Costa Rica Health Care: Public or Private?

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    Kat Sunlove,

    [update: scroll to end of article for update on health care strike]

    For some weeks now there has been the threat of a strike by health workers at Costa Rica’s national medical group, the Caja Costarricense de Seguro Social (CCSS). Last week on Tuesday, July 19, that threat was realized as members of the National Medical Union (NMU), which represents some 7000 employees of the Caja, as it is known, began an indefinite work stoppage to demand that the government of President Laura Chinchilla pay full disability benefits as part of their wages. Union spokespersons indicated that Emergency services would continue but basic outpatient and surgery services in clinics and hospitals in the Caja system would be affected. The union claims that the government also owes them some ¢400 billion colones (around US$800 million) in unpaid overtime and other benefits.

    In a nation that prides itself on universal health coverage for all its citizens, and indeed requires all legal residents, including expats in Costa Rica, to join the system, the situation is serious, as the parties have failed to come to a negotiated agreement despite numerous meetings in recent weeks. It is well known that the Caja is facing a financial crisis, in part because of funds due from the government for public employee insurance payments. Those payments total an estimated US$2 billion. Although the NMU approved only a 24-hour strike, other unions involved in the health care system indicated they were considering a more prolonged interruption of services. According to one news report, even a one-day strike could affect as many as 30,000 patients around the country.

    In the days before the planned strike, President Chinchilla went on national television to announce that the government would speed up payments due to the financially troubled Caja. She promised to transfer ¢85 billion colones, about US$169 million, this year to help reduce the current deficit.

    “The Caja is in critical and urgent need of serious and deep reform,” President Chinchilla said in her remarks, noting that the country’s public health system was in a severe financial crisis.

    But reports indicate even that amount will not be sufficient for the medical system to get its financial house in order. The latest internal audit suggested that the Caja would end 2011 with a deficit of some US$184; a recent study by the Pan American Health Organization indicated that without a slowdown in ever-increasing costs, the system could be in bankruptcy as early as 2015.

    Part of the problem apparently is similar to that facing the health care system in the United States: an aging population and demands for pricey high-tech procedures such as organ transplants and treatments for cancer and other deadly diseases. The problem is exacerbated by the widespread failure of Tico businesses to pay required fees into the program. Unlike the wealthy U.S., however, Costa Rica is still a developing country and although the health care system here is highly regarded as one of the best in the Western Hemisphere, escalating costs are putting that system at risk.

    Reports varied as to how many workers actually honored the strike on the first day of the protest. Government figures said a small minority of just over 10% were involved but union leaders claimed a much higher number of participants, as many as 90% of workers. Nevertheless, most of the major hospitals, such as Hospital Mexico and San Juan de Dios were reported to be functioning without major disruptions of service. On Thursday, hundreds of strikers took to the streets of San Jose in a large protest march, walking down the main thoroughfare to the Caja headquarters. Several other unions, including university workers and the National Association of Public and Private Employees, joined the hospital workers’ union in the demonstration. The strike continued throughout the week and at press time was still ongoing with further activities planned for the weekend and no progress in the negotiations.


    In my limited experience with health services in Costa Rica, I have not had occasion to use the Caja, opting instead for local private doctors. My husband Layne and I belong to Linea Vital, a private clinic here in Atenas, with offices also in the beach town of Quepos on the Pacific coast. For $65 per month, we have unlimited access to our English-speaking doctor, known by her first name as Doctor Candy, who is often there to greet us in the reception area when we arrive, sometimes without an appointment. Our monthly fee entitles us to appointments without a co-pay, phone consultations, referrals to specialists, ambulance services, a thorough annual physical exam and even house calls, when needed. Of course, we pay separately for lab work such as blood tests, chest x-rays or something like Layne’s brain scan, which he underwent earlier this year, but the costs of those tests have been a fraction of what they would be in the U.S.

    For many of the outside exams, Doctor Candy has referred us to doctors at CIMA Hospital, a privately-run facility in Santa Ana, about a 25-minute drive from Atenas, where the facilities are spotlessly clean and very high tech with ultra-modern equipment and well-trained staff. And although prices at CIMA are considerably higher than at Caja, they are still affordable. For example, the brain scan was $440 and a thorough eye exam was about $60. For routine tests associated with my annual physical, Doctor Candy sent me to Clinica Santa Fe, a less expensive clinic in Alajuela, where I paid a total of about $100 for a mammogram, chest x-ray and abdominal ultrasound.

    Caja, of course, is the primary care system for most Ticos who can’t afford even the relatively low-cost services of the private clinics and it provides most of the emergency care for expat residents as well. Second-hand reports we have heard on medical care at Caja vary greatly. Our housekeeper, for instance, was told she would have to wait a year or more for tests through Caja to determine if she might have cancer. Of course, if a biopsy showed she did have a cancer, Caja would treat her immediately as an emergency, but since she couldn’t afford the cost of a biopsy on her own, she would have to wait. When we learned that the test would cost only $100, we paid for it ourselves. Fortunately, it showed she did not have cancer and she now is receiving medication for a minor problem. In another instance, a Gringo friend took a fall and was quickly whisked to a Caja hospital where she received prompt and complete care of a broken leg. But on numerous expat forums, such as the Costa Rica Living group on Yahoo or the Association of Residents of Costa Rica website, horror stories with less happy endings are common. The bottom line is that individual experiences with the Caja vary considerably with no uniform outcome guaranteed.

    Meanwhile, the strike continues affecting thousands of Ticos. Let’s hope the Caja governing board and the unions are back at the bargaining table soon with a favorable outcome for patients who depend on them for medical care.


    Update: The strike against CCSS was ended on Saturday following a marathon 24-hour negotiating session in which, reports indicate, both sides compromised. The government agreed to create a commission to analyze the situation that led to the financial crisis in the Caja and will guarantee future budget allocations to cover union demands for full disability pay. By Saturday night, all Caja hospitals and clinics were operating as usual.

    Apparently the resignation on Wednesday of Eduardo Doryan from his current position as president of ICE (the national electric company) prompted the union to return to the negotiating table. It was during Doryan’s previous tenure as president of CCSS from 2006 to 2010 when much of the existing debt was incurred and union leaders place blame for the present crisis on his mismanagement. Union leaders have called for a criminal investigation of Doryan and other current and former Caja board members.

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