Foreigners arrested for ATM ‘skimmer’ fraud, stole thousands from ATM users

OK, I’m relaxed.

A problem is that most people can’t afford good coverage, and among these are often Americans. Although I’m sure there are some Americans who pay for quality health care, I’ve frankly never met a single one. Everyone I’ve known in the US who has had good health insurance has had it subsidized by either the US’s “corporate community” or the government.

Basically, quality health care costs, no matter what country we’re in, and somebody has to pay for it. Moreover, since the costs for any given individual are wildly unpredictable–some won’t ever need to visit a doctor, others may need millions of dollars worth of care–the only way to provide everyone with access in case they need it is either to make sure everyone pays a pro-rated part of the aggregate costs or soak only some people in order to give others a free ride (the US system). In theory CR tries to make everyone pay their fair percentage share, although in practice of course many don’t and there are many free riders.

I don’t know what the payroll tax for the Caja needs to be, but I do know that a chunk of that payroll tax isn’t even for the healthcare portion of the Caja and that lots of employers as well as individuals aren’t paying it. Herein lies the financial problem.

My own policy theory is that the Caja should establish the full pro-rated amount that the healthcare really costs, and then offer reductions for low-income folks made up for by general tax revenues. This would end the problem the high income people legitimately experience by having no cap on their Caja taxes. (The US Social Security system has such a cap, and I think it prevents the wealthy from grumbling too much.) It would also alert everyone what the true pro-rated cost of healthcare really is. Right now, I’m pretty sure that not many people have any idea how high this true cost is.

This said, it is only the financial part, and the Caja has troubles that run deeper than lack of money (although lack of money is a major problem). Based upon my experience, the problems are mostly traceable to the huffy self-importance of the Caja bureaucrats, which a doctor tells me is fueled by the fact that all of them are members of different unions. Medical directors in the Caja actually have no authority over the nurses, orderlies, lab people, or even the janitors. If they can’t get the bureaucrats to work, how the hell can the patients make headway?

So the anecdotes are legendary. A friend recently saw Caja doctors three times over as many months for stomach problems, and got no treatable diagnosis. I’m no doctor, but told her that it sounded to me like she was pregnant. Sure enough, she was. How can three doctors overlook the obvious?

Anyway, quality (and efficiency!) definitely need to be improved in the Caja, but it’s the only system most people have in CR. Indeed, although even half of Ticos go private, while lots of corporations have on-site doctors and/or offer private medical insurance, even most of these folks end up in the Caja when they get expensively sick.

There is no alternative, IMO, to making the Caja work. If this means cutting payroll taxes to encourage compliance, I’m all for that. One tax trick that few people in authority in CR grasp is that you’re better off charging a lower tax that people will pay than a higher tax they will evade. Also, of course, people need to make money before they can pay taxes on it. Governments can tax until they’re blue in the face, but if they don’t simultaneously provide the conditions where people can make the money to pay the taxes, they won’t collect the money.

Right now, the Caja tends to be good at both ends, so to speak. The EBAIS clinics are actually quite good at managing known chronic conditions, like hypertension, much better than the US is. The hospitals, while a mess, are also very good at fancy surgeries. It’s in the vast middle where the system breaks down–non-emergency surgeries, even pregnancies–and where the bureaucrats give patients the runaround. This needs to be fixed.

Even so, it astonishes that many expats begrudge paying the Caja a nominal tax. The ARCR even negotiated a tax rate lower than the law call for. Granted, many expats prefer to rely upon some other (usually subsidized) insurance and/or pay to go private, but it’s actually a low cost for what you get.

One old expat I know gets four times worth of pills more than he pays in Caja taxes every month, and this doesn’t count his myriad tests etc. Heck, a Caja doctor even makes house calls to him. It’s far from the best system, but it’s a bargain–and lots of people don’t have the usually subsidized option to buy the more expensive brand.

You know this, but this is exactly where the main treatment problem lies–in the “in between” areas like ultrasounds. Routine and emergency care are usually pretty decent, but anything that requires a non-emergency test or specialist can result in both a long wait and a serious runaround. I myself spent months and wasted five trips to see a dermatologist, only to give up when the clerk simply said that my file was lost and I needed to start over–and then went back to yakking on her personal cellphone.

A way that many handle this (and you apparently did) is simply to pay out of pocket for the in between stuff. If you can pay for the tests yourself, you can show them to the Caja docs and save some time and anguish. But this does cost some money.

Whether the cost is too high is a matter of opinion. At $150 per employee, some portion of which I assume is a pension rather than a healthcare tax, the healthcare cost actually remains fairly low–although you do get what you pay for.

Don’t let me get too personal, but an irony I’ve wondered about is that the Caja may work best for people with chronic conditions. I have one, and as a result the Caja mandates quarterly visits. This gets me in to see a doc every 3 months, and during that same appointment I can usually get any other concern I have addressed (although I believe this violates the Caja rules). This beats lining up at 5 AM. Also, the docs do things like order tests I’m suppose to have annually like 10 months in advance, simply because they know there will be a long delay. Of course, sometimes I just have to pay a damn dermatologist. The Caja-caca isn’t great.