“I Owe You My Life”

Many Americans share a similar nightmare: paying for healthcare. They fixate on that worst case scenario of how their life-saving procedure might nearly kill their bank account. Even among those with health insurance plans, some still face surmounting bills whose average annual cost is two-fold that of other wealthy countries and far exceeds the international average. All this for what President Trump calls “the best healthcare system in the world,” and yet the U.S. only ranks #31 on the World Health Organization's list of the countries with the longest life expectancy.

Spain, however, ranks #4 on that list — #2 in Europe after Switzerland — and is expected to overtake the #1 spot from Japan by 2020 according to an October 2018 article in Business Insider. In 2017, Spain also had the highest rate of deceased organ donors in the world according to the International Registry in Organ Donation and Transplantation. In addition, Hospital Clínic, Barcelona's large public hospital, ranks best in the nation in nephrology, pneumology and digestive medicine and #2 in analysis and investigation according to ThinkSpain.com

Numbers and superlatives aside, healthcare in Spain is essentially accessible, not just among its citizens but its foreigners too. In nowhere else is that more respected than here in Catalunya, whose CatSalut program currently covers all emergencies no matter where you're from. It also gives foreigners who are at minimum empadronats (registered) here access to second-level coverage in Catalunya, including primary and specialized care, reasonably priced medications, as well as mental health and rehabilitation.

Foreigners who are living and working in Catalunya get first-level coverage throughout all of Spain, which includes all of the services above, as well as complex procedures for a fraction of the price than in other countries. In 2015, for example, the average cost of an MRI scan was $1,116 in the U.S. and only $181 in Spain.

When it’s not being regulated by large insurance companies, pharmaceuticals and lobbyists, healthcare stops being a business and instead becomes a system that champions life. And that’s exactly what two Americans — Jamie Fulcher and Cole Ingersoll — had a second chance at thanks to living here in Barcelona and working with the teams at Hospital Clínic.

The pre-existing condition

Jamie was born with adult polycystic kidney disease, a very rare condition in babies that kept her in the hospital for the first month of her life and put her on dialysis as a kid. “All of my life, I was always poked and prodded at the doctor,” she told Barcelona Metropolitan. “So when I was 17-18, I ignored my kidney disease because I didn’t feel sick.” She stayed on her parents’ healthcare plan for as long as she could and hoped for the best.

It was around that time as teenagers that Jamie met Cole in a psychology class and they quickly became involved in each others’ lives. After stints in states like Florida, Arizona, California and Oregon, and countries like Korea, Mexico and Ireland, the pair decided to take advantage of Cole’s Irish passport by getting married and attempting to make a living in the only EU country where their knowledge of Spanish would come in handy.

In 2012, they arrived in Barcelona and with her background in childhood education, Jamie quickly found work at an English summer camp (which Cole eventually took on while his wife’s paperwork was processing). Shortly thereafter, Jamie wound up with a well-paid job at a primary school that was just opening up in the area; she’s still employed by that school to this day and is currently on unpaid leave for this year.

Yet just as Jamie was finding her groove in Barcelona, the music began to stop. What began as mild blood pressure issues while living in Mexico had been slowly tearing away at her body and she was losing steam. Short walks left her winded and small cuts became big bruises. Following a difficult trip to Italy toward the end of the summer of 2013, she decided to visit the doctor, even though she hadn’t yet registered for any health insurance, public nor private, in Barcelona.

As a person living here, Jamie was entitled to a CatSalut card, which she quickly registered for and then went to the doctor. Tests were run and she was sent home with medication for a kidney infection and instructions to come back the next week. But with 30 years‘ worth of kidney infections under her belt, she felt something was different this time. The next day she went back and explained more about her condition to the doctor, who expedited the test results from four days to that very visit.

“That was the scariest part: She hands me a piece of paper and says, ‘Do not go home. Do not pack a bag. Do not get anything. I'm calling a you a taxi. We'll go right to the hospital.’ And I looked down at the paper and it said ‘grave,’ as in grave.”

Jamie was rushed to the nephrology department at Hospital Clínic, the nearest public hospital in her area, where she waited for four hours keeled over in a wheelchair. But when it was her turn to be seen, she was admitted right away and almost immediately a catheter was inserted through a vein in her neck to start dialysis. The doctors were amazed by how calm she was despite the grave-ity of the situation.

Her mother, who happens to be a nurse, flew in that night from the U.S. to visit Jamie in the hospital and was surprised to see that her daughter was hooked up to top-quality equipment in a public hospital. Assuming that her mother was from out of town and that Jamie was too, the hospital staff showed her mother to an office where they presented her with a bill. It was only then that Jamie started to get stressed because she realized her CatSalut card was still processing.

But Dr. Miquel Blasco, her nephrologist at the time, advocated for his patient. He called a friend in the social security department to rush the card and had everything taken care of quickly, leaving Jamie to rest easy and recover with her mom and husband.

The miracle treatment

Jamie remained in the hospital for two more weeks. When she was discharged, she returned for dialysis three days a week, five hours a day, with all visits covered by CatSalut. (In the U.S. dialysis is covered by Medicare.) The state provided her with up to a year and a half of paid medical leave from work, which she could also extend unpaid for as long as she needed. By January, she felt ready to go back to working at the school and Jamie’s employers modified her hours to allow her to continue dialysis.

Yet earlier on in the fall, just a month after the incident, Jamie was already thinking about getting a kidney transplant. She knew if she had one within the year there was a higher chance that the transplant would be successful. She got in touch with Dr. Ignacio Revuelta, who was head of live donor transplant at Hospital Clínic, to discuss options. At first, Jamie’s father came in from the States to explore the possibility of being her donor. However, he was skeptical about giving his kidney to his daughter in a foreign country, even if Spain was rated one of the top countries in Europe for transplants, and Hospital Clínic was the best in Spain for kidney transplants.

It was then that her husband Cole volunteered to undergo the tests to see if he could donate his kidney. Even if he wasn’t a match for Jamie, putting him on Catalunya’s local donor list and Spain’s national donor list — the most robust per capita in the world — would have triggered a complex chain reaction in the donation and transplantation cross-network that might have increased his wife’s chances of receiving a kidney. (Cole’s tests were also covered by CatSalut.)

After months of waiting for the results, the couple returned to Dr. Revulta’s office in May. “It was one of those times,” Cole recalls, “where he’s like, ‘I have news for you.’” Not only was Cole’s kidney healthy, but to everyone’s surprise, it was a terrific match for Jamie — even better than her own father’s kidney.

While luck played some role in that, nephrology coordinator at Hospital Clínic Dr. Vicens Torregrosa mentions that for transplants, “ideally the kidneys have to be the same age because kidneys have a life too.” And after a decade and a half together, Jamie and Cole had spent the majority of their lives living with similar habits and in the same environments.

The doctors initially wanted the procedure to happen just two weeks later, but Jamie and Cole still needed time to get their heads around it. They couldn’t believe it was all happening so quickly. They were able to postpone it a bit longer, giving their families, friends and employers more time to plan.

The couple arrived at Hospital Clínic on June 10, 2014 for the procedure, which they knew would take up the majority of the day. They were wheeled into separate wards — she into nephrology and he into urology — and didn’t meet again until nearly 12 hours later. Still recovering from anaesthesia, they were wheeled into the same room and their hands met.

Jamie remained in the hospital for a few weeks while Cole was able to leave after just a few days, yet a post-procedure cough seemed to have ruptured a blood vessel in his stomach. During a FaceTime call from home while his wife was in the hospital, doctors were able to see his condition on her iPad and had him brought back to the hospital for a week longer. Aside from that unexpected turbulence, the recovery went smoothly for both. The day after Jamie got out of the hospital, she was already climbing the Sagrada Família with her mom, who was in town for just a little while longer after having flown in again to be there for the transplantation.

Behind the scenes

What happened to Jamie and Cole seems like it came straight out of a movie: the man who stole her heart and then gave her his kidney. But in reality, the medical care and actual donation and transplantation process, is a very complex system — one that’s rich in rewards for patients, not for private companies. It’s the result of more than 25 years of hard work spearheaded by Spain’s Transplant Procurement Management (TPM), which was founded in 1991 and merged into the Donation Transplant Institute (DTI) in 2010.

Dr. Torregrosa arrived at Hospital Clínic’s nephrology department just as TPM was getting off the ground. The idea was for doctors to collaborate with the TPM, which would help professionalize how transplants were managed. Dr. Torregrosa became coordinator, a role that hadn’t yet existed. “Transplantation is not as simple as ‘I take out an organ from this person and give it to this other person and that’s that,” says Dr. Torregrosa. “There’s a whole interplay as soon as the pathology is detected." With both regional and national components, the transplant list here in Catalunya and Spain is absolutely transparent and must be maintained, with no wiggle room. “People aren’t that aware that the inner workings of the matching system are not that simple.”

The development of DTI has helped transplantation specialists like Dr. Torregrosa share these successful methods worldwide as well as develop systems that can adapt to the unique circumstances of each country, many of which are ill-equipped and under-served to begin with. The organization hosts workshops abroad to help train local doctors and medical professionals to become transplantation coordinators, as well as offers courses here in Spain, with the national nephrologists congress held in Dr. Torregrosa’s hometown of Cocentaina, Valencia every year.

Since its inception, DTI has trained more than 14,000 people in organ donation and tissue banking, benefitting more than 100 countries and saving more than 2,450 lives. In 2017 alone, training increased 15% and 7% of participants were new students, with four new regions supported by DTI’s Foundation and six new delegations visited.

“There were very few people when it was first [just the] TPM,” adds Dr. Torregrosa. “DTI allowed for projects that have received grants from the European Union. Research has increased a lot.” It’s these E.U. funds that have also allowed for projects to spread the word about organ donation. Organizations like Transplantando Sonrisas work with DTI to create awareness campaigns that encourage the public to become organ donors and help those who are attached to dialysis machines or are terminally ill.

Like Cole, expats in Spain can become donors too. “People have no idea that there are hundreds waiting for something you already have, something that you don’t need at least when you pass away,” mentions Dr. Torregrosa. Spain currently leads the pack with the highest rate of actual deceased donors in the in the world at 46.9 per million people in 2017.

From numbers to actual people

Another number worth considering when it comes to transplants is $750,000. That’s what Jamie and Cole estimate their bills in 2013 and 2014 would have cost them in the U.S., where Jamie’s pre-existing kidney condition made it challenging and expensive to get health insurance.

The post-transplant medication for her new kidney currently costs her 29 euros a month, whereas in the U.S. it can be as high as $2,500 according to what Jamie looked up. Cole adds, “In the United States, it might look like a four-star hotel but that’s just the surface. Doctors here asked why we didn’t get this taken care of before and I was like ‘When I lived in the U.S. I couldn’t afford to go to the doctor or hospital.’”

But it’s not just the price tag that’s different, it’s the treatment itself as well. “They all have a very personal way of dealing with you,” Jamie explains. “It’s a very humanizing system and they don’t question why you’re using it. They just take care of you and it takes a lot of the fear away.” It not only relieves much of the stress, which has significant health benefits, but also allows for more measures like preventative care. And that can lead to a longer, healthier life.

“If you come to a place and you see elderly people walking — by themselves, not in an old people’s home — you know you’re in a good place,” says Jamie. “I see them go in for a chat with their doctor, even if they’re not sick, just to keep this open dialogue about their health because it’s important.”

That said, the system here is not perfect. Many often complain about issues such as wait times, but especially the recent reductions in the national healthcare budget. Signs that say “NO MORE CUTS!” in the form of giant scissors adorn the walls of Hospital Clínic, as well as multiple clinics throughout the region. The pair continues to defend the system wholeheartedly and encourages others to do so as well.

“You can’t tell people in the U.S. what life is like over here,” says Cole. “It’s like that barrier of understanding is wider than the ocean between us. They have no context for imagining that you can just get help because you’re a human and your life is worth more than the money.”

Ultimately, Jamie and Cole’s story is about more than just healthcare. It’s about actual care — and just like love, that’s something you can’t buy, no matter where you live.