The fall of the iron curtain led to the rise of a curious industry in Hungary. In 1992, the dentist Béla Bátorfi began treating a certain Viktor Orbán, who—as luck would have it for the savvy dentist—would go on to have a highly successful career as a conservative politician. Bátorfi would soon become a pioneer in Hungary’s “medical tourism” industry, drawing patients from Western Europe for dental procedures at a good price. However, his fortunes further improved after Orbán’s party won the 2010 elections, returning him to power as prime minister. Shortly thereafter, Bátorfi’s company won a slew of government contracts to direct the development of the country’s growing medical tourism industry. Over the years, this perpetually well-tanned dentist has become something of a national superstar: he now heads a sports club named after himself, directs the Budapest Ironman as head of the Hungarian Triathlon Union, and is reportedly moving into the entertainment industry, among other potential ventures.
The above story is told by journalist Sasha Issenberg in his revealing and timely new book, Outpatients: The Astonishing New World of Medical TourismA consultant hired by Bátorfi, in an interview with Issenberg, describes their aspirations aptly: “In Switzerland you get chocolates and watches. For Hungary you get dentistry.” Except, of course, that health care is neither a confectionary nor a luxury chronometer. The story of Hungary’s dental trade is but one small glimpse into a growing, profitable, and highly problematic industry—one that is now spreading throughout the globe.
Why do people travel for health care? For many (perhaps most), the issue of cost is paramount: in the United States, for instance, with out-of-pocket expenses rising even among the insured, the price of medical care continues to matter. Some travel for the types of treatments available outside their home, and perhaps others for the novelty of the experience itself. However, one stereotype of the medical tourist—that of an individual seeking a luxurious medical experience ensconced in a sumptuous setting enhanced by cultural amenities—probably does little justice to the typical experience for most.
The phenomenon of medical tourism has been in the spotlight for some years: A 2006 story in Time headlined “Outsourcing Your Heart” told the story of some unfortunate Americans who were pushed into “the swelling ranks of medical tourists,” going abroad for back and heart surgeries to save money. An article that same year in the New England Journal of Medicine described medical tourists as “middle-income Americans evading impoverishment by expensive, medically necessary operations,” and around the same time a report in the Lancet described medical tourism as a $60 billion industry. A sometimes cited but old figure puts the number of American medical tourists at an estimated 750,000 annually; today the number could be higher. Rising copayments and deductibles in the United States may provide further fodder for the thirsty industry in the years to come.
Issenberg approaches the issue from a unique perspective: he is mainly exploring the world of medical tourism in Eastern Europe, taking us along with him to two countries—Hungary and Bulgaria—where the industry began flourishing in the post-Communist era. What we see are people traveling less out of choice than out of some form of compulsion: “[T]he bulk of medical tourism today,” Issenberg justly contends, “at least beyond frivolous cosmetic procedures, is not undertaken as an act of privilege.”
To understand the emergence of the modern medical tourism industry, it’s not enough to only emphasize rising health care costs. Though no doubt circumstances differ from nation to nation, medical tourism can be better conceived as arising out of the intersection of three developments in the international political economy of health care.
The first of these is the emergence of the corporate health care industry itself. While there has always been a business side of health care, the appearance of a “large and growing network of private corporations,” as then editor-in-chief of the New England Journal of Medicine Arnold Relman wrote in a 1980 article “The New Medical-Industrial Complex,” which are “engaged in the business of supplying health-care services to patients for a profit,” is a much newer development. Today, however, it’s also an increasingly globalized phenomenon, with for-profit health care corporations seeking to “carve out more profit from … the global total of almost $5 trillion annually spent on health,” as journalist John Lister describes in his 2013 book Health Policy Reform: Global Health versus Private Profit.
Issenberg begins his book, for instance, with a description of a new hospital built by the Tokushukai Medical Corporation—a huge Japanese hospital chain—in Sofia, Bulgaria. The Tokuda Hospital Sofia, an oddly situated “nine-story ivory puzzle piece in a sort of corporatized-Bauhaus style,” as he puts it, draws patients from various nations in the region. As he walks through the Tokuda, he catches a glimpse of a fearful-appearing Libyan woman lying in a hospital bed, grasping the hand of a man he assumes is her husband. A hospital employee tells him that the Libyan civil war has strained that nation’s health care system, and as a result Libya started sending its knee surgery patients to the Tokuda. “Here was a Libyan woman,” Issenberg describes, “trapped in a Japanese hospital in the Bulgarian capital, all when at her most vulnerable.” This sentence nicely underscores both the odd internationalization of health care, and the fact that the position of the medical tourist is, in general, probably not one that we should envy.
A second development, at least with respect to the nations of the former Eastern Bloc, has been the impact of the post-Communist transition to capitalism on the health systems of these nations. The demise of the Bloc’s ugly authoritarian regimes was no doubt a long time coming. However, as epidemiologists David Stuckler and Sanjay Basu describe in The Body Economic: Why Austerity Kills, unbridled neoliberal “shock therapy” had a disastrous (and unnecessary) impact on health—and health systems—in many nations of the former Soviet Union. Nations that pursued “mass privatization,” they note (drawing on their own research), saw greater reductions in government health care expenditures and “substantial drops in access to healthcare.”
Issenberg situates the evolution of a medical tourism industry in Hungary in the context of its unique post-Communist transition. Hungary’s nationalized health system, he describes, served it reasonably (if imperfectly) for decades, with free health care available to nearly all (albeit with under-the-table payments to doctors an all-too-common expectation, the corrupt legacy of which lasts to the current day). In seeking to control health spending, the post-communist government of Hungary effectively capped the pay of physicians who remained in the public sector, and, as he notes, in 1995 it privatized dental care. Those who moved into private practice “thrived more than ever,” with dentists in particular looking abroad for cash-paying customers.
The dental tourism industry in the city of Sopron arose, for example, in part to cater to nearby Vienna, and by the end of the 1990s “had become the one city in this pastry-mad country where it was easier to find someone skilled in fixing cavities than a vendor of the sweets liable to provoke them” (one of Issenberg’s several nice turns of phrase). A bit of cronyism, it should be noted, factored into these developments as well, as with the bids won by Bátorfi. “It is possible to get the money through a complex application,” one news website (quoted by Issenberg) predicted, “but inevitably Viktor Orbán’s denist’s company will be awarded the billion forints.” Indeed.
Which brings us to a third development: persistent—and, in some instances, widening—coverage gaps within the health systems of high-income countries. Issenberg describes how Bátorfi’s business model revolved around attracting customers from Britain: he would eventually visit London once a month, performing consultations and forwarding amenable customers onward to his clinic in Budapest. Though Issenberg doesn’t get into this much, the demand for inexpensive dental care in England should probably be understood in the context of an inadequate supply of free public dental care available under the British National Health Service—a change instigated by the government of Margaret Thatcher. As health policy researcher Allyson Pollock describes in the book NHS Plc, the conservative government reduced reimbursement for dental services in the late 1980s, predictably and progressively pushing dentists into the private sector. This turned the NHS, Pollock notes, into a “‘residual’ dental service” for those who couldn’t afford private dental care. However, this was only one aspect of a much larger conservative effort to privatize parts of the British health system (which continues to the present day in David Cameron’s England).
In other words, rising demand for less expensive medical care for those in high-income nations can be seen as flowing (in part) through the interstices found within the fabric of these nation’s health systems. In some instances, these gaps opened as the result of the defunding or partial dismantling of these systems; in other instances, they represent more long-standing inadequacies. For instance, those seeking less expensive health care in the United States might include the uninsured, but also the underinsured (those with paltry insurance with high out-of-pocket health expenses). The average annual deductible for a so-called “Bronze” insurance plan purchased on the Obamacare exchanges, for example, will be $11,601 for a family in 2016, according to the firm HealthPocket. Such out-of-pocket exposure could understandably prompt some to seek less expensive care abroad.
A notable strength of this book is Issenberg’s keen and thorough shoe-leather reporting as he brings us through the hospitals of Eastern Europe, albeit also with an eye on the policy context. His focus—appropriately, in my opinion—is less on the medical tourists themselves, and much more on their providers and host nations. This is important, because in reality medical tourism impacts the nations receiving patients more than those sending them. Issenberg is aware, for instance, that medical tourism could potentially compromise the provision of care for a nation’s own citizens, for instance by directing domestic resources and personnel towards the service of a global elite. For instance, he notes that the tourist-serving Nadezhda Women’s Health Hospital in Bulgaria—nicely described as a “potentially dreary building … reclaimed from an insurance company and heroically jazzed up for gynecological uses by a television-set designer”—has a wait list for Bulgarians, but not for cash-paying foreigners.
There is something very unjust about a nation providing privatized health services for an international market while at the same time failing to provide universal health care for its own citizens. Zahra Meghani, associate professor of philosophy at the University of Rhode Island, went further in a 2011 paper in the journal Developing World Bioethics, contending that it was “ethically problematic” for Americans, on an individual level, to seek inexpensive surgical care in India. As she describes, such consumption of private health care by foreigners can draw from the public resources available to poor Indians, for instance through the inevitable “internal brain drain” that occurs as physicians seek employment at better paying private facilities and neglect the lower-paying public ones. Lister similarly notes that public subsidies for these enterprises—for instance through tax breaks or grants of land—represent a drain on the resources that might instead be used for domestic public health projects. And when the hospitals are owned by international companies, he points out, profits aren’t used for the care of the poor—they are simply whisked abroad.
There is no doubt much truth to these perspectives. I think Issenberg is right, however, to stress that foreigners can also serve as “convenient scapegoat[s],” when the real problem is the underdevelopment and underfunding of the health systems of these nations. More broadly, I’d suggest that the problem is not so much that care is being provided to outsiders, but instead that different care is provided to those in different economic strata, frequently with a for-profit private tier for the well-off (whether they be domestic or foreign) and an inferior public system for the rest.
In this respect, Issenberg’s conclusions fall very short. Medical tourism, he fairly argues, shows us that the deficiencies of our health care systems are not preordained, but are instead the result of policy choices. He adds that by taking flight, tourists are engaging in “personal defiance against the state’s monopoly on decision-making about medical economics, and the trade-offs between access, quality, and cost that are at the heart of every national system.” In other words, patients that find their own health system inadequate in some way—whether because of high costs, inadequate facilities, or poor performance—can fly for care for respite. Now it is true that some compromises are no doubt inevitable in any health system. Medical tourism, however, is in reality the downstream consequence of a much larger compromise: a conscious embrace of health care commoditization over health care rights.
And there are costs in that choice. The medical tourism industry is an intrinsically entrepreneurial endeavor: it seeks the maximization of profit. Those without sufficient cash are, of course, excluded. Lucrative, in-and-out procedures are emphasized, while costly long-term follow-up is left out. A surplus is skimmed, and the old, the immobile, and the poor are left behind. The main harm of this model of medicine is not that it happens to take place in a foreign country, but that it takes place at all.