In Central Europe, Better Health Care Comes With a Cost

By NICHOLAS KULISH
PRAGUE, 27 may 2008 — In the Czech Republic, you can now see a doctor for about $1.85. A day in the hospital can verge on $4. This is not cause for celebration.
For Czechs, who visit their doctors more often than anyone in Europe, it has led to great outrage. In fact, the idea of charging anything at all for health care can generate significant controversy, not to mention abrupt about-faces in policy, here and in other Central European countries.
In Hungary, health care fees were resoundingly defeated in a nationwide referendum in March, which resulted in the firing of the health minister. Here in the Czech Republic, which began imposing the modest fees at the start of the year, the prime minister himself was forced before the constitutional court in Brno to testify as the court weighs overturning them. It is scheduled to rule on Wednesday.
Countries rich and poor struggle with how best to provide affordable health care to their citizens without breaking the bank. In places like the Czech Republic, there is a sense of betrayal, because the state long took care of them, but also a justified fear for those left behind in the recent years of growth and change. Even in Prague, known as the golden city, new wealth for some — and their rising expectations for top-notch care — has meant only higher prices for those trapped with low salaries or fixed pensions.
“I have to save so I have money for food,” said Kveta Lachoutova, 78, a widow who is a retired statistician. In an interview in the waiting room at her doctor’s office here, she said that she was trying to live on a monthly pension of about $600, while spending close to $400 on rent and utilities. “I don’t buy anything else.”
For healthy people with jobs, the fees are quite literally pocket change, usually paid with the same 10 and 20 crown coins as streetcar tickets in Prague ($1 is worth around 16 crowns). Affluent Czechs will admit privately that they spend far more on veterinary care for their cats and dogs than their own medical care, even with co-payments for some medications.
But many Czechs see it as a matter of principle that health care should be free — though the system is financed in part through payroll deductions — along with a strong sense of solidarity for the poor. “The only analogy I can think of in our political culture is primary schools,” said Marc J. Roberts, a professor of political economy at the Harvard School of Public Health who has worked in Central Europe. “Most people in the United States believe that primary education should be free and open to all and that it shouldn’t be subject to market principles.”
The region has been a laboratory of health care reform in recent years. The effort has been led by free-market advocates from booming Slovakia, which sports a flat tax and scorching economic growth, at a rate of over 10 percent last year.
Slovakia introduced modest payments for doctors’ visits and hospital stays in 2003. But, as would later happen in Hungary, the fees did not last. The left-wing government that came to power in 2006 rolled them back later that year, within just a few months of taking office.
“What we want to achieve in the health system is a higher individual responsibility, making the consumers more responsible for what they consume,” said Peter Pazitny, executive director and one of the founding partners at the Health Policy Institute in Bratislava, and formerly the principal adviser to the Slovakian minister of health.
The need for reform in the region, Mr. Pazitny said, is obvious. Statistics from the Organization for Economic Cooperation and Development show that the Czech, Slovak and Hungarian health care systems rank at or near the bottom of all member countries in life expectancy, as well as mortality rates for strokes, heart disease and cancer.
The Czech government was receptive to the Health Policy Institute’s input and even employs another of Mr. Pazitny’s partners in Prague. But the members of the opposition would prefer that their former countrymen left them — and their health care system — alone.
“I would understand if these Slovak boys would do it as a paper for their seminar at university, but here they are introducing it into real life,” said Michal Hasek, leader of the Social Democratic caucus, the largest opposition party in Parliament.
The Czech Constitution says that “citizens have on the basis of public insurance the right to free medical care and free medical aids under the conditions defined by the law.” The new payments were not only unconstitutional, according to Mr. Hasek, but also causing real pain in some segments of the population. Opponents and the local tabloid news media have made premature babies in incubators, whose parents must pay the hospital fees, into symbols of the new system.
Experts disagree on whether upfront fees to discourage doctors’ visits are a good idea from a public health perspective, and even question whether they create much in the way of savings for the overall health care system. “Most expensive, unnecessary services are not asked for by patients, but suggested by the physicians just to generate more revenue and more income for them,” said Peter Gaal, professor of health policy at Semmelweis University in Budapest.
The fees here, $1.85 for a prescription as well as a doctor’s visit, and twice that for a day in the hospital, are clearly having an effect on Czech behavior. The Health Ministry said the number of prescriptions fell 40 percent in the first quarter, though some of that may have been a result of stockpiling at the end of last year. The government estimated that public insurers had saved more than $100 million in the first quarter compared with the previous year, while providers collected $62 million in fees.
“We try to take out some of the costs that people can pay for themselves from the health care system,” said Tomas Julinek, the Czech health minister, in an interview in his office last week. But there is a cap on payments, set at just over $300 for the year, which Mr. Julinek said would also protect the seriously ill.
Several chronically ill patients said that they were not sure how the cap would work, or exactly which costs would be included. “So far, I see the negatives and I experience the negatives,” said Lenka Vondrackova, a multiple sclerosis patient struggling to get by with her husband and two teenage sons on about $1,200 a month, a combination of his salary and her disability benefits.
They live crammed into a tiny apartment in a Communist-era apartment building in Cerny Most, a neighborhood in the far eastern part of Prague. Her regimen of medications requires five pills in the morning, a nasal spray once a day and three more pills in the evening, along with a shot administered by her husband or one of her sons. Before the reforms, they were able to save a little each month. “Now everything that’s left is taken up by the fees,” said her husband, Pavel.
“I believe that in the future it will become evident that there will be more money for better equipment and medication,” she said, wishing in particular for pills that could take the place of the painful injection she dreaded each night. “If it works out,” she added, looking away, torn between skepticism and hope.