By David Morrill and Greg Medeiros
Health care and health insurance options for Ecuador expats changed dramatically at the beginning of 2014 when the government allowed legal residents to join the country’s Social Security (IESS) health care program for a monthly fee.
Before, choices for foreign residents were limited to private health insurance plans with in-country or international coverage. The good news, then and now, is that private health insurance costs a fraction of what it does in other parts of the world, including the U.S.
HEALTH CARE IN ECUADOR
Before looking at insurance options, both private and through the IESS health care program, it’s important to understand Ecuador’s health care system.
Since 2007, when Rafael Correa became president, health care in Ecuador has improved impressively. Various surveys have shown that the country has moved from the middle of the pack of Latin American countries in health care quality, to being one of the top five. Annual funding has more than doubled for public health care from previous levels. A 2014 Bloomberg survey of overall health care efficiency, factoring both cost and quality, listed Ecuador 20th in the world. The U.S., by contrast, ranked 46th.
New public hospitals and clinics have been built while existing facilities have been upgraded. High tech diagnostic and treatment equipment, previously unavailable even in private hospitals, has been purchased, and a large number of doctors, including some specialists from Spain and Cuba, have been hired.
Ecuador offers two levels of public health care.
Social Security health care. The first, mentioned above, is administered by the Social Security, or IESS, system. It has seen the largest infusion of funds and the most dramatic improvement over the last eight years. It offers services through full-service hospitals in large towns and cities, and dozens of clinics in smaller communities (in Cuenca, the IESS hospital is José Carrasco Arteaga Hospital on the Azogues autopista). Services are available to those who have paid into the IESS system through payroll deduction and, in now, to “voluntary members,” including several thousand foreign residents who pay a monthly fee of about $65.00 with a dependent or spouse paying an additional $12.62.
The plan covers all costs, including medicine (no deductibles or co-pays). There are no age or pre-existing conditions restrictions. Most expat members give the program good reviews.
A notable benefit of the IESS program that is particularly important to expats is that, in case of emergency, they can receive service at any emergency room in the country, including private ones, with IESS picking up the tab.
The downside to IESS is that it is part of a government bureaucracy and operates like one. Foreigners with limited knowledge of Spanish can have difficulty understanding and navigating the paperwork requirements. Other frustrations include occasional long waits to see a specialist or to line up a test, and some medicines are not available in the IESS pharmacy and have to paid for out of pocket.
Public health care. Although it shares some of the same resources and personnel with IESS, the public health care system is technically separate and receives less funding on a per patient basis. Its services are free to everyone, citizens, expats and visitors, fulfilling a constitutional mandate that no one in Ecuador can be refused medical care. As does the IESS system, it has hospitals in major cities as well as hundreds of walk-in clinics (the public health hospital in Cuenca is Vicente Corral Moscoso Hospital, the city’s largest). There are restrictions: in some cases, the system reserves services and supplies, such as inoculations and vaccines, for high-risk patients.
Most foreign residents who have used the public system give it fairly good marks, almost always mentioning that you can’t beat the price. Cuenca expats have used it for everything from respiratory illnesses to open heart surgery, with positive results.
Although the current economic recession has caused deep budget cuts to many public institutions in Ecuador, EISS and the public health care system have seen only minor cuts.
Private health care. The quality of private health care in Ecuador ranges from very good to non-existent. The best private hospitals, clinics and professionals in the country are in Cuenca, Quito, and Guayaquil, with costs being the lowest in Cuenca. Quality varies in other areas and some rural communities have no private options as well. In Cuenca, there are 10 private hospitals and clinics that offer emergency services.
In general, private doctors are well-trained, many of them educated in the U.S. and Europe, as well as in Argentina, Chile and Cuba, known for having the best med schools in Latin America. It is extremely important, however, that expats conduct a thorough vetting of doctors they are considering using. Many doctors speak English.
Due to the rapid expansion of the IESS health program, it is not unusual to find doctors who have joined the IESS system but who keep part-time private practices. For expats, it makes sense to use one of these doctors as a GP, since they can provide valuable assistance navigating IESS red tape.
HEALTH CARE COSTS
Health care is a bargain in Ecuador. Cost for services run from 10% to 30% of those in the U.S. A private hospital room in Cuenca, with full medical service and meals, averages $225 a day compared to $950 in the U.S. Most medicines cost much less and many are available without a prescription at local pharmacies (newer, name-brand medicines may cost more).
The removal of a subcutaneous benign lump with local anesthesia runs about $125. A colonoscopy, which costs $2,700 in the U.S., is $350 in Cuenca. A set of simple x-rays runs $45, while a full battery of blood tests costs about $75.
On average, general practice physicians charge from $25 to $35 for an office visit, while specialists charge $30 to $50. It should be noted that patients receive much more face-time with doctors in Ecuador (most do not have nurses), and many of them still make house calls.
The Bloomberg health study cited earlier, reports that Ecuador gets excellent results for its health care spending; $332 per capita for health care, compared to $8,608 for the U.S. A 2014 report by the World Health Organization, said that Ecuador spent 7.8% of its GDP on health care, compared to 18.2% for the U.S.
An important caveat: Some hospitals and doctors have a two-teir fee schedule and try to charge foreigners more than Ecuadorians. This is where an Ecuadorian doctor or friend comes in handy, and can make sure foreign patients are not paying the “gringo price.” The IESS system, by the way, has one fee schedule for all patients.
PRIVATE HEALTH INSURANCE OPTIONS
There are a number of good reasons to consider private health insurance. Most important is the fact that there is much less red tape in the private health sector and patients can work directly with their private physician. There are no long waits. Appointments with specialists can be made a few days, sometimes hours, in advance. The same is true with medical tests, even those requiring high tech equipment.
There are several options for private health insurance.
Ecuador-specific health insurance policies. Like those in many other countries, including the U.S., policies can be written with of variety of deductibles and specifications. A middle-of-the-road policy for a 64 year-old-man in reasonably good health, costs $175 a month from Salud, one of the largest companies in South America. A 64-year-old woman would pay $125 for the same policy. In addition to Salud, other companies writing insurance in Ecuador include BMI, Confiamed, Cruz Blanca, Ecuasanita, and Generali.
International private health insurance. These policies, sometimes called travel insurance, are written by a large number or companies, Aetna, ALC Global Insurance, Allianz, AXA PPP International, Best Doctors, Bupa, Cigna, Geo Blue, GMC Services, Health Care International, Integra Global, William Russel and Woldwide Medical Group being the most popular. Policies provide coverage in any country cost considerably more than an Ecuador-specific policy, since international costs are averaged. For a 64-year-old man in good health, most plans cost in the $350 to $600 a month range, depending on deductibles, although some run as high as $700. Salud offers cheaper international coverage but only provides compensation based Ecuadorian costs.
Hospital-specific policies. These policies offer a price beak if you use the hospital that writes the policy, either offering no, or very low deductibles. If you use another hospital in Ecuador, you will pay a higher deductible, typically 10% to 20%. Premiums for hospital-based programs tend to be slightly lower than those for large insurance companies.
This is a very brief overview of the health insurance market in Ecuador; many other factors affect costs. As in the U.S., costs rise with age and pre-existing conditions, and customers can be denied coverage altogether. The majority of private health insurance companies will not write a policy for those 65 and older. Those that do, will continue the policy beyond 65 but at higher rates, and often, with reduced services.
SELF INSURANCE AND ALTERNATIVE HEALTH CARE
Many foreign residents in Ecuador, possibly the majority, carry no health insurance at all. Because of the low cost of care, they will pay out-of-pocket for routine care and emergencies, or plan to go back to their home country for major medical procedures.
There are also a wide variety of choices of alternative health care in Ecuador, many more than you will find in the U.S. and Europe. Alternative practices, in fact, are frequently incorporated into the care provided by traditional physicians. The right to seek your choice of health care is protected by Ecuador’s constitution.
Greg Medeiros is an expat and medical care consultant in Cuenca. He works with expats, providing advice on medical issues and assistance in planning and scheduling medical procedures. He can be contacted by e-mail at email@example.com. He is co-director of the Cuenca Holistic Health Network and Cuenca Holistic Health Guide, available at www.CuencaHolisticHealth.com. David Morrill is editor of CuencaHighLife.