No charge

Thank you so much. Nice to meet you!

We stepped out of the clinic room and headed for the front desk. I handed over a small slip of paper where the doctor had checked a couple boxes, presumably indicating what kind of visit we had just completed. I instinctively pulled out my wallet, ready to present identification, insurance cards, and a credit card to pay. The secretary glanced at the paper, looked up, and said, "Thank you, have a great day!" When we paused for a second, she clarified, "There's no charge for today." Bemused, I put my wallet away and walked to the car with my family.

Sunset over our street

Although we are fortunate to have few health problems, as a family we do have a small number of regular prescription medications. Our doctor in the US had kindly prescribed a 3-month supply before we left, but we needed to get established here with a GP to take on these regular prescriptions before our supply ran out. Collecting and submitting the paperwork to enroll with a clinic here took some work, but once established, it was easy to get an appointment scheduled. The receptionist on the phone was even apologetic that we would have to wait a whole week and a half for the appointment--new appointment slots are longer and harder to book, she explained. We had a good laugh about that one. Imagine getting into your doctor in the US for a routine visit in less than two weeks.

At the appointment, the doctor himself called us back to the room, measured the vital signs, and reviewed the records we had brought. We chatted about the move, my work at the hospital, the rainy weather (quite disappointing by local standards, though pretty mild to my taste). One of our prescriptions did require a special authorization from the national pharmaceutical regulatory body, so he sent a referral to a specialist. Then we left without any copays or fees.

A week later, we picked up the prescription at a local pharmacy. Once again, at the counter, I was informed "there's no charge for that."

It is difficult to explain how bizarre it is to receive medical care at no cost. Even though it was routine care and fairly low stakes, the effect is stark. I can't count the number of times patients in the US told me they couldn't afford their medications, so they stopped taking them, or skipped days to spread them out, or took a friend's medication instead. How many no-shows for appointments were because of concern over the bill that would result? Many of my patients were dismissed from clinics because of unpaid medical bills. They would later be admitted to my inpatient team in crisis.

Here, many patients still struggle to access care. Some have limited transportation. Many live in remote areas with limited access and services. And there are unacceptably long waits for some services, especially the more technical or specialized. But cost is not a barrier. And medical bankruptcy doesn't exist here. Were I to be struck by a bus or a life-threatening illness tomorrow, I wouldn't have to worry about debilitating costs along with devastating illness.

But also, as a doctor, this completely changes how I practice. Cost considerations entered into nearly every medical decision in the US, no matter the patient's insurance status. If the patient had insurance, we had to worry about the insurance formulary and often had to take extra steps to justify our medications or treatment decisions to avoid out of pocket costs or denials. If the patient had no insurance, we would spend inordinate amounts of time trying to figure out how to get them the care they needed, often to no avail, stymied by a $100 out of pocket cost to see a specialist or a pricey prescription with no generic alternative. I cannot understate how much of my time and cognitive energy was consumed by accounting for the costs of the care I was trying to provide. Of course, this was exacerbated by the opacity of medical pricing--I rarely knew the actual cost to the patient of that care. Only in hindsight would I realize my medical plan was not financially feasible.

Leaving that behind in my practice here means more time with patients, more time focused on their medical concerns, and more cognitive space to figure out the best course of action for their care. In short, I can get back to practicing medicine. It turns out removing barriers to care improves the experience for both patients and doctors.

Obviously, though we did not pay out of pocket for the care we received here, it was not free. With universal coverage, we all pay for the health system through taxes, and those taxes are used to pay for all aspects of the health system, including my salary. As with other countries with universal coverage, there are challenges with ensuring availability of all services and there can be long wait times.

But the costs of care in the US are high as well—higher than any other country. They come in many different forms: insurance premiums, deductibles, copays, and yes, taxes. The diffusion of the costs hides their impact, but the result is the same—an enormous societal burden. The costs also go to a lot more places, including the profits of insurance companies and hospital systems, and only a fraction of the money we pay for health care ends up paying directly for the care received. And for all the technological prowess in the US, many health outcomes are abysmally low, far behind other developed nations. No matter how the payment is extracted, we all pay for health care, and in the US, we pay far more for worse outcomes.

But the costs of the US system are not just financial, nor are they limited to the substandard care produced by that dysfunctional system. The costs are also borne by the doctors and nurses and receptionists and everyone who works in healthcare, in the form of a slow, steady leaching of our moral fiber, bleeding dry the joy that should be the lifeblood of medical practice.

Working in a system where everyone can afford the care they need is so restorative because both doctors and patients can focus on being well.