The Great Health Care Divide

Since the health care debate is the main topic of conversation in the United States right now, many people have asked me about my experience with socialized health care. Germany is a mix of private and public health care. Everyone that works here pays into the public health system, and they and their dependents automatically qualify for public insurance. However some people choose to upgrade to private insurance so they can go to specific clinics or doctors and get more services like the gestational diabetes test covered.

Back, when Paul and I lived in VA, we paid out-of-pocket for private health insurance, because Paul’s employer’s health plan was super expensive, and they didn’t contribute towards it. The premium amounted to 9,6% of our gross salary. This did not include maternity coverage. To get maternity coverage we would have to pay an additional lump sum which would have amounted to 12,3% of our gross salary. Furthermore we would have had to pay for the maternity rider for six months before I could even get pregnant to qualify for the coverage. If I got pregnant five months and twenty nine days after we started the maternity rider, I wouldn’t have been covered. And, we could only add this coverage in six month intervals from when we first enrolled. When I got pregnant with Maggie, it wasn’t planned, and if we had been in the USA, we would have had to pay for the whole thing out of pocket.

When we asked our friend, a health insurance sales representative, he told us we wouldn’t be able to find any less expensive coverage. Furthermore, this coverage would not cover any pre-existing conditions, so it was a good thing that we were all healthy. We also maxed out our health savings plan in six months with co-pays and uncovered services, like visiting the optometrist and the dentist. This doesn’t include what we paid for prescription drugs.

In Germany, there also is no such thing as pre-existing condition or maternity riders. For this we pay 7,45% of our gross salary, Paul’s employer pays the same amount as required by law. For each doctor we visit in a yearly quarter, we pay 10€. It was a good thing I got pregnant in Germany where the public health insurance has no such thing as a maternity riders or rules on how to qualify for coverage.

Total out of pocket expenses from my first check-up all the way to post-birth care for two pregnancies: 125€. This included the 3 standard ultrasounds, all the regular maternity visits to my OB, all the standard tests, a gestational diabetes test, a strep-b test, giving birth twice, staying four days in the hospital after Max’s birth and three days after Maggie’s, and getting an epidural once. I paid 0€ when I went into the hospital for a uterine infection staying another four days, and they let me bring Max with me. Though, we did have to pay for Paul and my Mom to stay in the hospital room overnight to help me with Max. My health insurance covered the rental of a Medela Symphony breast pump, a pre-natal class, and a midwife who visited me at home after the birth as long as I needed her. If I choose to, I could have paid 0€ to take an ante-natal get back into shape class. Additionally, I’ve paid 40€ for 3 months of birth control, and I will pay 175€ for an IUD which is good for 3 years.

Regarding pediatrics, we’ve had equivalent care as we had in the States. For sick visits, we’ve get in to see the doctor the same day, for well-visits, we schedule about two weeks in advance. With Max, our pediatrician actually visited us at home after he was born. We only pay 10€ a quarter to the pediatrician including all the World Health Organization recommended vaccinations. We paid 10€ to the pediatric optometrist for a check-up and scheduled within two weeks. We paid 10€ for the pediatric dentist and scheduled the same week.

After three ER visits, we’ve had to pay 0€. When we take the children to the ER, we take them to a children’s hospital, of which there are at least three in Munich. When we took Max for what we thought might be bronchitis, we waited about two hours on a Friday night. When we took Max after he swallowed hand sanitizer, we waited about five minutes. I’m pretty sure every time I’ve ever been to the ER in the States; I’ve never waited less than two hours. When I was in the car accident in Ann Arbor, brought to the hospital in an ambulance and had my neck in a brace, I waited four hours before I saw a doctor. I thought they had forgotten about me. I don’t know how much, but I know my parents got an enormous bill for that, and now ten years later, they are still owed money from the University of Michigan hospital for being over billed.

When Paul went to the ER for his broken clavicle in Germany , he waited three hours on a Thursday night, paid 0€. He scheduled his follow-up with an orthopedic surgeon one day in advance, and paid 10€. His physical therapy to rebuild his muscles will cost 10€ a quarter. In the USA, Paul went to the ER for his appendix, we waited about four hours the first time. When he went to the ER for his appendix the second time for his appendix we waited another four hours. We walked out of the ER the first time because his tests came back negative, but the surgeon still wanted to cut him open, even though he couldn’t even look at us because he was too tired. Out of pocket, we paid $2000 in hospital bills for what the health insurance wouldn’t cover.

Of course the ERs aren’t full of uninsured people seeking basic medical care in Germany, because there are no uninsured here.

For sick visits to general MD, we’ve gotten in on the same day (even if we have never been to the doctor before.) I’ve been denied by doctors in the States because my health insurance was from a different State. When I had the ovarian cyst in DC, I had to call six doctors before anyone would see me, and the one who did see me only did because I was crying when I called. For Paul’s root canal, we paid 0€. For my cleaning, we paid 0€, and Paul had a special cleaning which he paid 80€ for out of pocket.

All this government running of health care hasn’t ruined it. Saudi Arabians and other nationalities from around the world come here to pay out of pocket when they get really sick. They could certainly afford to go to the USA if they felt the health care was better there. In fact, Munich airport has a medical center for people who fly here for health care. Even the plastic surgery industry is highly desired.

Obviously, I can only speak from our personal experiences with both systems, but in the States, I had many complaints about my health insurance. Here, I’ve not yet had one. And maybe giving birth, uterine infections and broken clavicles aren’t serious enough to be worthy of comparison, but I think they are. They didn’t bankrupt us like medical bills for similar services have done to so many Americans.

Finally, yes Germany has the fourth largest economy in the world, and yes its population is only 82 million, but the United States’ Gross Domestic Product is three times larger than Germany's.

Secret Smiles

My mother and I are both convinced that Maggie has been smiling since she was just a couple weeks old. My pediatrician thinks I’m mad, which might be true, but has nothing to do with whether or not Maggie is an early smile-er. Of course Maggie refused to smile during her U3, the German well baby one month check-up. However, can you blame her, she was being poked and prodded, hung by one leg than the other and flipped this way and that at a time of day when she is usually sleeping.

Most people explain those early baby smiles as gas, but gas has certainly never made me smile. Maggie’s smiles are becoming more frequent and more obviously a reflection of how she is feeling. When Max leans down to her and whispers “Hi baby,” tickling her with his blonde fringe, a big toothless grin lights up her face. When I speak dinosaur talk, the rolling lips, the clicking of the tongue or the popping of lips, she looks at me, gives me her silent baby laugh and coos.

Those easy un-conscious smiles are one of the best gifts my children can give me. When everything else seems to be falling apart, and I’m not sure I can take it anymore, just one precious smile from one of my children, and I can go on. This time is fleeting, and one day their smiles will be forced if the photographer can coax one out of them. So please don’t take away my babies’ early smiles, they are my little nuggest of gold, the moments I will hold on to when they reach those teenage years, when the smiles become rare and few in-between.

PANIC and running around aimlessly

My first day alone with the two children, and we ended up going to the emergency room before we'd even reached lunchtime. While I was attending Baby Maggie, my two-year-old, Max, got into his father's backpack and swallowed an unknown amount of hand-sanitizer. He ran into me crying, holding the half empty bottle trying to get it out of his mouth.

The hardest part about being in a foreign country where you don't speak the language, is dealing with emergencies,

My first reaction was to PANIC and run aimlessly around the apartment half-crazed, while trying to peel back the label for the promised "additional drug facts." After the 30 seconds which felt like forever it took me to peel back the label I read "Keep out of the reach of children. If swallowed, get medical help or contact a Poison Control Center immediately."

My reaction more PANIC and more running aimlessly around the apartment half-crazed. I didn't know the phone number to a German poison control, nor can I speak German to someone on the phone. Not being able to use body language makes it almost impossible to communicate even with people who understand English pretty well.

My brain addled by the PANIC I was still feeling, I called my husband. He told me to call the ambulance, which was a pretty appropriate response to the amount of PANIC I was conveying over the phone, though not appropriate to the situation. Max was showing no signs or symptoms of being poisoned and was immensely enjoying chasing his wild eyed mother around the apartment.

The PANIC and running aimlessly around the house half-crazed briefly paused, and I told Paul I was going to call the pediatrician. This led to more PANIC and more running aimlessly around the apartment half-crazed in a wild search for my wallet which has the pediatrician's card on it, because when I am in PANIC mode, my brain can't compute the obvious. The wallet was in my bag where it belongs.

I tried calling, but after ringing a couple times, I got a strange message in German, and elevator music which is not at all soothing while PANICKING and running aimlessly around the apartment half-crazed because your two-year-old just swallowed an unknown amount of hand sanitizer. I hung up and dialed again, and got the same result. More PANIC, more running around aimlessly. I called Paul back and was met by a busy signal. More PANIC, more running around aimlessly.

Not sure what to do, I attempted the pediatrician again, at which point Paul showed up on call waiting. I told him I couldn't get through to the pediatrician, and he sensibly asked me if the pediatrician was open. I retorted, "Of course, the pediatrician is open." He suggested going straight to the pediatrician's office instead of calling.

My addled brain responded with, "THAT ISN'T EXACTLY EASY WITH TWO KIDS," no car, a stroller in the basement bike-room, and at least 30 minute door-to-door commute if I catch the bus at the exactly right moment.

His response, "That isn't the point, is it?"

My response, "Sometimes I hate you for bringing me here where I feel so helpless," which was really my way of saying, "I hate that you are being reasonable, while I am PANICING and running around the apartment aimlessly half-crazed." So I hung up and accidentally turned the phone off, which meant more PANIC and more running around aimlessly because I had to search in our file cabinet for the stupid pin number to turn the phone back on, because I can never remember it. Who puts stupid pin numbers on cell phone anyways?

After more PANIC and more running around aimlessly, I found the pediatrician's card that I had set down in the bathroom during a previous episode of PANIC and running around aimlessly. I looked at the back and realized that the pediatrician’s office was about to close for lunch and wouldn't be open again for another three-and-a-half hours, enough time for the hand-sanitizer to take effect, and my child would no longer be laughing while chasing his wild eyed mother around the apartment.

I called Paul back, and told him that I had to go to the emergency room. Still the voice of calm and reason, he told me he would call a Taxi when I was ready. So after I retrieved the baby's car seat from the attic and put shoes on Max and me, I made sure I had my wallet with health insurance cards, when I realized that I didn't have any cash. More PANIC and more running around aimlessly, I called Paul and told him I didn't have any cash to take a taxi. Still calm and reasonable, he told me to ask the Taxi to take me to a bank.

Once I was in the taxi, the PANIC and aimless running around subsided, because I now had a sense of direction, but mostly because I was restrained by the seat-belt. Max was sitting in the taxi's car seat happily babbling away about taxis and autos. We got to the children's hospital, and we were almost immediately triaged in to see a doctor. This was disappointing to Max who was having fun riding the carousel in the waiting room.

After the doctor contacted a Berlin Poison Institute about Max's choice of poison, she informed me that the amount missing from the 1oz bottle wasn't enough to do any harm. She still did a full examination of him to make sure that he wasn't showing any signs or symptoms of poisoning, and with a reassuring smile she told me that every child this age swallows something like this.

Crisis averted.

First Impressions; Flashback to Munich Part I

WARNING: This is a really long post about pre-natal health care.

When I was pregnant with Max, I was considerably more ambitious about recording my pregnancy experience than I am this time; I kept a journal as well as sent various emails to all of my family about our experience. Here is an edited snippet from an email about my first impression of pre-natal and labor and delivery care in Munich.

"We finally found an Obstetrician. In Germany, they (the proverbial they) recommend that you pick where you want to give birth, and then find the doctor. We went to an orientation at the Frauenklinik Roten Kreuz (the women’s Red Cross hospital). It was amazing. It was a beautiful hospital, very clean and all the latest technology. They have an on-site NICU. The doctors are all highly regarded, and they are one of the few hospitals that have been able to maintain a highly qualified and full nursing staff despite the nursing shortages. The hospital is number three in the country for obstetrics.

Hindsight: Reading between the lines, many of our friends and family were concerned that the "socialized" health care in Germany would be a detriment to the quality of care I and my new baby received. I went a bit overboard in reassuring everyone that I was getting care on par with the care in the States.

They use the latest technology in Cesareans which has the shortest recovery time. And they have all the pain medicine available should you choose to use them. However, pain medication is not encouraged.

Hindsight: Again, I had to reassure everyone that I was getting the best care. While it's true that they try to encourage you to have the baby naturally, my midwife was the first to suggest the epidural to me. I was only half way through the labor, and she could tell that I wasn't dealing with the pain well. I have a very low threshold for pain, and a high intolerance for discomfort. She read me very well, and I don't regret the epidural at all. I received the epidural six hours into the labor at two cm dilated. I fell asleep immediately after the epidural, and when I woke up I was fully dilated, and ready to go.

Every birth is assisted by a doctor and a Nurse Midwife.

Hindsight: While this was true, it was really the Nurse Midwife who did all the work. The only reason the OB ever came in to the room was to make the episiotomy. They have doctors on hand for complications, but they don't do the brunt of the work for the majority of the births.

They have eight birthing rooms with all kinds of birthing assistance. Over the bed is a rope/towel thing hanging from the ceiling to help you situate yourself. There was a birthing ball, a birthing stool, and they recommend all kinds of different ways to help ease the pain. They also have three birthing tubs, which they highly recommend using to deal with the pain of labor. They offer aroma therapy, homeotherapy and an extensive library of music for you to play during the birth. They encourage you to bring anything from home that will make you comfortable from candles and scents to music.

Hindsight: The only thing I really took advantage of was the birthing tub, and the minute I got out of the tub, the pain got 10xs worse. This time around, I'm hoping to stay in the tub longer, because I really do believe that it is much better for pain management.

Standard of care is to stay in the klinik for three to four days afterwards. They have lactation consultants to help you learn to breast-feed, and a special nursing room with the gliding rocking chairs and nursing pillows. They also have a room with a glass ceiling so you can see the stars, where they encourage you to use the time to bond as a new family. If they have the space, they’ll let you have your own room and the father can stay overnight.

Hindsight: This paragraph highlights the best parts about my hospital stay. Max and I spent four days in the hospital afterwards. I only had a roommate for half the time I was there, and Paul, Max and I spent a lot of time in the atrium once my roommate moved in. The nurses were so fabulous too. I would have given up breastfeeding if it wasn't for the encouragement and support I had received from them. Afterwards I sent all the nurses chocolate as a Thank You.

Oh and they have classes before and after the pregnancy that are free of charge. They have everything from your “crash course” on birthing to back building exercises and gymnastics. They also have a class after the birth to help you get back in shape.

Hindsight: The classes aren't really free of charge; your health insurance pays for them. However, it was still really fabulous to have them available. We went to a different pre-natal class, which was lead by an English speaking midwife. I didn't take advantage of the post-natal get back in shape class, but I've gotten mixed reviews on its quality. For health insurance to pay for it, you have to enroll three months after giving birth, and the quality of the class depends on the midwife leading it. My friends who attended the classes, all said that it was pretty low-impact, which I guess is good if you just recently had a baby. However, I'm generally only into high impact exercise classes like spin and kickboxing.

And, if you’re really alternative you can get acupuncture for 15 Euros to help you with the discomforts of late pregnancy. I’m not that adventurous, though if I get desperate, we’ll see.

Hindsight: I didn't take advantage of this, but I have friends who did and really thought it helped them.

The hospital is amazing, and the doctor that gave the orientation is going to be my doctor He told us that most of the doctors and Nurses speak English, and they will make sure that we have English speakers in the birthing room with us. If a shift ends in the middle of your labor, they actually take an hour with the next staff person to get them up to speed."

Hindsight: This wasn't true at all. All of the doctors spoke very good English, but only a few of the nurses knew more than a few words. However, it wasn't difficult to communicate with my Midwife at all. She was one of the most experienced midwives in the hospital, and though she didn't speak a lick of English, and we spoke very little German, we had no problem communicating with her. She was really awesome, and came to visit me after the birth of the baby in my hospital room. We also had no problem communicating with the nurses despite the language barrier.

When you really want your mommy

I haven’t been adding much lately, because we’ve all been sick, and not just “cough, cough, sniffle, sniffle" sick, but violently sick. The kind of sick that makes you writhe in agony praying for a release that only death can bring.

After four days of agony and no indication of letting up, we reluctantly decided to go to the doctor. Now I say reluctantly, because this is one of the drawbacks of living without a car, despite the great public transportation. Because when I’m sick, and I can barely make it down the hall to the bathroom, the thought of dragging myself, my husband and my 17 month old son, into the 40 degree weather, down to the bus stop, onto the bus and down to a doctor’s office which we’re only vaguely familiar with its’ location is less than appealing.

So, after we manage to get to the doctor’s office, we have to argue with the receptionist in our broken German and her broken English to take us despite the fact that our insurance cards haven’t arrived yet. After about an hour, the Doctor, kind soul that he is, takes us back into his office, where I almost cry when I realize that he’s going to treat us. He tells us it’s viral, to take some Imodium AD, go home, and we’ll feel better tomorrow.

Only, we didn’t feel better the next day, nor the next day, and the Imodium, it didn‘t work. After the ordeal of going to the doctor the first time, we were even more reluctant to go the second time. Though, this time we were more prepared, we found a quicker and easier route, and there was no arguing at the front desk. The doctor was surprised to see us again, but quickly realized that we had more than just the flu. Being the good German doctor that he is, he’s not going to prescribe an anti-biotic until he’s confirmed that we have a bacterial infection, and to do so he needs a stool sample.

Now, Paul and I have spent almost a week swallowing a pharmacy of anti-diarrhea drugs to get the poop to stop, but the one time we really want it to come, it’s not forthcoming. We knew that eating is the most likely way to get our bowels moving, and it just so happens that the doctor has a bunch of health cookies that he willingly provides for the task at hand. Now, had we not been in such a weakened state, we might have noticed the over eagerness of the doctor in pawning those cookies off on us. Because those cookies only loosely resembled cookies. They more closely resembled birdseed. After only eating bananas and apple juice only week, we were supposed to figure out how to eat these things. It was like holding your nose to swallow bad medicine. We couldn’t even eat two.

The doctor recommended some biological medication and live culture yogurt to help reestablish the natural balance of bacteria flora in our bowels, kind of like yoga, only for the intestines. And after two days of this new course of treatment, while we wait for our lab results, we’re finally feeling better. I’m adding live culture yogurt to our permanent grocery list.