How is Healthcare Different Outside of America?
After living in the U.S. for most of our lives, we now live internationally. What's changed in our health and dental care?
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In late 2017, Michael and I left America to travel the world as digital nomads, planning to live in lots of different countries. We had many questions about many things, but one of the biggest was: What are we going to do about healthcare?
After all, we’d spent most of our lives in America. We had no idea how medical care worked in other countries.
Seven years later, after seeing doctors and dentists all over the world, many of our questions about healthcare have been answered.
But others still living in the U.S. have the same questions we had back then. Plus, a lot of non-Americans might be curious about how things work in the United States. Is it as bad as people say?
That’s what this article is about.
Be forewarned: I’m making generalizations.
That said, as different as healthcare can be between different countries, I’ve come to believe there is more of a difference between healthcare in America and healthcare in most of the rest of the world.
America is one of the world’s only developed countries that doesn’t have some kind of “universal” healthcare. The U.S. system is regulated by the government, but it’s private and for-profit, financed by a combination of public and private sources, including insurance. For non-seniors, healthcare is usually connected to your place of employment. The Affordable Care Act (ACA or “Obamacare”), passed in 2010, was a huge step forward for fairness and universal access, but it didn’t fundamentally change the system.
America’s healthcare system is fragmented and extremely complicated, which is part of the reason why it’s the most expensive in the world: generally, healthcare costs are about twice what they are in similarly developed countries — and individual costs can be far higher than that. (But despite all that extra spending, healthcare outcomes in the U.S. are arguably much worse.)
Full disclosure: I’m not an expert. I’m just a guy who lived in America for most of my life, and now for seven years, my husband and I have lived all around the world.
This is why I decided the best way to illustrate the differences between healthcare inside and outside of America was to simply describe the various procedures the two of us have had in America compared to similar treatments we’ve had elsewhere.
Here are a couple of important things to keep in mind:
On average, Americans are much wealthier than the rest of the world. In short, what’s “inexpensive” for Michael and me is not necessarily cheap for locals.
Every country we’ve visited has a two-tiered medical system: universal or near-universal healthcare for locals, usually a public system, and a better, private system for wealthier residents and tourists. We are fully aware that as “rich Westerners,” the healthcare we receive is not the same as what most of the locals get.
For insurance, we use Genki Explorer travel insurance for our international healthcare, and in case either of us ever has a serious, chronic health issue, we keep a subsidized ACA policy back in the U.S. Here is a longer explanation.
Also, I recently wrote about my experience with “medical tourism” in Istanbul Turkey.
And now, on with the case studies!
Skin Cancer Treatments
In America
In 2017, before we became nomads, Michael had a suspicious lesion on his face, but he needed to see his primary care doctor at our healthcare provider, Kaiser Permanente, to get “approval” to see a dermatologist. The dermatologist ($20 USD co-pay) confirmed it was cancer and recommended surgery. Michael then had a video conference with the surgeon. The time from when he first saw his primary care doctor to the surgery itself was seven weeks, even with Michael pushing hard.
We’re self-employed, so we were insured through the online ACA exchange. But even with a “silver” plan (and a combined $16,000 USD annual premium, pre-subsidy), our deductible was very high, and no one would tell us in advance the cost of Michael’s treatment.
Post-surgery tests confirmed Michael had basal cell skin cancer, and our out-of-pocket costs (deductible plus some incidental expenses) ended up being $6500 USD.
Michael was told to get annual skin examinations for the next five years, and he had the first two done in the U.S. back when we were there for visits.
It was always extremely difficult to get dermatology appointments, and he had to schedule them months in advance. Those examinations were always very brief: the doctor would spend less than five minutes examining Michael, and he had growing suspicions about the quality of this care. Since we were now on a more limited “bronze” plan, these co-pays were $40 each.
In 2021, I too had a dermatologist examination in the U.S. and had several spots burned off the top of my head. My out-of-pocket cost was $700 USD. My entire visit also lasted, at most, five minutes. I’m not sure I ever actually made eye contact with the doctor.
Outside of America
It got so difficult to make his annual dermatology appointments in America that Michael skipped one year altogether. He then started seeing dermatologists outside of the country. His most recent check-up took place in Bangkok in 2023, in conjunction with an overall, full-body health check-up we both had ($95 each — the most thorough check-ups we’ve both ever had, by far).
After that general check-up, Michael was able to see a dermatologist that same day, with no advance appointment necessary. The examination was incredibly thorough, lasting about thirty minutes. Since it was not “emergency” care, we assumed our travel insurance would not pay, but we hadn’t met our then-$50 deductible anyway, so we paid the full $40 cost out-of-pocket.
Last month here in Fethiye, Turkey, Michael noticed another spot on his face and made an appointment with a local dermatologist via the AirDoctor App that comes with our new travel insurance, Genki. Michael met with the dermatologist the very next day, and then the surgeon the day after that. They recommended the lesion be removed.
It took three days to get approval from Genki, which covered everything, and the surgery took place the day after that. The total cost was $2400, but we only had to pay our Genki deductible of $55.
Here it should be said: unlike in America, the Turkish surgeon did not offer “Mohs surgery,” which is done to reduce scarring, and Michael didn’t think it mattered, since his lesion was so small. But the resulting scar is larger than he expected.
A few hours after his surgery, Michael thought he had a problem with his stitches. He visited the emergency room at the same hospital and was seen immediately. The staff examined his incision, determined there was no problem, and rebandaged him. There was no additional charge, although he did have to pay $3 for an antibiotic cream.
Meanwhile, back in Bangkok in 2023, I had my own skin problem: a rapidly expanding mole. SafetyWing, which was our travel insurance at the time, refused to pay for any treatment, even the initial examination. The doctor recommended removal, and it involved four stitches. All told, we paid $850 out-of-pocket.
Two months ago, in Valencia, Spain, I had several more concerning skin lesions. I contacted a local dermatologist, waited a week for my appointment, had a long consultation with a full-body, twenty-minute exam, and then was immediately led to a surgical room, where I had two lesions taken off in a minor procedure (scraping, no stitches). The full cost of everything, including lab tests and prescriptions, was $160, of which Genki paid for everything except the $55 deductible.
The Rabies Vaccine
In America
While visiting the U.S. in 2020, we were out walking at night, and I was brushed by a fluttering bat. Since this was such unusual bat behavior, an online rabies helpline recommended I get the rabies vaccine. We were in Colorado, not our home state of Washington, but our healthcare provider, Kaiser Permanente, has offices there. Even so, Kaiser Permanente is apparently a different entity in each state, and I spent many hours on the phone trying to coordinate between them.
Seriously, this can not be emphasized enough: I probably spent a total of six hours waiting on hold on various phone calls, trying to get answers to my questions. It was Kafkaesque, and I alternated between tears of frustration and rage. And no matter how hard I pushed, no one would ever tell me anything about what it would ultimately cost.
Finally, I got authorization to see a doctor, who gave me approval for the vaccine. I needed a series of seven shots over two weeks, but the vaccine was only available at certain locations. There were long wait times everywhere (but, admittedly, this was mid-Covid).
At the time of the final shot, Michael and I had planned to be in the neighboring state of Montana, but we were told that the only way for me to get my last shot there would be at the local emergency room, and no one would tell me what that single shot would cost either. After more pleading on the phone, someone finally said, “At least $2500, maybe more.” This wouldn’t be covered by my insurance.
Stunned by the price, we opted to stay in Colorado for the final injection, eating the cost of some of our Montana lodging. A month later, I finally got the bill for all seven shots from Kaiser Permanente: $6500, of which my ACA insurance required that I pay $980.
Outside of America
Not long after I was brushed by that bat, a good friend in Mexico (who uses they/them pronouns) was bitten by a stray dog. They went to the local hospital and immediately started the series of shots for the rabies vaccine.
The total cost for all the shots was $400. Their insurance paid $350.
Our Dental Care
In America
When we lived in America, we had dental insurance that cost us a total of $85/month (or $1020/year), and this paid for two annual cleanings, with discounts on other procedures. I wear a nightguard, and Michael wears a retainer, and we replace both every few years for about $300 each — paying 50% of the $600 total, the other half paid by the insurance.
Because it was insurance, we could only go to certain dentists, and we never felt like any of them were top-notch.
After we’d started nomading, we once went to a highly recommended dentist back in America for cleanings and full check-ups, and we did get what seemed like excellent care. But it cost $700 for the two of us.
Outside of America
I have issues with plaque build-up, so we get cleanings every 4-5 months. The cost of a cleaning and examination is now usually somewhere between $20 to $50 each, which comes out to a total of about $220/year for the two of us (including occasional x-rays) — $800 less than the cost of our old American insurance for more cleanings.
We’ve both had our mouth pieces replaced twice now, and the cost has always been around $50 each.
As for the care itself, it’s ranged from absolutely fantastic (in Romania, Serbia, and Georgia), to decent (in Mexico, Thailand, and Turkey), to borderline-scary (in Bulgaria, Vietnam, and another place in Mexico).
We find dentists via recommendations from friends, other nomads, and local expats. Sometimes we use Google and carefully peruse the reviews. But the system obviously isn’t foolproof.
The Bottom Line
I was very clear at the beginning that I’m not claiming that our “rich” tourist healthcare is the same as what the locals receive. But we’ve also asked a lot of local friends what they think of their healthcare.
In poor countries like Bosnia and Bulgaria, the locals have told us their healthcare is terrible.
In wealthier countries like Spain, Thailand, and Turkey, they’ve said, “Well, it’s not the healthcare you tourists receive! But it’s not too bad, and it’s free.”
(Yes, I know their healthcare is not really “free.” These countries just pay for it via their taxes.)
And in fully developed countries, the locals say about their healthcare: “It’s pretty good” — except for the U.K., where the locals say their healthcare used to be decent, but after recent Tory budget cuts, it is now terrible.
Incidentally, we don’t feel guilty about getting better healthcare than the locals, because the “high” prices they charge tourists like us help subsidize healthcare for everyone else.
My final takeaways:
We’re extremely happy with our nomad travel insurance — Genki — which pays even for things we don’t expect, and reimbursements have always been a snap. We were much less happy with our old provider, SafetyWing.
While the 2010 Affordable Care Act improved many things about healthcare in America, the overall system is still deeply dysfunctional and outrageously expensive.
The healthcare we’ve received outside of America has been about three to ten times cheaper (even after insurance) and, frankly, it’s usually been much better too.
P.S. How would I reform America’s healthcare system? Part of me thinks it’s now essentially impossible, because it would require that corporations make a lot less money and that most doctors become merely upper middle class, not multi-millionaires.
P.P.S. Michael and I have a lot of problems with skin cancer, don’t we? And we’ve always worn sunblock religiously — even though I absolutely hate the stuff. Go figure.
My other nomad/expat health insurance articles:
Who Has the Best International Health Insurance: SafetyWing or Genki — or Someone Else Entirely?
Which is the Best Travel Insurance: SafetyWing, World Nomads, or Genki?
Is Genki a Good Health Insurance Option for Nomads and Long-Term Travelers?
Brent Hartinger is a screenwriter and author. Check out my new newsletter about my books and movies at www.BrentHartinger.com.
The lack of price transparency in US medical care is a major issue! And all of the rigamarole of whether a doctor is in network or not etc. I had to have retina surgery two years ago. There was only one doctor less than a 45 drive through horrendous traffic in my “network”. The wait in his office was 4+ hours—ex. appointment at 1:30, see the doctor at 5 or 5:30, and he was only in the room for 5 or 10 minutes. every time I went. It was miserable! This was after going though everything, even setting up a surgery date, with another doctor only to find out the day before surgery he was tier 2 (vs. preferred), even though the other docs in his office were preferred (but not accepting new patients) on my network and the procedure out of pocket would be in excess of $20k, though no one could give me an exact cost (after multiple hours on the phone) because the doctor, anesthesiologist and surgery center all billed separately! Anyone who wants to understand why Americans are fed up look should at our healthcare system! It is definitely at the top of the list of our frustrations.
Thanks for sharing these detailed impressions and recommendations! Even though you call them “generalizations” it is still much more nuanced than most Americans who default to either “healthcare in other countries is AMAZING with NO downsides!” -or- “healthcare outside the US is a dystopia of death panels and horror.” Also appreciate you acknowledging that the experience and prices of tourists is necessarily different than locals.
I am curious if and how much your recs would change for people permanently moving as ex-pats compared to long term tourism?