wrote earlier this week about the new mammogram standards, "What’s optional for one woman may be the difference between life and death for another." She also added that "blanket guidelines are just that -- they're fine for covering the many, and they are not laws we have to follow." A woman and her doctor still have to take into account her individual history and particular risk factors. That has always been the case and continues to be so. As Norsigian from Our Bodies Ourselves said: "You give women the scientific evidence and let them make their own choices."
The Penis Has Landed
Payment for prayer "treatment" in healthcare overhaul
Medical Malpractice Revisited on NPR
Yabba Dabba, Dont Worry About It.