Voting for who runs your health care provider. Meaningful voting. Wow, I really am in a foreign country!
(Here is Part 1 of our occasional series on getting health care in Uruguay.)
I just now picked up this news from the Montevideo Portal website, a Spanish-language commercial news and services hub:
Elecciones en la Asociación Española Usted decide / Montevideo Portal – www.montevideo.com.uy. Got it from this Tweet.
Here is the “Marcos Translate” version (and lots more about the many health care options in Uruguay, after the break):
Asociación Española will hold elections this Sunday, to choose the officers of the institution through 2016. They will select the members of the Board of Directors, Assembly Representative, and Fiscal Commission. All members of the mutualista over the age of 18, who have been members for at least seven months, are able to vote. They must present their membership receipt for February or March 2013, their heath card, or their national certificate of identity (cédula). Voting hours are 9am to 6pm. Locations are the Central office, and the clinic branches in Pando, Paso Carrsco, Solymar, Salinas, Atlántida, Piriápolis, Punta del Este, Canelones, and Las Piedras, among others.
I joined it for free from my BPS Uruguay Social Security payroll tax deductions, while I was working for BigCloudSoftwareCompany, before everybody came to their senses and I returned to my much-preferred freelancing. About a month later (really almost 2 months) after my last pay, I had to re-enroll as a “socio en particular“, an individual member. For $1646/month! Before you drop, $ means Pesos Uruguayos, or UYU, here. If that were US Dollars, USD, the symbol here is U$S. At current rates (see our handy sidebar live-rates currency converter), that is all of U$S86 dollars. Oh, and I have to pay about $167 UYU to see a doctor (under 9 bucks). Except when it is to monitor and determine medications, in which case it is free.
The closest USA equivalent is the subset of HMOs (Heath Maintenance Organization) that are both non-profit and operate their own hospitals and “medical home” type polyclinics. That’s a rare model in the US but one which studies show has good outcomes. Rather than the more common US HMO model of private physicians offices in multiple networks of competing HMOs, plus PPOs (preferred provider organizations with discounted insurance member rates), where your care is essentially uncoordinated and your Doctor or Nurse Practitioner has to have an expensive staff of billing experts to deal with all the different arrangements that she accepts.
But either kind of HMO is a heck of a lot more money monthly, whether through your employer, a private policy you buy from them, Medicare Advantage alternative to regular Medicare Part A & B. Or the HMO/PPO plans from the 35 enlightened States that had pre-Obamacare High Risk Pools, the 2010-2013 “Transitional Obamacare” of mandated Federal Pool Preexisting Condition Insurance Plans (PCIP) in every State (whether they were one of the 35 or not), or Massachusetts community-rated RomneyCare, which is pretty much exactly what you should expect from “Full Obamacare” in 2014.
We’re talking significant values of 3-figures monthly for premiums for any of the above, with 4-figure annual deductibles and high 4-figure out-of-pocket expenses, no matter which side of the US medical care debate you fall, no matter whether the Patient Protection & Affordable Care Act helped you, hurt you, or left you about the same in terms of affordability of care. Figures with a $ in front of them, in a country where $ means US Dollars.
HMOs have fallen out of favor in the US, and even within the HMO industry, most are just “go to a doctor on our network list” with extra red tape and required referrals to see any specialist, in exchange for lower rates than the PPO where you can self-refer to a specialist in the “network”. Where “network” simply means “agreed to take our low payments and bureaucracy” rather than any real supervision of quality or coordination of care, despite all the expensive TV ads to make you think they do.
But the mutualista model is the most popular of the three tiers and models of health care here in Uruguay. Or 4 tiers, if you include the “Type One” expats who are horrified at the idea of immersion in the society and thus only buy special Expat Insurance that promises to whisk them off to “civilization”, defined as the USA or UK.
Tier 1 is the ASSE, Uruguay universal health care at low rates, or free for indigents. Including anybody in the country legally as a resident or resident en trámite with a cédula. The huge Hospital de Clínicos in Montevideo is the main hospital, with some others in the interior of the country. In addition, in any given area, one or possibly more of the “Tier 2″ (in my taxonomy) providers, a mutualista, will be the local provider to ASSE patients. For example, in our town of Atlántida, it is Circulo Catolico mutualista. In a different municipality it may be a competing mutualista. The “tier 3″ private system providers also do provide services to ASSE patients in emergencies or when medically necessary under some circumstances. I don’t know enough of the details on that to give you solid info yet. But very few expats and immigrants will be in this tier 1 system. Though it is gratifying to know that we are covered as soon as in the legal immigration process.
Tier 2 is the mutualista system, where you get to choose your own mutual heath society either as an individual member, or if a retiree or a taxpayer “con actividad”, it is paid for you for free from BPS. The is a 6% tax deduction from your gross pay, but jobs in Uruguay are quoted and offered at your bottom-line-direct-deposit net pay. (Or your non-direct-deposit if a US citizen due to the abusive FATCA law of the USA where banks have decided to fire their US customers instead of becoming an extension of the IRS.) If you have children under 18, your dependents are covered by an extra 2% withholding, which includes your spouse or your legal “concubino / concubina” (domestic partner, opposite or same-sex). If you have to pay individually, there are discounts for members of some societies and groups, such as for the Atlántida Retirees and Pension society. Which I really should join, both to get the deal, and because they run cool street exercise and tango events.
If you do have “activity”, and do not choose a mutualista, I was told by my uruguayo co-workers that the govenment health system, FONASA, will assign you to one, which may not be your choice. BPS enrollees are only allowed to change every 3 years, from what they told me. Reason? To avoid unnecessary excess government expenditure in the Tier 1 Public system for people who should be in Tier 2. Also to save on initial enrollment payments to each mutualista, preventing the costly practice of member “churning”. Thus I made sure to make my selection before my first paycheck, right after their bookkeeper registered me into the BPS and the DGI (income tax) systems.
Tier 3 is the Private system, the best-known being Hospital Britannico and its affiliates like a private hospital in Maldonado, SEMM Mautone; Medicina Personalizada (site in English here); and Blue Cross & Blue Shield (which just like in the USA, is now a part of a private profit-making brand franchise.) There is at least one more, whose name escapes me at present. If you are a pensioner or a person “with activity”, you can choose to have your BPS credits used as partial payment to a private insurance scheme. It will not pay for all of it, unlike if you choose a mutualista.
There’s one more major class of care providers, but they are really more a supplement – the emergency services, private ambulance, and urgent care clinics run throughout the country by various groups or companies like SEMM, or here in the Canelones Departamento along Costo de Oro, SAPP. These also act as extra-cost supplements to some of the Tier 2 and Tier 3 providers, and as out-of-region care for those partners’ members.
Important: Many “Expat Blogs” and “Uruguay Information Sites” lump Tier 2, the Mutualista system, and Tier 3, the Private system, in together as “Private Medical Care”, and then tell you that you have to shop around to find out which ones charge higher based on age, which ones exclude pre-existing conditions, etc. That is incorrect and is a misunderstanding, thinking that mutualistas are the same thing as private medical care. They are not. For obvious reasons, I am not linking back to examples of what are, at best, innocently misunderstood or oversimplified information. But if you have been considering moving to Uruguay, you no doubt have or will run across it.
Tier 3, of the three official tiers, is the only one that does US-style “Medical Underwriting” where your premiums, and possibly even your acceptance and/or exclusion of certain conditions, is based on your age, health, and pre-existing condition. Tiers 1 and 2 are for everyone. Sure, maybe I could “choose my own doctor”, but it would be a world of hassle, exclusions, and cost.
The “best health care in the world“ is the health care you can afford to buy, for ongoing monitoring, prevention, treatment, to keep you out of the hospital. Which is a big reason why we chose Uruguay. Once here, a big reason why we chose the “tier 2″ mutualista system instead of the oft-pushed-by-the-Institutional-Expat-Biz “British Hospital only” schtick, or worse, the “Global Expat Insurance” hawked via affiliate deals from many of the big Expat sites and magazines.
As to our particular choice of mutualista: A balance of locality (new clinic opened on the beach about 5 blocks away the month after we moved in), price (not the cheapest but competitive), and reputation for quality and prevention. After speaking with many Uruguayan friends, neighbors, coworkers, and fellow US/Canada/UK expats, we chose Asociación Española, known for its prevention emphasis. Have heard almost exclusively good things about it, except for being slightly more expensive for a per-service “ticket charge” than the competing Médica Uruguaya mutualista. We had a choice between five competing mutualistas just right here alone in Atlántida: Española, Médica Uruguya, CASMU (also well regarded), CAAMEPA (a regional affiliate of the Uruguay-wide FEMI cooperative, Federación Médica del Interior), and the Catholic Church-run Circulo Catolico.
Obviously if you want abortion or contraception services, one would not choose Circulo Catolico, and under the new abortion legalization, providers can opt out. However they are required to cover those services for their members from alternate providers, even if not normally in their organization. Female, and male, contraception is available at highly discounted (but unlike Obamacare, not mandated totally free) prices, such as Asociación Española prices of $28 UYU (a dollar and a half) for a month of birth control pills or $10 UYU, about 50 cents per pop (sorry, couldn’t resist) for a box of condoms.
Pretty reasonable system if you ask me. You even get to vote for who runs it! Can you imagine actually having a say in who runs Aetna, US Healthcare, Humana, or even a meaningful say in the supposed non-profit giant organizations like Kaiser-Permanente? Not happening.
(edit 20130304 19:58 UYST – spelling)