COLUMBIA — Almost 1,600 international students from 90 countries are enrolled at MU this semester to pursue undergraduate and graduate degrees. Another 200 more are on campus as visiting scholars for training and other programs. They bring with them a world of experience that puts the U.S. health reform debate in perspective.
Most of these countries are far behind the United States in per capita spending on health care. In 2006, the United States spent $6,714 per capita, the highest among industrialized countries, according to World Health Organization. But in 2008, the United States came in last among 19 industrialized countries in preventable deaths.
The World Health Organization is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.
As lawmakers debate a public option and managed care, some of MU's international students and members of international student organizations gave the Missourian their view of the health care systems in their countries and the health care reform debate in the U.S.
- Population: 61.3 million
- Life expectancy at birth m/f (years): 77/84
- Total expenditure on health per capita (in 2006): $3,554
Tim Pale, 25, doctoral student in biological sciences, from Paris:
Pale tore a ligament in his leg during a soccer game last semester. He went to University Hospital, where his leg was put in a cast, and he was put on medication. Pale's doctor in the U.S. suggested he go for surgery. He sought a second opinion.
“My doctor in France said surgery was a bad idea,” Pale said.
France has a universal health care system where part of the taxes paid by employers goes toward providing health care.
In France, a student pays 150 euros, or $223, a year for health care until he gets a job. Pale’s mother, a university professor, has two insurance policies — apart from the basic government coverage — for complementary care, such as eye and dental care. Those complimentary policies are half private and half public, and the premiums are paid by her employer.
When Pale tore the ligament, his international student health insurance plan paid 80 percent of the cost, around $12,000, and his French health insurance paid the rest.
“Drugs don’t cost much either, and (are) reimbursed by the social security, which is the basic health care system in France,” Pale said.
Patients don't need an appointment to see a general practitioner, but an appointment is necessary to see a specialist, such as a gynecologist or a cardiologist. Sometimes, the wait is months at a time, although it's shorter in an emergency.
The cost to see a general practitioner is 23 euros ($33), and it is the same throughout the country. But social security pays back 22 euros ($32), making the out-of-pocket costs one euro.
Everybody has the same basic insurance or can get complementary coverage. Pale's mother pays 100 to 200 euros a year for complementary coverage.
Poorer people, whose income is not sufficient to pay for coverage in old age, don’t pay for treatment.
“In France, people who don’t have money don’t have to sell their cars and houses to pay for health care because government covers it,” Pale said.
But France’s cradle-to-grave health care coverage has its own problems. A few years ago, the government spent 42 billion euros on social security.
“That shows there is something wrong with the system,” Pale said. “People use (it) way too much, and people are taking advantage of that. They don’t pay pretty much anything.”
- Population: 86,206,000
- Life expectancy at birth m/f (years): 69/75
- Total expenditure on health per capita (2006): $264
Giang Nguyen, 19, undergraduate student in business and finance, from Hanoi, Vietnam:
Access to primary health care in Vietnam is sometimes difficult, Nguyen said, because hospitals are crowded. People usually do not make an appointment to see a doctor.
“It seems like the primary health care can be accessed at any time, but actually, it is one of reasons that make the doctors in our country always feel tired ... when they have to see so many patients in the same day,” he said.
The stress can lead to exhaustion and carelessness in patient treatment, Nguyen said.
Despite government regulation, people in Vietnam have easy access to most kinds of drugs. For instance, even though a prescription is required for birth control pills, lax enforcement means they are available over the counter.
“In Vietnam, we can easily get it from any drugstore without any doctor’s prescription,” Nguyen said.
Since people can drop by a doctor anytime, waits can be long — even as long as a day — during busy hours. Wait times are shorter at private hospitals, but they are much more expensive, Nguyen said.
Overworked physicians have so little time with each patient, there's little chance of overtreatment, he said.
- Population: 86,264,000
- Life expectancy at birth m/f (years): 64/71
- Total expenditure on health per capita (2006): $223
Jerryl Peralta, 21, undergraduate student in pre-nursing program and president of the Filipino Students Association, from St. Louis:
Primary health care isn't as accessible in the Philippines as it is in the United States, said Peralta, whose parents are from the Philippines.
"Those in the underdeveloped areas of the Philippines don't really have access to primary health care unless they can make it to the city, which wasn't possible most of the time,” he said.
In August, the Philippine government began to subsidize purchases of medication to make it more affordable. The country offers Medicare plans to cover those who can't afford private or employer health insurance.
Doctors are too overloaded with work and the number of patients they have to see each day, Peralta said.
“There's no incentive for doctors for overtreatment of patients unless they do it out of the kindness of their hearts,” he said.
There are more private health care facilities than public, but there are few private hospitals in between major cities, he said.
Peralta thinks the health reform debate in the U.S. is going in the right direction.
“Even though the United States is one of the countries with better health treatments, not everyone can afford it," Peralta said. “There’s no point in having such great health care treatments if it can’t be afforded by those that need it.”
- Population: 27,589,000
- Life expectancy at birth m/f (years): 71/75
- Total expenditure on health per capita (2006): $300
Cecilia Turin, 38, doctorate student in rural sociology, from Lima, Peru:
Peru’s public health care option is cheap and caters to poorer sections of the society, Turin said. But it is in a bad shape.
The wait time at public hospitals is long, ranging from three weeks to months, depending on the urgency. A general check-up can cost $3 for the first appointment; seeing a specialist costs $5 . Once admitted to a hospital, patients have to pay for their medicine and bring personal items, including blankets, from home.
The private system caters to the middle and upper classes. The private health care system is made up of small clinics, which are concentrated in the urban areas.
The public sector has hospitals as basic care delivery institutions and has an extensive network that covers rural areas. It also provides specialized care. However, the private health care sector does not provide treatment for cancer or tropical diseases. These sectors are covered by two public hospitals in Peru.
Each district has a small public hospital and mobile hospitals to treat people in remote areas.
“In these (mobile) hospitals, attention is good with good service,” Turin said.
People usually don't have private insurance and don't have to pay for public insurance. Clinics treat patients with or without insurance.
Drugs in Peru are not free, and many find them expensive.
The doctors don't have a tendency to prescribe a lot of medicines, Turin said, “because doctors know that medicine is costly and people will not continue (through the full course of treatment)."
Turin wants to see a public option in the U.S. health care industry. She also said she believes that patients should have more contact with doctors.
- Population: 160,943,000
- Life expectancy at birth m/f (years): 62/63
- Total expenditure on health per capita (2006): $51
Faiza Rasul Rias, 28, graduate student in political science, from Islamabad:
People have better access to health care in Pakistan than the United States, Rias said. But while government hospitals are cheaper, they are overcrowded.
Sometimes people wait for days for both an outpatient visit and to get admitted, she said. Emergency cases are attended to faster.
The fact that they are overcrowded shows that the country needs more public hospitals, Rias said.
But public hospitals in Pakistan have a long way to go in sanitation, Rias said, recalling her visit to a public hospital in Islamabad a few years ago. It had poor ventilation even on the hot summer day and discarded disposable needles were lying on the floor where Rias got her injection.
The private health care sector mostly caters to richer citizens, and the care delivery system is quicker than at a public hospital, Rias said. But the private hospitals are more expensive. Few, such as Shaukat Khanum Memorial Cancer Hospital and Research Center, founded by the country's leading sports personality Imran Khan, offers free specialized treatment to financially disadvantaged patients.
People usually pay out of pocket for treatments, and there is no government reimbursement system for health care costs. Health insurance policies aren't popular; few people can afford them, she said.
In the United States, Rias said, health care reform is long overdue. One of her friends, who is a U.S. citizen and uninsured, opted to go without glasses because he couldn't afford them, Rias said.
She also sees a class division reflected in the debate as President Barack Obama was called a socialist when he wanted to introduce public option health insurance. But perhaps rich people have a bigger responsibility because of their wealth, Rias said.
- Population: 38,140,000
- Life expectancy at birth m/f (years): 71/80
- Total expenditure on health per capita (2006): $910
Magdalena Gornicka, visiting journalist, from Warsaw, Poland:
The Polish health care system, despite its flaws, provides basic universal treatment – without pressure of bills for patients, Gornicka said. And nobody can opt out of it, she said.
The Polish constitution guarantees the right to access to health care for every citizen, regardless of age, job or material status. As a result, all social groups are covered by health insurance, including students, farmers, social security benefits receivers and the unemployed.
There is almost no wait time to get an appointment with a general practitioner. General check-ups are free.
"But if we want to receive additional medical services (those not covered by the government) we should turn to private health care," Gornicka said.
Employers offer private insurance to sweeten compensation packages.
"Premiums — set by the government — are estimated on the basis of average wages, similar to taxes," she said.
Medicines are cheaper in Poland compared to other countries with universal health care, Gornicka said.
Generic drugs are popular, and most prescription costs are fully or partially refunded by National Health Fund. While prescribing medicines, doctors try to pick those the patient can afford, Gornicka said.
Pharmacists also help patients find cheaper, generic drugs.
Generally, Poles take a lot of medicine – sometimes even without consultation with a doctor, Gornicka said.
"They think drugs are a ‘miracle wand’ and often go straight to the drugstore," she said.
Doctors salaries' are estimated in hourly rates. She thinks that's why overtreatment of patients isn't a problem in Poland.
The country is engaged in a debate over whether people should have to pay a small amount to increase the health care system's effectiveness and cut down on its overuse, she said.
- Population: 22,974,347 (CIA handbook)
- Life expectancy at birth m/f (years): 72/75 (For China, from WHO)
- Total expenditure on health per capita (2006): $342 (For China, from WHO)
Annie Liao, 23, graduate student in journalism and a staff member for the Columbia Missourian, from Taichung, central Taiwan:
Liao’s grandmother lives in a rural area, and there are at least two clinics near her house. To her, that makes health care in Taiwan seem pretty accessible.
However, most hospitals and clinics are closed on Sundays, and their hours of operation are not convenient for some patients, Liao said.
The wait time varies. Depending on reputation of a doctor and the season, waits can range from 10 minutes to five hours, she said.
Taiwan has national health insurance, which the government extends to every citizen. As long as the patient brings his or her insurance card to the hospital and pays the service fee, which is usually less than $10, the government takes care of the rest.
The insurance is paid for through the payroll tax.
"Because the government covers most of the treatment costs, people in Taiwan tend to turn to the doctors whenever they feel sick rather than go to the pharmacy," Liao said.
Liao supports a national health insurance program in the United States. The U.S. government should make the health care system affordable to every citizen because health is the most important asset to a human being, she said.
“I find it hard to believe that wealth determines one's ability for wellness condition in the U.S.,” she said. “It’s the government's responsibility to take care of its people, and the staggering economy and budget deficit shouldn't be excuses for depriving people of their right to their own health.”
- Population: 20,530,000
- Life expectancy at birth m/f (years): 79/84
- Total expenditure on health per capita (2006): $3,122
Tom MacLean, 20, exchange student in journalism from La Trobe University, Melbourne, Australia:
The Australian health care system strikes a middle path between the French and U.S. health care systems, MacLean said.
The government-sponsored health care plan is called medicare, and it covers all citizens. The system reimburses 75 percent of the costs with a receipt of the treatment costs.
Because costs are not as high as in the U.S., people can afford private insurance. They can get extra services for extra fees. For instance, a private insurance plan will provide a patient room, longer time in the hospital and a choice of doctors. But private hospitals are not as well organized as public hospitals, MacLean said.
The public hospitals encourage shorter stays. But they are often more up-to-date, efficient, quick and organized, MacLean said. Private hospitals offer elective surgeries, such as orthopedic and urological surgeries.
The wait time for a general practitioner is short, but patients wait longer for specialists. For example, the wait for a dentist can be a few months.
Medicines as well as immunizations are subsidized. Vaccines can cost AUD$50 ($45), but 75 percent of the cost is reimbursed.
Doctors in public hospitals are paid per hour, and there is little incentive for overtreatment, MacLean said.
He finds the differences among the U.S., Australian and European health systems interesting because they reflect the differences in their economic systems.
The European health system is more socialistic while the U.S. system is more reflective of the capitalistic society, he said. MacLean, though, would like to see a public option and lower costs in the U.S. health care system.
- Total population: 3,579,000
- Life expectancy at birth m/f (years): 43/46
- Total expenditure on health per capita (2006): $39
Lischen Reeves, 20, undergraduate student in magazine journalism and political science, and vice president of African Student Association, from Monrovia, Liberia:
In Monrovia, Liberia’s capital, access to primary health care is always on a first-come, first-served basis. The government-owned John F. Kennedy Memorial Hospital and the private St. Joseph Catholic Hospital are most the popular.
A patient usually waits a couple of hours to see the doctor, Reeves said.
“There are many doctors, and one gets to see a doctor according to your particular need,” she said. “There are also many small privately owned clinics that meet the needs of the populace.”
According to the Ministry of Health and Social Welfare, 52 percent of Liberia’s health facilities are managed by non-governmental organizations.
No appointment is necessary to visit a doctor at the two major hospitals and other government-owned hospitals. Some private clinics require appointments, and there are long lines every day, Reeves said.
“People with money make appointments,” she said.
Some public hospitals charge a small fee — around LRD$10 (14 cents); private clinics are more expensive.
One doesn’t need insurance to get treatment, Reeves said. Sometimes insurance is provided by non-governmental organizations.
On the reform debate, Reeves thinks that Obama has devised a vague plan for such a big reform. But she said she has faith "in the candidate that has been chosen to run this country.”
Reeves also said that it is important to acknowledge the president’s willingness to work with Republicans in the House and Senate on health care reform.
“However, sometimes a bit of partisanship can give things an extra lift.” Reeves said.