What’s wrong with this picture?

Feb. 9, 2011

When I was 27, I went to Spain to teach English. I thought, two years in Spain, enough to learn Spanish, a marketable skill back home. Then I’ll come back, possibly to Boston, a city I love. Life, however, intervened in my plans. I met a man, married him, had a child, bought a house, started a business, got divorced … and so in my late thirties I found myself still living in Spain, a single mother with a business to run, exhausted from trying to keep everything together, depressed at being alone on holidays when all my friends were with their families (nuclear families, which for me was my daughter and myself, which seemed lonely, or extended families, of which I had none… in Spain). Sad, feeling isolated and out of place after so many years, which only further saddened me, I went to talk to Silvia, a fabulously wise and insightful therapist I’d turned to several times in the past at difficult moments.

“Why don’t you go back to the U.S. for a year and live near your family?” she suggested. I blanched. To me, going back was an all-or-nothing business. I had spent 17 years in Spain, struggled for 6 years as a single mother determined to keep my daughter near her father, even though her upbringing was 99% my job, proud of having grown a successful business, in love with Barcelona and its vibrant cultural life, although, yes, feeling disconnected, disjointed, out of place, dejected. Going back was like surrendering, admitting defeat. But I’d never considered going back for one year, just as a brief respite to recharge my batteries in the glow of the love and care of my family and friends. It sounded just like what the doctor ordered.

I started thinking about it logistically: My business was translating; it operates entirely on the Internet, so that could move with me. My daughter was in 4^th grade and would be going into 5^th,, so basically I still entirely made decisions for her. Still, I asked her what she thought. She loved the idea, although as it drew closer she started to have some – very natural – misgivings. Nonetheless, she was in favor of it. Her father put up no real objections, much to everyone’s surprise. As for my home, at first some friends were going to stay in it for me, but when they backed down I decided not to rent it since rental laws in Spain totally favor the tenant and I would risk not being able to get my home back when I wanted it. Plus, we were going to visit in mid-winter and wanted to go home then, not to a hotel or friend’s house. I asked my father and he agreed to let us stay at his house for the year, not the ideal situation as he had gotten used to his solitude after my mother’s death and I had been independent for so many decades, but workable for a year. So… with no real impediments I informed my friends and clients, threw a huge farewell party and set out for what was to be a year-long adventure. Knowing the healthcare situation in the U.S., I bought travelers’ health insurance in Spain which would basically cover us for any emergency. And we were off…

As soon as we got here, I registered my daughter in school, set her up at a stable where she could ride horses (her passion) and then a pony, Fancy, sort of fell into my lap, so I bought her Fancy. Her own horse! Finally! Her school was almost a one-room schoolhouse affair, a tiny, alternative private school where she positively flourished. Being an essentially rural child, she loved her life here – full of nature, horses, a huge, grass-covered, forested playground at school, a pony of her own – everything her heart desired. As for me, I was near my boyfriend (long story, no longer long-distance!), my sister and her family, my father, and my best friend in the world, and I soon reconnected with a very important friend from my college years, a resumed friendship that is extremely meaningful for him, me, and my daughter. Then, I got word that the local university needed ESL teachers, and since that was where I originally got my start teaching, I applied and got hired as a part-time adjunct. Plus, one of my goals when in Illinois was to bring Mediterranean, specifically Catalan, cooking there, so I started teaching Catalan cooking classes at the local co-op, a dream come true.

Things were falling into place. One day, my daughter looked at me and said, “Mommy, I’d like to stay here.” She was echoing my own thoughts. “Really?” I asked her. “I’ve been thinking the same thing.” We started to talk about how she wouldn’t see Daddy very often, how she might miss her friends Maria, Carlota, and Andrea in Spain, how she would miss the big “Nit d’Estels”, a special all-night affair for the graduating sixth-graders in her elementary school in Spain that kids there dream about for years and prepare for months. I also told her that we would have to find a home of our own, and that meant I couldn’t afford her private school anymore so she’d have to go to a public school. Much to my surprise, Cecilia was willing to accept all of this to stay in America. Wow. I was a little more ambivalent. I missed the city. I missed the sea. I missed the opera. I missed the amazing food and champagne. I missed my home and its halls echoing with the laughter of Cecilia and her friends. I wasn’t sure how I could make things work here – surviving off a business in distant Spain and having travelers’ insurance was good as a temporary measure, but it wouldn’t work out forever so I’d have to figure out a way to earn a decent living and get us healthcare in the U.S. Still, we weighed it all and decided to stay on.

So, after the summer in Spain I rented a little duplex, furnished it (and got into debt doing it), renewed my travelers’ health insurance from Spain one more year since after looking into health insurance in the States I realized I couldn’t afford it, registered Cecilia in the public schools and got all her immunizations up to date, and embarked on life in the U.S. with an intention to stay. I kept working as an adjunct at the university, since I had missed a big hiring campaign the previous year, before I knew we were staying, and there was now a hiring freeze. My adjunct position came with no insurance. Well, actually, my boss said I could get health insurance, but it would be $800 per month… out of the $1,000-1,500 I was earning. Somehow, um, earning $200-700 a month for half-time work didn’t seem like a good deal. The health insurance I had from Spain worked on reimbursements. I had to pay the bills, then submit them and get reimbursed. I had used it once last year for a minor sinus infection and gotten promptly reimbursed, so I felt good with that. But still, if we were staying I did need insurance here.

Then my first health issue arose. For years I’d had a tiny cyst on my back. My dermatologist in Spain said he could remove it, although there was no real need to unless it got infected, so I had always ignored it. Well, it got infected. It turned into a large, red, throbbing golf ball on my back. Sleeping was difficult; swimming was out of the question. I called a dermatologist’s office and the first question I got was: “What insurance do you have?” Not, how serious is it? Does it hurt? Is it oozing? Nothing like that. Just, “What insurance company do you have?” When they heard I had none (because saying I have travelers’ insurance from Spain just doesn’t register here) the next sentence was, “An office visit costs $150, payable in cash the same day, plus any additional expenses for further treatments.” Okay, still no questions about my health, although I’m talking to a doctor’s office. When I assured them I’d pay it, they then scheduled for me an appointment in ten days. Ten days?!?! I had a huge, angry infection on my back! Wasn’t there anything sooner? “Sorry, ma’am, ten days is the soonest opening the doctor has.” What could I do? And this doctor had come recommended by a friend. The emergency room would be too expensive, plus, was it a real emergency? I didn’t want to be one of those people crowding up the emergency room unnecessarily. So I waited ten days, my back oozing, sore, smelly. What was this? I had a condition – minor in the grand scheme of things, but still, needing attention – and couldn’t get the care I needed. Finally, ten days went by and the doctor confirmed, yes, that my cyst was infected. He gave me two treatment options and then I hit him with the fact that I had no insurance. He paused, then said that he would just do the simpler treatment there, on the spot, without charging me. I was flabbergasted, in the best of ways, utterly grateful, ready to fall on my knees to express my relief and appreciation. He treated it, my daughter had to care for the wound for ten days, and it mostly went away, although next summer, when I’m back in Spain, I’ll have the whole thing removed. Of course, I can’t afford to here. And there it won’t cost me a cent. And I don’t even live there anymore.

In the meantime, I had called my health insurance company in Spain. They said that if I needed further treatment they would set me up with a doctor, but in the meantime that I should send the bills for reimbursement. I did, although the bills were far smaller than they would have been if the doctor had actually charged me. One week later I got a phone call at around 10 pm. It was the insurance company in Spain. I had a gut-wrenching feeling. Uh-oh. What’s wrong? The woman on the phone said, “I was just calling to see how you’re feeling, how your back is healing, if you need anything. If you need anything, any further treatment, please call us and we’ll arrange it for you.” What the heck? I think “insurance” and fear strikes my gut; here’s an insurance company calling me to see if I’m all right? I was blown away. Then I was blown away by the fact that I was blown away. Imagine that! An insurance company that follows up not to pursue payment, deny coverage and issue warnings, but to see if I’m ok, offering me more treatment if I need it. How sad that not only is this not a regular occurrence here, but that I’d already been conditioned to fear a call from my insurance company.

Fast forward to winter. I get the flu. Not wanting to spend the $113 on the doctor’s visit plus medicine, I tough it out. Not wanting to be absent from work because I want to get hired fulltime (not because I really want the job, but because I want the healthcare), and because I don’t want to burden my fellow teachers with subbing my classes, I go to work despite a low-grade fever. Mistake. The next weekend I’m flat on my back, feverish, lungs burbling. I bite the bullet, wait three hours, spend $113 to see a doctor. Conclusion: he thinks it is pneumonia and informs me that I need a chest X-ray. When I tell him that I have no health insurance and ask him how much an X-ray will cost, he said between $200 and $300. So he offered to medicate me for pneumonia with a strong antibiotic and steroid that would reduce the inflammation, and told me to come back the next week if I’m not better. Again, I think: in Spain if I needed an X-ray I would just get one. My co-pay would be around $2. My doctor would insist. I realize that the doctor here didn’t insist and instead medicated me for an illness I may or may not have without the right diagnostics in order to save me money, a favor, I guess. But that once again spotlights how healthcare works in this country: money considerations come first, health comes second.

In the meantime, my daughter is still riding horses. In fact, she’s training to participate in eventing, a dangerous sport which involves jumping over obstacles while galloping full-speed through open fields. Before she gets started when the warm weather came around, I decided that we absolutely had to have health insurance for her here, if for nothing else than because I was ashamed of having to sign her up for everything and having to leave the spaces for “primary physician” and “health insurance information” blank because we didn’t have either a primary physician or health insurance. I had to do that when I signed her up for school, for U.S. Pony Club, for Girl Scouts, basically for everything. But here, how do I get a primary physician without health insurance? Who wants us? How can I pay out of pocket for intakes for a doctor I later may not be able to afford, or may not want to see us, because we have no insurance? I felt like a neglectful mother, yet I had always given my daughter the best care. We have always been prosperous, educated, aware. That’s how I perceive myself. Here it has to change; here I’m unable to care for us because I can’t afford monthly payments of upwards of $500, the minimum to have any sort of decent coverage (of course, after deductibles and copayments it’s much more, if the policy covers the care you need, that is…).

A friend told me about a state program that provides health insurance for needy children. Wow, here in my own country I’m the head of a needy household. But Cecilia needs (no, we both need) healthcare, so I went and applied for both of us. I felt ashamed, humiliated. Because of this country’s lack of universal healthcare we had been brought down to the level of welfare care. Not all clinics take this insurance because it pays doctors little. I just hoped it would be enough; we’re still waiting to see if we get covered. I feel reduced, humiliated, vulnerable. How had this happened to me? In my own country? Wasn’t going back to your own country like going back into the fold? Being where you’ll be cared for and valued? Didn’t I come back to my country for some care, for some ease? I did, but apparently in this country care and ease are elusive.

All of this has made me think about this country. What’s wrong with this picture? Let’s rewind and compare from my own personal experience:

When I was travelling through Thailand with my father soon after his retirement, while I was in my mid-twenties, I mistakenly (I should have known better!) ate pineapple from a street vendor. After 12 hours of vomiting and diarrhea, my father asked at the hotel desk and found a nearby hospital. There, a polite, American-trained young Thai female doctor put me in my own room, gave me two or three I.V. drips and left me there 24 hours. The bill upon release? $75.

Fast forward two years. I had just moved to Spain, and my travel-happy father and I were now meeting in London for ten days of sightseeing. The first night he fell down the steep, narrow staircase in the cheap hotel we were staying at near Paddington Station. He seemed fine, with just a bit of pain, until the last night. A stoic former Marine, he rarely complains, but that night he woke me up asking me to get him to a hospital; the pain had become unbearable. I asked at the hotel desk and we called an ambulance to pick up my father. It took him to a nearby hospital, where the nurses treated him with great care, got him muscle relaxants and painkillers for the trip home and took him back to the hotel. The bill upon release? Nothing – although donations were welcome. And of course once home my father sent them a generous donation, amazed that they would truly not charge him a nickel.

Now fast-forward quite a few years. My parents are visiting us in Spain, about to travel to Paris for their 45^th wedding anniversary trip, a gift from my sister, brother, and myself. My father and I walk to a nearby takeout restaurant to get a quick lunch before we drive them to the airport, my father falls near a construction site, and in a freak accident a gas canister nearby falls, glancing off his head to land on his hand, severing the tips of two of his fingers. The ambulance comes and takes him to the nearest hospital, part of the public healthcare system. The doctor comes out to tell us he needs complicated surgery. They wheel him in and operate on him for five hours, reconstructing the one finger they can salvage and neatening up the tip of the severed finger. He stays in the hospital for three days. Obviously, the trip was off. The bill upon release? $3,000. And if he had been a resident of Spain it would have been free. What would that bill have been here? At least $30,000. When he gets home, his doctor checks out the surgery performed by a public health doctor in Spain, and says he couldn’t have done a better job himself.

What is the moral of this story? Don’t travel with my father, you might say. Well, we have cut down on trips lately… But the moral is, in any other country, if you need healthcare you’ve got it. No questions asked. It’s a fundamental human right, like education, like drinking water. And when you need healthcare, certainly the first question is not “How are you going to pay?” The first questions are “What do you need? How can we help you?”

What is wrong with this picture is that in any other developed (or not so developed, if you include Thailand) country, the healthcare system is there to care for people’s health – whence the name. In this country, I’m not sure what it’s here for – to enrich the system itself, I suspect, a huge entity steamrolling over all us, or at least my daughter and me. But caring for health, for everyone’s health, does not seem to be high on the agenda.

What’s wrong with this picture is that there seems to be a myth about public (or – perish the thought! – socialized!) healthcare systems, about the horrible waits, the stringent quotas, the government control. But are there worse waits than here? Ten days with an infection? Does anyone mete out care more stingily than insurance companies in the U.S.? Is any doctor in a socialized system told by the government what to treat? (None that I know of… and I’ve asked.) All of these myths come from people with absolutely no experience in a country with a public health system, people who gather “horror stories” from God knows what source. Words are cheap; anyone can invent horror stories about unknown lands perhaps ridden with that scourge: socialists (akin to fascists, they believe). I’m the horse’s mouth; I’ve experienced socialized health. Ask me. It works. For everyone.

What’s wrong with this picture is that here doctors and healthcare managers make decisions based on saving money for the insurance companies, not based on their patients’ health. Could there be any worse pressure on a person who has sworn to protect and save people’s health than that? Don’t medical professionals in the U.S. have uneasy consciences knowing this? Or do they assume that things work that way everywhere? I was fortunate to meet one doctor, the dermatologist, whose humanity came before his kowtowing to the system, but I was lucky. Now, Spain is an extraordinarily corrupt country – if you can fool the system, you do. Yet there, healthcare is universal, and the costs are far cheaper than here. My thyroid medicine there costs me $4 for 40 days; here it costs $20. It’s the same medicine. I’m not paying for a better drug; I’m paying for a corrupt system that makes a business of out people’s health, and a profit off their illness. Am I the only person who thinks it’s a scandal that medicines are advertised in big-budget, melodramatic, beautifully scored TV commercials? We’re paying for that, you know, all of us. In Spain, you can also get private health insurance if you’re prosperous and want more choices. I always did – at a total cost of $200 a month for my daughter and myself. When I had my daughter, I stayed in the hospital (the refurbished Hilton Hotel – not bad digs!) for five days, with a bed for my husband, and menus we could both choose from every day. The bill upon release? $2 for a phone call we made (this was pre-cell phone).

What’s wrong with this picture is that as an active, positive, contributing member of society I have to suffer from constant low-grade stress, which turns into acute stress when I get sick, because I feel that my daughter and I are vulnerable.

I am trying to figure things out so my daughter and I can stay here. I have two solutions. One is to work fulltime at the university. The work is killer – I’ve never seen people work more hours for less pay than at this school, nights and weekends included (not mandatory, but hey, you can’t let your students down… and you can’t, it’s true!). But at least I would have healthcare coverage for my daughter and myself. It’s not what I want at this stage in my career, not at all, but it’s a way to take care of us. In Spain, a much less wealthy country than the U.S., I was able to be an entrepreneur, to follow my heart and my brain, and to earn far more than I would earn working at the university here (and thus contribute more taxes to society) because I knew healthcare was not an issue. We were cared for. Here I don’t have that freedom. I’m forced into the system, a system that strips me of my freedom to live life as I choose. The other alternative is going back to school. That way at least I’ll have healthcare for myself and I’ll only have to purchase it for my daughter. I’ve applied to and been accepted to the PhD program at the university. I’ve even been put up as a candidate for a doctoral fellowship. How wonderful! If I get it, I’ll earn $1,500 per month (minus taxes). From that I’ll have to pay rent, utilities, oh, and healthcare for my daughter.  I’m 46 years old. Is that an attractive option? That’s sliding back 20 years in my life. But at least one of us will be covered, and I’ll learn something in the process.

The point is: all my decisions since I’ve been strategizing about how to stay in this country revolve around how to get healthcare for my daughter and myself. This is not freedom; this is slavery to a hostile system. In Spain, I made decisions based on my dreams, hopes and desires; they turned out well and I was successful. As a result, I was a fruitful member of society, contributing plenty of taxes and a healthy future citizen. Just to live here with any measure of safety, I have to give up dreaming, hoping, and desiring and instead cling to any option that will ensure nothing less than our survival.

That’s what is wrong with this picture. We think we’re free here; it’s our national myth. America is the bastion of freedom! The model of freedom! Everyone wants to emulate us, live here! I speak to my students – from countries like Haiti, Colombia, Libya and Saudi Arabia – and they are shocked that some people in this vastly wealthy country have no healthcare, that society does not take care of each other. No, we are not free. Actually, it’s the opposite: we’re enslaved to the system; the system rules our lives, and we are prostrate before it.

That’s what is wrong with this picture. Welcome home.