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Emergency Medicine News:
doi: 10.1097/01.EEM.0000414680.04210.0c
Screened & Examined

The Kiwi Tradeoff: Free Medical Care for Forfeiting the Right to Sue

Ballard, Dustin MD

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Author Information

Dr. Ballard is an associate emergency physician at Kaiser-Permanente in San Rafael, CA, and the chair of the CREST ED Research Network. His writing credits include co-authorship with Angela Ballard of the award-winning travel narrative A Blistered Kind of Love: One Couple's Trial by Trail (Mountaineers Books, 2003) and authorship of The Bullet's Yaw (IUniverse, 2007). Dr. Ballard writes a biweekly-medical column for the Marin Independent Journal, which he posts on his blog: http://incisionanddrainage.blogspot.com. He is currently working at Starship Children's Hospital in Auckland, New Zealand.

Imagine that you've driven your car off the road into a Eucalyptus tree, and busted up your ankle. During the subsequent ambulance ride, what thoughts might pop into your head?

The New Zealand spor...
The New Zealand spor...
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"Ouch!"

"Thank goodness no one else was hurt."

"What in the heck were those possums doing?"

"I've never liked Eucalyptus trees."

"How in the world am I going to pay my medical bill?"

An average American could conceivably have some or all of these thoughts. But here in New Zealand, at least one of these notions would be quite unusual. And, no, it's not the one about possums; they are as plentiful as sheep around these parts. Rather, it is the bit about medical costs.

You see in New Zealand, accident and injury-related medical care is fully compensated, regardless of insurance or fault. More about that in a minute, but first, for those who may have missed my last column, I'm in the midst of a six-month stay in Auckland, grappling with how Kiwi perceptions of health and wellness differ from American ones. I recognize (disclaimer alert!) that perceptions of health are diverse and that this endeavor hazards broad generalizations. Perhaps my query is as unanswerable as the age-old "nature versus nurture debate." Nonetheless, identifiable differences in geography, culture, and statute seem to shape how health is perceived in these two countries.

Take medical care for the wounded. We all know that some injured patients in the United States just cannot pay for health care, but eventually they are likely to receive treatment anyway (probably in an ED). Everyone else picks up the tab for this through higher insurance premiums and other cost-shifting mechanisms. Of course, in some cases, it's not that simple. Some uninsured patients might be able to pay their medical bills but risk bankruptcy in the process.

Injuries are handled quite differently in New Zealand under a system called the Accident Compensation Corporation (ACC). First enacted in 1974 and revised many times since, the ACC hinges on a crucial tradeoff: free medical care for injuries, regardless of fault, for all citizens and non-citizens alike in return for higher taxes and, importantly, for forfeiting the right to sue for damages.

Let's say an American tourist tries zorbing, a "sport" in which one is rolled down a steep hill inside a large plastic sphere that looks like an overfed yoga ball. This American then suffers an unscheduled tumble into the path of a van. When he is taken to the Accident and Emergency (AKA the ED), the physician will complete an ACC form, verifying that he has sustained a valid injury and that his medical care will be paid for by the ACC. In return, said American cannot sue the zorbing company, the driver of the van, the physician who treats him, or anyone else. He can, however, take solace in the fact that any party that has acted negligently may be criminally prosecuted (as opposed to sued).

This system, it seems to me, helps mitigate fear. I've noticed this on many levels, but it's most pronounced with children. A tool bench at my son's preschool is equipped with actual carpenter-worthy hammers, screwdrivers, nails, and screws for actual building projects (take that Bob the Builder!) The kids go shoeless much of the day; they take off their kicks when they arrive at school and (maybe) put them back on when they leave. Of course, the lack of poisonous snakes or spiders helps make this a safer proposition than it might be elsewhere.

Trampolines and "bouncing pillows" are common, as are the injuries they cause. Kids play rugby without helmets, which does not seem like a good idea to me. This fearlessness manifests in young adults as adventure sports such as white water river sledging (river rafting on a boogie board). But it's in professional life where diminished fear may make the most substantive difference. Kiwis I've spoken to are amazed at the thought of staying in a bum job just because it offers good health coverage. An American physician who spent a decade in New Zealand put it this way, "We [Americans] have to buy protection against the health care system that could make us poor. They have freedom from that fear."

Of course, these are perceptions, not hard facts, and fear (especially the type that softly itches at you each day) is a difficult thing to measure objectively.

Certainly the ACC scheme has its downsides: a two percent earner's levy (income tax) that caps at approximately $2000 a year per person as well as the potential for fraud and reckless behavior. Kiwis are certainly adventurous but not particularly reckless. The roads are safe and well-policed, and fatal motor vehicle crashes are rare (396 in all of 2008) and less frequent (per vehicle) than in the United States.

I see far more unhelmeted cyclists here than at home, but I also note far fewer folks texting while behind the wheel. Any freedom that an individual might feel to act carelessly seems to be more than counterbalanced by a public health incentive (financial and otherwise) to prevent severe injuries. The only truly reckless activity I've heard about is a coed rugby squad called the Nude Blacks. (If that isn't explanation enough, search that term on YouTube.)

"Normal fear protects us; abnormal fear paralyzes us," wrote Marin Luther King Jr. True enough, but what is "normal," and how much is it defined by the social contract of the society in which we live? It would seem that American society creates certain "abnormal" fears that may not exist in New Zealand. And this might help explain how differently the two peoples regard their health. It does not, however, explain what the heck those possums were doing in the road.

© 2012 Lippincott Williams & Wilkins, Inc.

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