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Some Thoughts on Health Care

Everyone had a good laugh when President Trump suddenly announced that “no one knew how difficult health care was going to be” but it may be (unintentionally) the most truthful thing he ever said. Obamacare was a partial solution that reduced the rolls of the uninsured by raising the numbers in Medicaid, creating state exchanges for some, and requiring health insurance for young, healthy individuals who did not want it (or “taxing” them, per the Supreme Court). The Republican’s AHCA is so full of holes in barely merits consideration.

The problems of Obamacare are obvious. Greatly increasing the number of people on Medicaid without increasing the number of doctors accepting Medicaid reimbursement meant theoretical health care, if at all, for many of the poor and sick. State exchanges turned out to be successful as long as federal reinsurance for providers and federal subsidies for consumers were guaranteed to continue to increase indefinitely. And counting young, healthy people as “insured” with a product they never wanted is a unique approach to accounting. So if all this was pretty predictable, why did the Obama administration try it? Why didn’t they go for a single payer option? Federalize healthcare? And why are the Republicans so unprepared to replace Obamacare, if they knew it wouldn’t work and had seven years to prepare to replace it?

“Facts are stubborn things,” as John Adams once said, and here are several facts about health care in America that must be faced directly if we are ever to make any real progress.

Insurance is not health care. Offering insurance where no health care providers participate is a sick joke. This is the challenge of enlarging Medicaid any further. It was also the challenge undermining the state exchanges, where health care providers are leaving because they can’t make enough profit to justify being in the market. Unless you are willing to “draft” our existing health infrastructure into federal service, you have to address the profit motive, and health care supply and demand. Doctors and hospitals (even non-profits) are a limited resource. Those who still desire to federalize health care need look no further than the VA for a probable outcome, and the TSA for a worst case scenario.
More Americans get their health care through their work…still. Many policy types hate this fact, and it does cause the complication that those who lose their jobs also lose their health care. But it is a stubborn fact that can not be ignored, and should not be changed just because it is inconvenient to the good ideas of policy makers. Health care has been, and remains, one of the various benefits employers use to attract employees.
Appeals for empathy are part of the problem, not part of the solution. Attempts to portray any new idea or policy as “killing grandma” simply ensure nothing will change. Hard cases like the “Jimmy Kimmel” challenge are a case in point. To remind, Kimmel’s newborn son had a congenital heart condition who required emergency surgery to survive. He cited this case as an example of the horror awaiting the poor who don’t have their children born at expensive, private hospitals. Perhaps he is unaware of the Emergency Medical Treatment and Labor Act (EMTLA) of 1986, which requires public hospitals to provide life-saving emergency medical care without payment/insurance. So his hard case is already covered in law. Such appeals only provide more smoke and heat, but rarely shed any light.
Americans are unwilling to adopt healthy lifestyles, and unwilling to accept anything that smacks of health care rationing. This is my most debatable “fact,” but one I think most would admit. Too many American’s approach to health seems to be “leave me alone to eat and drink as I like and do no exercise, but be there with a wonder drug when something goes wrong. If things get worse, continue trying to make me better or just keep me alive no matter what.” In some respects, this is like the economic concept of inelastic demand, in that the health consumer wants the best regardless of cost. Unfortunately, this results in poor health outcomes, elevated costs, and a miracle pill mentality.
Insurance is a tool that covers catastrophe, period. The concept is you get insurance to cover unforeseen costs which would otherwise be unpayable. If you try to use insurance for more than that, you are misusing the tool, which will backfire. Car insurance covers your catastrophic loss, or repairs if your car is damaged and unusable. It does not cover fuel, or oil changes, or new tires. These are all good things to have for your car, but not for insurance to cover. Why should health insurance cover routine or non-emergency health care issues?

Here is where those facts lead, pointing to the beginning of a solution:

Accept that many Americans will work, and most will get their health care through their jobs. Do not fight this legacy: treat it as a feature, not a bug. Plug the gap that exists when people leave a job by allowing them to continue their previous insurance at a greatly reduced rate for a period of one year (maximum, not extendable), with the government picking up most of the insurance tab, like a low-cost version of COBRA. This would also facilitate workers changing jobs and careers, which would enhance mobility. The federal government should also establish certain minimum standards for work-provided health insurance, so it does not turn into a bare bones offering which ends up sending workers to emergency rooms for treatment.
Promote policies which increase access to health care. Remove limitations on health care provided across state lines. Enhance tuition assistance for medical professionals, including reimbursing student debt for those who agree to work in high-need areas or accept Medicaid reimbursement. Provide tax breaks to groups sponsoring wellness and walk-in clinics addressing preventive medicine and routine care. None of these is a panacea, but they are a start at getting more points-of-service for more people.
Establish a national, catastrophic health insurance program. Everyone is automatically enrolled, but this is the ultimate safety net for those who are one day healthy and the next day near death, as well as those with lingering, debilitating conditions. If you have private insurance or can afford to cover your own costs, you are welcome to do so. Run it as an offshoot of Medicaid, with strict rules on what is covered and how service is rationed. Yes, I said it, rationed. Even those who laud health care in Canada or the UK must admit they ration care.
Attack health care cost inflation. Limit the opportunity to sue for medical malpractice and the potential damages, perhaps by direct legislation or placing a significant tax on law firms which profit from the same. Slap a windfall tax on excessive profits for health care providers, medical professionals, or pharmaceutical companies; they can avoid this tax by providing low- or no-cost goods/services to poor Americans. Incentivize average Americans to make full use of preventive care by offering a generous tax credit to those who complete a set of routine tests/services (blood test, flu shots/immunizations, blood pressure, physical, etc.,) annually. Consider additional incentives in the form of government payments into health savings accounts for those who address significant health issues (lose 40 lbs, get $ in your HSA). Empower hospital emergency room physicians to reject non-emergency cases; penalize Americans who use emergency rooms for such care by withdrawing their HSA incentives. The emphasis here is to get Americans to try to stay healthy, mitigating future costs for treatment/prescriptions.
Incentivize states to be the laboratories for new health care policies. Given all the preceding recommendations, there are still gaps for people out of work with health care issues that are neither life-threatening or debilitating. Different states may want to address that gap in different ways. Provide states with block grants that reward programs which identifiable health outcomes (not outputs). Encourage other states to copy successful programs, and defund programs which do not produce such outcomes. If California wants to provide single-payer for its residents, good for them; maybe we can all learn something from that.
Bury, once and for all, the notion of a US-wide single payer system. Countries which have such systems are struggling to pay for them, they ration care, and they have poor deployment of innovative medicine. While the existing US system is sometimes described as heartless and Darwinian, it still produces the greatest array of medical and pharmaceutical innovation in the world. The trick is to retain the benefit of such innovation, while finding a way to reduce the uneven access to good health care at a reasonable cost. Single payer is not the way there.

I have not submitted these concepts to the CBO for a cost estimate, but there is much here to chew on, and I believe it could be tweaked to come in at a reasonable cost. The status quo pre-Obamacare was morally unacceptable; the status quo today with Obamacare is financially unacceptable. The Republicans attempt to repeal and replace Obamacare is DOA mostly because they tried to do it through an obscure Congressional process known as “reconciliation” which limits what could be in the legislation. You can not fix a comprehensive issue with a limited tool kit. The Republicans need to leave Obamacare alone, fully funded as-is for the next two years, and start over with a complete re-work. During those two years, the successes and problems of Obamacare will be evident to even the most ardent partisan, and can inform the development of a bipartisan way forward.

More Healthcare, Better News

(Continued from previous post)

On Wednesday I duly fasted and then headed to the clinic. I immediately saw the cardiologist, Dr. Salas, who reviewed my current health and family history. He took one look at my previous ECG and discarded it, saying that device was notoriously inexact. He even showed me on the computer print out where it said left ventricle when the data it showed as abnormal was about the right side of my heart. He told me based on my physical condition, he really doubted I had any heart issue, but he had his own ECG machine with him, so he wired me up and ran the test. He said it looked very normal, with just one reading slightly “off.” He suggested I come up to the hospital on Monday for a stress test, to put the issue to rest. I agreed, and he reiterated he felt confident the test would find nothing.

Next I popped into the surgeon’s office, who gave me another ultrasound. Sure enough, you could see my gallbladder very clearly. It is supposed to be a long oval; mine looked like a pair of connected golf balls. The surgeon told me this was probably a condition I was born with, but the small connection between the two parts of my gallbladder was probably closing from the gunk (my word) that goes through your gallbladder. This was causing the inflammation and other results noted in my blood tests. He said he has seen this condition many times, and most such patients eventually have their gallbladder removed. He said I could wait until I have severe pain, or I could just have laparoscopic surgery anytime. I scheduled the surgery and went home.

It didn’t take long for doubts to set in. I was so relieved by the cardiologist’s demeanor I probably would have agreed to a prefrontal lobotomy. Then I started to research gallbladder surgery, and I learned it is controversial NOB, as so many are being performed. Most gallbladder removal is related to gallstones, which are very painful, but could be treated by preventive measures and lifestyle changes. I had no physical symptoms, just blood work and an ultrasound showing an apparently congenital condition. No one had suggested any diet or lifestyles changes. While the laparoscopic surgery is fairly routine, it is still surgery with a potential for complications. Friends reminded me that doctors here are used to older patients with adequate resources, so there is a tendency to over test and quickly resort to surgery.

I e-mailed my surgeon and asked for a written diagnosis so I could get a second opinion via my insurance, and cancelled my surgery. I will send a detailed e-mail to the Cleveland Clinic, which has a program to give second opinions on surgery for my insurance program.

On Monday, I headed to Guadalajara for my stress test. At the Angeles del Carmen hospital, I met with a cardio technician (Carlos) and a nurse (Edna) who would administer a sonogram and then a stress test induced by Douramine. Basically they hook you up for a sonogram and an ECG, then administer a stimulant through an IV which causes your heart to accelerate up to your maximum heart rate. They monitor your vitals throughout, and constantly ask you to describe anything you feel. It was quite odd to feel one’s heart beating rapidly, without feeling the need to breathe quickly or pant, and while laying completely still. Other than that, I felt fine. It took about 30 minutes total time, and cost 5500 MXP (about $300 USD).

After they gave me a decelerant to get my heart rate back down, I went back to the waiting room. Carlos came out and handed me a portfolio with written reports on all my heart data, an annotated ECG chart, and a DVD with all the numeric and visual data (in case I want to entertain my friends?). I went back to Dr. Salas office, where he reviewed the data. He said my heart is perfectly normal! The unusual result that the earlier ECGs showed is something my heart consistently does, so while it is not textbook, it is normal for me. In my records, I had found another stress test done on me at National War College 20 years ago, and when I showed that to the Doctor, he pointed out even that result was consistent with the current ones. He told me to cut back on bad cholesterol, improve the good type, or he will prescribe statins for me. Other than that, all good.

So in the course of a single week, I went from feeling fine/eating whatever, to sick heart/bad gallbladder, to questionable heart/gallbladder, and back to healthy heart/need better diet. It was quite a ride, and a great dry run for dealing with doctors and hospitals in a foreign land, which is a major expat challenge. Lessons learned: be an educated patient, and research whatever your diagnosis is. Ask questions! Know what the doctors in your area are used to; it affects what they see and how they respond. There is an old adage for medical diagnosis: “when you hear hoofbeats, look for horses, not zebras.” It means look for usual causes first, not unusual ones. But what your doctor thinks is normal will be influenced by where they are and type of patients they see.

Sorry for the long post(s) and the unusual delay, but as you can see, I have been busy. Thanks for all the thoughts and prayers!

The Challenge of Healthcare (and then some!)

So you decide to move to Mexico for the healthy living, but you know that it requires more than exercise, good eating habits, moderation in drink, and adequate rest. It requires good preventive medical care, and if needed, good emergency care. We have been here a few months, so it was time to get started on picking a doctor, dentist, etc.

So the first thing we needed to find was a dentist. We heard good things from other expats about Doctora Candy Ugalde who has a small practice in our town…yes, I know, a dentist named Candy. Anyway, we made an appointment about a week out, and went in for an exam and cleaning. The office was clean with all the usual modern equipment, the staff bilingual and very friendly. We were seen on-time, and the visit lasted about 30 minutes. We did not receive any pressure to get x-rays or

whitening. My dentist, Juan, is Candy’s brother, and he said I will eventually need to get an x-ray, but no rush; when I asked about a whitening, he told me about a discount they are offering, but that was it. Total cost for exam and cleaning for two people: 600 pesos (a little over $30 US dollars). You can see why some expats bring their grandchildren down for dental (orthodontia) tourism. Overall experience: very good.

Before I get to medical care, first I need to explain something about our health care situation that makes us different from the typical expat. Based on my federal service, we have excellent health insurance, based on the US Foreign Service Benefit Plan. It is one of the thousand or so insurance programs offered by the US government to its employees, and it continues to cover us in retirement. This program was initially developed to support US foreign service personnel stationed overseas. As such, it is very familiar in dealing with foreign languages, foreign currencies, and working with customers anywhere in the world. When overseas, the program works on a reimbursement basis (100% for preventive, emergency, and inpatient services, 90% for office visits, surgery, and outpatient services), with all doctors and healthcare providers outside the US considered “in-network.” Deductible of $300 USD each per year. So while we are responsible for paying upfront for care, our health insurance is set up to immediately reimburse us via electronic document submission and direct deposit.

We decided we needed emergency coverage when we are travelling around Mexico, or around the world. Our Foreign Service Plan continues to cover us in these instances, but we wanted coverage that would give us the option to be medically evacuated at our own request (this last phrase is important). Most insurance, even emergency travel insurance, only approves medical evacuation when it is medically necessary, which is a decision of the doctor and the insurer, not you. We wanted a service which left that decision up to us. We signed up with SkyMed, which specializes in coverage for expats, covers our medical stabilization onsite in the event of a medical emergency, and leaves the decision to evacuate up to us. Many expats here in Mexico sign up for such coverage, so that in the event of a very serious condition, they can be evacuated back to the States to get care. Here’s where we differ: we got this coverage so we can be brought back to (drum roll) Guadalajara. We feel the care here in Mexico is so good, this is to where we would want to be evacuated, if we got sick or hurt out traveling in the wider world.

For our family doctor, we chose Doctora Lupita at Integrity Medical Clinic. We had some false starts here. First, we made an appointment one day for the next morning, arrived, and found no record of the phone call or appointment we made the day before. The office called to postpone our second appointment, because the Doctora was having emergency dental surgery (ouch). When we were finally seen, we each had a nice office call with the Doctora, who ordered a standard suite of blood tests. We had these done at the lab across the street, and got the results by e-mail later the same day. Costs were 400 MXP each for the office visits, and a total of 2500 MXP for the lab work, or a total of approximately $230 USD for both of us.

We scheduled to meet back with Dra. Lupita to review our results, and here is where things got interesting, as they say. Judy’s review went perfect, with all normal results across the board. I knew I had a few lab results which were out of the normal ranges, but the trouble started as soon as the nurse came to take my vitals. She took my blood pressure/pulse four times, using two different machines. Any time the nurse asks you “are you having chest pain?” that is NOT a good sign. Then she asked the Doctora to come in and do it again. I felt fine: thirsty, as I had salty foods for both breakfast and lunch, and I had worked out at the gym for 90 minutes before lunch, but otherwise great.

The Doctora said my pulse was racing (over 100 bpm), and she wanted to do a ECG right there and then. They brought the cart in and hooked me up; a few minutes later, she shared my results, indicating left ventricular distress, possible a blockage. She said she wanted me to see the cardiologist in her clinic on Wednesday (two days hence) for another ECG and consult. Oh, and the lab results said I probably had a gallstone; her ultrasound could not confirm it, since I had just eaten lunch, so she wanted me to fast on Wednesday and she would have a surgeon follow up on that, too.

To say I was shocked would be a severe understatement; in shock would probably be spot on! Those who know me know I was a lifelong, daily runner, in very good shape, and rarely had so much as a headache. Since we arrived in Mexico, I even lost a few pounds, took up an every-other-day weightlifting/stretching/stationary bike routine and hiked once a week up the mountains. I never felt better. I just could not square the results staring me in the face with how I felt. I had 48 hours to kill until the cardiologist visit, so I dug up my old records and took to the internet.

First I learned that gallstones and even a ventricular irregularity could be asymptomatic; meaning feeling fine was not out of the ordinary. Gallstones, although painful, looked like the lesser concern: some never end up causing pain, and surgery to remove the gallbladder is practically routine. So I decided to focus on my heart’s ECG results. Amazing what you can find on the internet: full descriptions of how to read one and what it means in laymen’s terms.

Probably the most interesting thing I learned was that an irregular ECG could result from environmental conditions, such as an electrolyte imbalance. I noticed after I returned home from the Doctora’s office that I was very dehydrated, and Doctora Lupita mentioned that some newcomers have poor ECG results due to their heart’s difficulty in acclimatizing to the elevation here (5200 feet). I hung my hopes on this slender reed and prepared to see the cardiologist and surgeon on Wednesday.

To Be Continued…

Goin’ Mo-bile!

A musical interlude, before we commence the blogging:

I know I am too old for teenage rebellion, but there is something about getting a new vehicle which just requires dipping into The Who’s “Who’s Next” album for a golden oldie.

We spent the last several weeks investigating our automobile options. We knew we wanted a new car, as my Toyota FJ is 11 years old, can not be nationalized for Mexico (damn that NAFTA), and is a hot deal on the stateside resale scene.

The new-car buying experience is similar between Mexico and the States. You work with dealers, in big showrooms with lots of salesmen, and they offer a standard suite of models with trim/option packages. So far so good. Now for the differences.

New car prices in Mexico are set by the manufacturer on a monthly basis and are uniform across the country. No haggling, no imaginary MSRP, no “INSANE” labor day sales. The only way you can change the total price is by varying the options or by using dealer provided financing (which is relatively new here). This is nice, since we didn’t need to wonder whether the dealer across town had a better deal.

At least in our area, the dealers were all in Guadalajara. In the States, it seems like every small town has a few car dealerships, who are often big fish in the local business community. Does not seem to be the case here. And that’s important, because in Mexico, when they say “you should use the dealer for all maintenance”, what they mean is “…if you want to maintain your warranty.” That’s right, any unauthorized (i.e., non-dealer) maintenance, or any missed maintenance, VOIDS your warranty.

What happens when the grass is greener on the other side of the road?

Now you may think that the warranty is not a big deal, but maintenance is a major factor in your Mexico driving experience. Roads here vary between normal pavement to cobblestones to dirt streets, often with massive potholes, accompanied by roadside livestock, cyclists and mopeds which pass on all sides, and of course, random pedestrians. Even if you are very alert, you’ll face the ultimate Mexican driving challenge: the topé.

Topés are a cross between speed bumps and the Czech Hedgehog. In place of frequent police radar traps, these silent sentries pop up everywhere to slow you down. Sometimes they are a series of rumble-strips on steroids, or metal bumps which rattle your frame, and the always popular undercarriage scraping raised platform. Sometimes they are foreshadowed by warning signs, sometimes not. Sometimes old, worn

topés are left in place, and they no longer work, but you don’t know that! In general, the poor roads, erratic traffic, and topés = double your maintenance costs.

Sorry, topés brought on a rant, back to cars: dealers here don’t seem to be the cutthroat experience of the States. Apparently sales staff are NOT paid on commission, and are not necessarily expert on their product. Just-in-time inventory is not quite. We went to one Subaru dealer who was selling still new 2016 models because they had not received any 2017 models, and yes, this was as the 2018 models were coming out! When we asked about the turbo option on another car, we received the following answers: yes, no, never, of course, and finally, yes. Yes was correct.

We were looking for an SUV, and preferably a manual transmission with a sunroof. This is the unicorn of new cars, and we quickly realized we needed to compromise. Like in the States, manual transmissions are less than 5% of new car sales, and generally not even available on most models. Now if you know me, you know I love my manual transmission, but it was clear that requirement needed to go. Judy had a 2008 Subaru with a continuously variable transmission (CVT), but that really did not satisfy in the acceleration department. We did research, and learned that the CVT’s had become much more responsive; I also ran into Volkswagen’s dual clutch transmission, which intrigued.

We test-drove the Hyundai Creta, Kia Sportage, VW Tiguan, and Honda HRV. We found some models did not have cruise control (?), or lacked a turbo, which we found necessary for automatics. It came down to the Kia and the VW, and we ended up selecting the VW. There was only one left in stock: a special edition Wolfsburg.

We were taken on our test-drives and met with the dealer’s/sale staff accompanied by Spencer Shulman, who runs S&S Auto, a local car retailer who also serves as a buying-service for expats. Spencer also completed all the paperwork, helped us transfer money to the dealer (all electronically), got the car registered and plated, and delivered it to us. He will also assist us getting all the maintenace done. He was also invaluable in explaining how dealerships work here, what is and is not available.

You’ll see us driving our VW with Jalisco plates back in the States sometime. We’ll be passing you, maybe even on the left!

Czech Hedgehog: I hope the Mexican government never learns about these!

Observations on Daily Life II

My second set of observations on expat culture here in Mexico may have as much to do with being retired from Washington DC as anything else. Let me explain.

Washington DC may be the nation’s capital, but it is also the “type A” capital of the world. The DC metro area is full of very highly educated, very dedicated professionals set on making a difference. Everybody is in a big hurry, and few people suffer fools lightly, if at all. Making policy is the name of the game, and it is a competitive business. There is a degree of insularity which resembles that of a company town, but in the big-city way that New York is a company town for fashion and business, or LA is one for entertainment.

In social situations in DC, I found it generally took about a minute for the “what do you do?” question to come up. Being at a social event was like speed-dating: 30 seconds to make a determination whether the stranger you just met was important or interesting enough to talk to. Even people who retired in the region tended to keep “in the game.” Former officials kept their titles, and were understood to be waiting the next round of administration changes to get back “in the game.”

People really seemed to identify who they were with what they do/did. (Note: I am told by friends from NY and LA it is the same there…sigh)

Fast forward to retirement and move 2400 miles southwest.

This picture has nothing to do with this topic, but I liked the view of Ajijic

Here, I know how many kids/grandkids people have, where they have traveled, what pets they have, or where their favorite seafood restaurant is. At most, I hear something like I was a teacher, or a banker, but rarely any details. There are a few folks who take “border promotions,” meaning they now claim a more prestigious job title than they actually had. But in general, nobody cares. Partly that’s because what you used to be is irrelevant to your identity as an expat. Partly it is because our (collective) circumstances are so different, what we each have the most in-common is our commitment to live the expat lifestyle. That first conversation between new expat friends is inevitably about something you like to do.

Unlike the increasing trend in the States to live among like-minded people, expats end up being thrown together socially, if not literally. If you live in a gated community, there might be some less mixing, but the property costs may be low enough that it is still not as extreme as NOB. If you live out among the locals, you’ll quickly notice that most properties have a high wall, and behind that could be an enormous hacienda or a series of tents, all in the same neighborhood!

Out socially, expats do tend to flock to certain restaurants and bars, but not segregated in any way. As an expat, you’ll acquire friends from all political stripes, from anarchist-to-nationalist. You’ll meet libertines, libertarians, librarians and Rotarians. While most of these folks have settled views that aren’t amenable to change, the fact we are all strangers-in-a-strange-land makes everyone just a little more accepting. Oh, if you want a debate, you can get one on any topic, but there’s a sense that you don’t push arguments too far here: no sense “harshing the mellow” in paradise.

I would like to think being among the Mexican people has something to do with it, too. They are among the most easy-going, friendly, and welcoming people on the planet, and that has to rub off on the expats. Even with all the vitriol during and after the recent US election, which offended the Mexican people’s pride, I have not heard a harsh word directed at the expats. As one local told me, “we (Mexicans) are used to crazy people in charge, you gringos not so much.”

The DMV

The last stop in our normalization process sent us to the offices of the Secretaría De Movidad, the Mexican equivalent of the Transportation Department, which also runs the equivalent of the stateside DMV, or the BMV, depending on where you live. Wherever you live, it is a visit most people dread, since the bureaucrats who process drivers licenses are universally considered some of the most inept and/or incompetent on the planet.

(Note: not intending to insult any of my former state and local government colleagues; just making an observation. While I am on thin ice, may I take a moment and request that my Washington, DC-based friends join me in fighting the use of the phrase “the Dee-Emm-Vee” to refer to the Washington metropolitan area? I hear it with increasing frequency on local radio and TV, and it needs to be crushed as quickly as possible. It is Washington, or DC, or NoVa if you live on the correct side of the Potomac. Why would anyone want to borrow such an odious acronym? What’s next, a new car called the Edsall? A new dirigible called the Hindenburg?)

Sorry, end of rant. The SDM complex is in Guadalajara, and we arrived on a recent Tuesday after the long Semana Santa holiday. That detail is important, since the government offices had been closed for two weeks, creating much pent up demand for licenses. We entered the building and got in a long line, which naturally stretched out into a central courtyard under the tropical sun. The line crept forward, about ten people at a time. A man with an official looking lanyard was giving advice on the testing procedures, and offering to sell a quick look at “sample” test question for a few pesos (free-marker capitalism at work). After about an hour, we worked our way up to the first guard official, who was controlling access to the office.

When he let us pass with a cursory glance at our paperwork, we were in the entrance hall, where four officials were set up to review our paperwork. They ensured we had a valid visa, copies of our passports and US drivers licenses, and a bill or other document attesting to our current address in Mexico. When they approved, we were let into the main office through another guarded doorway.

This room held about 70 plastic chairs which were numbered, and we were directed to take a seat at the very back. One at a time, the applicant at the front of the room was called forward to the next available official, and the rest of the room got up and moved forward one chair. This went pretty quickly, and within 30 minutes we were being processed, but the musical chairs approach was a sight to behold. According to Francisco, who accompanied us through the process, they used to give out numbers, but people would pay others to get a number for them, so they made it a more physical process. I will admit it was quite orderly, and even when too many people were let in the room by the gate guards, everybody quickly re-established the queue.

Once we were called forward, a nice official took our paperwork and entered it into the computer system, then had us verify it was correct. We were asked our blood type, whether we wanted to be organ donors, and what was our current phone number. Next we went for photographs and fingerprints, which took about 5 minutes, and soon we were in line for the written test.

Most of the people getting their first licenses were very young. If we had been 60 or over, we could have skipped all the waits and gone straight to the front of the line, but we waited with the young people. We had some fun conversations with Mexicans who spoke excellent English and had been through the same process in the States. Finally, our turn to test came up.

In the testing area, my wife pointed out the “No cell phones” sign

The written test is just ten questions on a computer kiosk, but you must answer all ten correctly. Make a mistake, and you either have to take a training course or come back to retest in two weeks. They show you a video or a road sign and give you three choices for what you should do, or what the sign means. We asked for the “examen en ingles” and both Judy and I were routed to kiosks for the gringos where we were supposed to get an English-language version.

The key word here is “supposed,” because we were dealing with computers, so of course, things started to go wrong. On my computer, one side of the screen read “El pregunto no requiere un imagen.” The other side had three answers, in English. Hmmmmm. It took me a minute, but I figured out that the left side said “No image was required for this question” but how was I to answer without a sign or question? When the official initialized my test, he simply hit the forward button, so I tried that. Now I was on Pregunto Dos, with the same “no image” on the left and three new answers on the right. Not good. I hit it one more time, and of course, the same result: Pregunto Tres, new answers.

I looked up from my kiosk (a no-no) and saw Judy with a similarly perplexed look. We gave each other a shoulder shrug. We could not talk, nor could we get the attention of the officials who were administering the test. Judy later told me she decided the “test” was fixed, so she started hitting any answer just to get through it. I started waving my hands over my head and said “Una Problema!”

This got the official’s attention, and he was none too happy, not so much with me, but at the distraction from his well-planned administration of the test site. He came to my kiosk, grimaced at the screen, then started re-initializing the test and downloading the English language images (a-HA!). I pointed at Judy, and he went to her kiosk to effect the same fix. However, I was still on question three! So I dutifully answered the rest of the questions. The screen told me I got seven out of ten correct, and the test was done. Oh-oh.

Once more outside, waiting for the final call

I got in line to see the official proctoring the test, and when my turn came I started to explain “only seven questions” but he waved me off and said “no, no, ok.” He stamped my form and sent me on my way; Judy got the same treatment. Somehow we “passed.” We got in line for the driving test, where a name check and our US licenses got us past the requirement. Now we just had to pay at one window, then wait about 40 minutes at the second for our final license.

All told, about four hours, not including travel time. Francisco, who we retained to assist us, was able to accompany us throughout (except at the test kiosks), which greatly improved the experience. It was a typically Mexican experience, with high and no-tech abiding side-by-side, long lines but orderly movement, and everybody invariably polite. We just heard the Mexican government is introducing an online registration system that will reduce the experience to just the written and driving tests, so perhaps we experienced this particular bit of Mexico just before it passed into history.

What we do all day, Part I

One retirement activity we were looking forward to is hiking. A couple can hike together, you can do it at any age and ability level, and it is amazingly good exercise. We had already decided to eventually hike the Camino Frances to Santiago, Spain, next year. So in the meantime, we joined up with the local hiking club to hike the mountains surrounding our lakeside home.

While long-range hikes require a lot of planning and special gear, day hikes don’t require much beyond good hiking shoes. Our local club gave us two makeshift hiking poles, and of course we already had the necessary water bottles, hats, and sunscreen. But all we had for our feet were running shoes, which only work for long flat hikes.

That led us to the Merrell store in Guadalajara to get good, lightweight hiking shoes. The store, set in a mall, was a little underwhelming. The place was tiny, and the staff did not seem to have any expertise in hiking. We had done research, and seemed to know more than the sales staff, who did not even have a device to measure our feet.

Using our limited Spanish, we were able to make our needs known, but it quickly became apparent this was going to be complicated. First, we had a challenge about shoe sizes. We knew our US shoe size, and the Merrell shoes have sizes listed in US, EU, and CMs, so this should have been an easy translation, but they had almost no inventory in our size for the shoe we wanted. Mexican feet run smaller, apparently.

We looked at other models, but they had no women’s shoes large enough for Judy. Mexican women’s feet run even smaller. So we were both looking at the men’s selections. As I asked for various sizes to try on, my poor Spanish confused the staff about whether I was asking for US, EU or CM sizes, so I was getting a random selection of sizes. I built up a pile of rejected shoes next to me as I waited for the next offering from the shoe lottery. Eventually we both found acceptable hiking shoes. We almost left without buying Merino wool socks (a must!) because the sock display was turned toward the back wall, where customers could not see it.

Back home we started meeting with the hiking club, which heads out from the local donut shop (no kidding) every Tuesday and Friday at 9:00 am. The club informally breaks out into a beginner’s group (usually a 2-3 hour hike on a trail up the mountains), an intermediate group (4-5 hours, sometimes on less improved mountainside trails). Some real hard-core types go off in a group for really long hikes to make new trails or clear old ones.

Here are shots of the flora along the trails; lots of prickly things!

In addition to exercise, the hikes are a great way to meet other expats or visitors, see great lake vistas, and learn a little about our unique environment. Sometimes we hike trails in ejido land, land given to the indigenous Mexican peoples during the early 20th century land redistribution. It is often on the mountainsides, with little or no access or infrastructure. Local peoples still clear it, farm it, graze cattle on it, and sometimes live on it. We have had to share the trail with dogs, horses, and even cattle, who seem as surprised to see us as we are to see them!

See that little chapel at the top of the photo? Been there, done that.

Semana Santa

Holy Week, as it is known NOB, is a whole different enchilada here en Mexico (pun intended). First off, the holiday comprises two weeks, Semana Santa (Holy Week) and Semana Pascua (Easter Week). Second, it is the official vacation season in Mexico: schools close, the government shuts down, and Mexicans head to the coast or their favorite colonial cities in the mountains for a break.

To put it in an American perspective, Semana Santa is like Easter, Labor Day, and Spring Break combined. The emphasis on Holy Week may not surprise you, given that Mexico is an overwhelmingly Catholic country. But it is not only that; it is also the fact that Mexico is a Catholic country with a connection to a Latin (i.e., Spanish) heritage that helps to explain the importance of this week.

Party in the square, branches in the street

Semana Santa officially begins on Domingo de Ramos (literally, Sunday of Branches, aka Palm Sunday). Here in Ajijic, there is a festival in the town square starting at 4:00 pm and running into the evening. Volunteers provide all the goods for sale, do the cooking and cleaning, even provide the bands for entertainment. We enjoyed the bands and the tostadas, pozole, and tamales, all home-made. All the proceeds go to cover the expenses of the annual passion play, which are considerable. The highpoint of this day’s activity is a procession which starts at the end of town and proceeds past the square to the Church for a 7:00pm mass. Townfolk line the procession route and cover the cobblestones with alfalfa; actors playing the parts of Jesus and the 12 apostles lead the procession through town and into Mass.

The next few days are quiet, leading up to Maundy Thursday, or Jueves Santo. After a re-enactment of the Last Supper, the crowds move up a steep hill overlooking the town for scenes from the garden of Gethsemane. This location will also serve as Golgotha on Good Friday (Viernes Santo). The night ends with Jesus’ arrest and a torchlit procession to take him back to the church square for his trial the next day.

…looking closely, you can see three post holes!

The theatrical quality peaks on Good Friday morning. Crews erect an impressive stage and backdrop, which is modified ingeniously between sets to portray the outside of Pilate’s Palace, Herod’s palace, and back to Pilate’s palace. A crowd of locals fill all the Passion play roles, from Roman guards to the Apostles, the Sanhedrin, and even human statues. The dialogue, costumes, and sets represent a significant commitment in terms of time and money, all done by volunteers.

Pilates palace with balcony and porticos

“Ecce homo!” (note the human statues behind Pilate)

Quality sound and light-systems and special effects complete the scene. The most surprising thing about all of this is it is staged by a small Mexican village, and it is only one of many Passion plays staged in our area (Lakeside)

Locals consider it a high honor to be chosen to participate. The day concludes with a Via Crucis (Way of the Cross), as Jesus carries his cross back up that steep hill for the crucifixion.

Sábado Santo (Holy Saturday) is the grand finale; the day is mostly quiet until the vigil mass of the Resurrection (with a re-enactment, naturally) in the early evening and a large festival afterwards. The festival includes la quema de Judas, where Judas effigies (including fireworks) are set alight. Sometimes unpopular political figures are also burned/exploded, all in good fun.

Like many holidays in Mexico, Easter Sunday is quiet time to spend with the family, or to recover from the vigil parties. If you are ever in Mexico during Holy Week, do brave the sun and the crowds and enjoy a Passion play experience for yourself.

Hope you enjoyed this overview of Semana Santa, and Happy Easter all!

You have to find “the guy”

You don’t go on the internet to get something done in rural Mexico. You certainly don’t look for advertising in a paper or on TV. I have never seen a Mexican phonebook.

No, when you want to get something done, you tell a friend, and they tell you about “the guy” they have to get it done. Now I know you’re thinking “that’s no different than in the States” and to some extent you’re right. Back when we lived stateside, we had a go-to mechanic and a guy who did home repairs. But for most things, we could do a search, use Consumer Checkbook, the Better Business Bureau, even Yelp for good tips.

Mexico, at least rural Mexico, is very much a word of mouth society, and it works. We have a “guy” for just about everything… even though many of them are “gals.”

Julia Vargas and her associate Francisco have guided us through the immigration and visa process, and we’ll work with them to get our Mexican drivers licenses next. Working with them, we avoided long lines, paperwork mistakes, and all the potential hassles one could encounter when dealing with any government bureaucracy.

Christina Peña is our interior designer, arranging for all the purchases to equip our new home, and even driving us to Guadalajara several times to visit the various carpenters, artists, plumbers, etc. we needed to see. We

Marcos with Christy and our new headboard

never would have found the places she took us to shop and outfit our home, and in some cases, if we had found them, we would not have been let in, as they don’t market their wares retail.

Marcos oversaw the building of our house, and we ask him back to consult when we make any changes. He has been responsible for many of the handyman services involved in complex installation.

Georgina Russell is our property manager, making sure our taxes and dues are paid on time, arranging for our gardener and house-keeper, and watching over the place all those years before we even moved here. She also advises us on maintenance issues and watches out for us in general.

We just met with Spencer Shulman, who serves as the middleman when dealing with all the new car dealerships in Guadalajara. New cars here are “set-price” but there is all the paperwork that goes with licensing, as well as the requirement to have all servicing done by the dealer, which his office can facilitate.

We’ve gotten tips on where to meet the “vegetable guy” for fresh produce from a local farmer, the “coffee guy” who comes to town a few days each week with newly harvested beans, and the “steak guy” who sells filet for a few dollars a pound.

When I needed a special type of masonry screw, I even got a tip for the “screw guy,” which could have lead to many different types of places, but eventually got me to a hardware store. 🙂

Tile over concrete on a brick skeleton: sturdy!

Some of these services are “pay-as-you-go” at the very low local labor rates. This replacement job on our shower (along with installing the aforementioned headboard) lasted several hours across two days and cost us about one hundred dollars.

Some of the more selective services are retainers, with a fee based on what you purchase or which services you use. Again, rates are very reasonable. Can you process your own visa? Yes. Can you buy furniture and art on your own? Yes. Could you replace your own shower? Yes. What you are buying in each case is local knowledge and expertise. You are paying someone to reduce the friction, either because they know how the shower was constructed, or they know how the immigration office works, or they know which woodworker makes the exact table you want.

All of these services work to make the challenge of becoming an expat that much easier. But they are also part of learning how things are done here, by “the guy” or “the gal.”

Breaking Good

So yesterday, Judy and I went from “in-process” to owners of genuine Mexican government-issued visas, aka green cards. We were notified by Francisco, who we retained to shepherd us through the immigration process, that our cards were ready for pick up. We dutifully headed to the nondescript INM office in nearby Chapala and joined a gaggle of expats queuing up out front before the 9:00 opening time.

When the office opened, we all shuffled in; we were #16/17 in line. The queue was established by writing your name in a giant notebook at the front of the small office, which looked like every other bureaucracy waiting room in the world. Queue discipline was enforced by a stern-looking gentleman in a guard uniform who called out the names one at a time, kept a stray dog from entering the building, controlled the remote for the waiting room TV (we watched “Hoy!”…you guessed it, “Today!”), and occasionally shouted “Silencio!” when the crowd got too rowdy. We were out in under an hour, after signing for receipt of our cards in another giant notebook. The women who processed our applications did have and use a computer terminal on the counter, but the queue process and receipt were pure analog.

As I mentioned in a previous post, I applied for a residente temporal visa and Judy for a residente permanente visa. Let’s start with the latter. As the title “permanente” implies, Judy has permanent status in Mexico as a resident alien. She never has to apply for, pay for, or further adjust her status in Mexico (unless they change their laws, but in general, when they do, they grandfather your existing residency status). She can freely leave and return to Mexico as often as she likes, and whenever she crosses its borders she uses the same lanes that Mexican citizens use. She cannot vote in Mexico, and she remains a United States citizen. She cannot engage in Mexican political activity (a big no-no), although she could remain politically-active in US politics (but why would she?). She could work in Mexico (but why would she?). She can get a Mexican driver’s license (in addition to her US/Ohio license), buy/sell property, own and register a Mexican car, and buy/keep a (single) gun (but why would she?). One note: as a permanente, she cannot drive a foreign-plated (i.e., US) car in Mexico, so my FJ is off-limits.

I applied for the residente temporal, which has mostly the same privileges and restrictions, except it is only good for a set duration (annual up to four years) and has to be renewed. I have a one-year visa. One advantage of the temporal is it has lower income/resource requirements (i.e., you have to show you will not be a drag on the Mexican economy if you apply for a temporal or permanente, but the latter has higher minimums). The application costs almost as much as a permanente, but the permanente is a one-time cost, while the temporal is recurring. Probably the biggest single difference is since a temporal visa holder is theoretically only visiting Mexico, the temporal can own/drive a foreign-plated car while in the country. This was the main reason driving us (pun intended) to choose the mixed visa route: I could load/drive down the FJ and take it back to the States later for sale. I cannot sell the FJ in Mexico: but why would I, as the resale market for FJs is pretty hot back in the States.

So with our newly-minted green cards, we’ll next undertake our single largest purchase since arriving in Mexico: a new car. I will update y’all on how that compares to the “thrill” of car-buying in the States in a future post.

Poor resolution is intentional; don’t want to enable forgery (old habits die hard)