Think Our Health Care System’s Bad? Try Lebanon’s.

A Lebanese friend of mine recently survived a major motorcycle accident. He doesn’t remember much: downshifting to first gear, the sound of brakes from behind him, waking up in a hospital bed, completely disoriented, and in great pain. In between these moments, he now knows, he was scooped up by an ambulance from the Lebanese Red Cross (they are a truly remarkable volunteer service), and delivered, with shattered bones and internal injuries yet unknown, to American University of Beirut Medical Center, one of the finest private hospitals in Beirut.

And then he waited. My friend had no insurance, and so the hospital contacted his mother and told her that his treatment would be very expensive, and unless she was willing to put down $20,000 in deposit, the hospital couldn’t care for him. After six hours of waiting in a hallway, his family decided to transfer him to the government hospital, named for former Prime Minister Rafik Hariri, where he underwent several operations, and spent the next week in bed.

This story is hardly unique, or unique to AUBMC. (It is also, I should note, pieced together by my groggy friend ex post facto, so take the details of the account with some latitude. The spokesman for AUB told me that she could not respond fully without the name of my friend, which I would not divulge, although someone else at the university’s office of public relations told me that, generally speaking, it’s true that a person without insurance would be asked to provide a deposit before receiving care.) The truth is that the medical system — both for emergency and preventative care — is such a confounding hodgepodge of public, private, and confessional-based payment structures, that you’ll find a similar story practically anywhere you look. Take this episode, from a 2008 IRIN report:

When Hamza Shahrour had a heart attack in June last year, the 24-year-old Shia might have hoped to survive it, given that he was just a few blocks away from the Rafik Hariri hospital, named after the former five-time Sunni prime minister.

But because Hamza’s family had no health insurance and could not afford to pay the thousands of dollars deposit demanded, the doctors refused to treat him.

Worse was to come. In Lebanon’s current political standoff between a Sunni-led government and the Shia-led opposition, Hamza was discriminated against by the doctors, according to his mother, because of his sect.

Hamza was transferred to the Rasool al-Azam (Mighty Prophet) hospital, owned and controlled by Shia group Hezbollah in Beirut’s southern suburbs, where his mother said the family receive free medical care, despite their lack of insurance. But Hamza died as the Lebanese Red Cross drove him across town.

“I wish my son had been a Sunni,” Hamza’s mother, Raheja Shahrour, told IRIN. “Maybe he would be sitting next to me now instead of dying, having been turned away from the Hariri hospital.”

(My friend, who is Sunni, found treatment at the Hariri hospital to be exemplary. I have no reason to think that his treatment was any better on account of his sect.)

To bring this full circle, I recently heard about another person, a Shia who lived in the Southern suburbs but is not a member of Hezbollah, who went for treatment at a state-of-the-art, Hezbollah-run hospital in his neighborhood. Upon discharge, he was presented with an exorbitant bill, and when he asked for a discount — a relatively doable thing in everything-can-be-negotiated Lebanon — was told that treatment is free for Party members; everyone else pays full price.

So: a Sunni with no insurance is turned away from a private hospital, because he can’t pay, and sent to a public, Sunni-run hospital where treatment is free; a Shia with no insurance is turned away from the same Sunni-backed public hospital and sent to a Shia-backed private hospital because, allegedly, of his sect; and a Shia who doesn’t belong to the right political party gets expensive, but top-notch treatment at a private, but otherwise free, hospital run by his sect.

Something has gone very, very wrong here.

As it stands now, there are two basic tracks for health insurance: private — with a private hospital or consortium — and the government overseen National Social Security Fund, in which one contributes small premiums and is entitled to mostly free treatment at public hospitals. In practice, there is a third track, taken by 58% of the population: no insurance. (If you are employed, your company is required to enroll you in the NSSF. If you are unemployed or retired, you are not eligable for the NSSF. Take a look at this confusing, but thorough, Yahoo! Answer from a Lebanese physician about how insurance works here, and see if you can make heads or tails of it.)

In August, the Minister of Health announced a plan to streamline the National Social Security Fund by, essentially, requiring everyone in the country without other health insurance to participate. (The NSSF is presently running a $500 million operating deficit.) This was portrayed in the Daily Star as way to “widen access to health care for the population, and reduce the cost of treatment for all,” which seems, on its face, true: under the new plan, the NSSF would be opened to the unemployed, and more types of preventative care (including terminal care and procedures like dialysis) would be offered for free. What the Daily Star article didn’t make clear was that more of the cost of other treatments would be handed down to patients. According to IHS Global Insight,

Depending on their choice, the payment for individuals at point of delivery will vary, from 5% (for public hospitals) to 20% (for private hospitals) of the total cost incurred. The government will pay 40% of a beneficiary’s total healthcare costs, while premiums will account for 30–40% of expenses, and payment at point of delivery (co-payments) will account for the remaining 20%.

In other words, patients who were uninsured and being treated for free, would now pay as much as 60% of the cost of treatment, premiums included. It’s yet another conundrum, with no solution, logistically or politically, in sight. Maybe Olympia Snowe can lend a hand.

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