<— Read Chapter 11: Tackling the Overwhelm of PreparingRead Chapter 13: Lack of Continuity while Traveling Full Time —>
No matter how you look at it, healthcare, and specifically health insurance, is a headache. The US healthcare system, for all of its advancements, is painfully expensive and a complicated mess.
Things may be getting a bit better, or at least changing, with the Affordable Care Act (ACA – aka ‘ObamaCare’).
The challenge is magnified for the self-employed, and for people without a fixed home. Which makes healthcare an extra challenge for us working aged, often self employed, nomads.
This article is geared specifically towards US based working-aged nomads who are not eligible for Medicare or Tricare benefits, and there is a strong intention to keep this chapter non-political.
The healthcare problem for nomads
The US health insurance industry has grown from a foundation of locally negotiated contracts between insurers and providers, and there are very few provider networks that are extensive enough to be considered nationwide.
Many healthcare plans don’t even cross county or state lines due to different accreditation processes and regulations that vary from state to state.
This localization presents a unique problem for those who are mobile.
Nomads must shop carefully for plans that have access to a provider network that are in locations they are most likely to travel. And they should pay specific attention to what a plan’s dectuble for ‘out of network’ services will be, as they stand a higher likelyhood of needing to access care while away from a provider within their network.
Some nomads specifically will shop for the lowest premiumed health plan they can find, counting on (hopefully never) using the higher out of network deductible. After all, when it comes to attempting to isolate yourself from a $100k+ medical expense, the difference between an in-network $2500 deductible and an out-of-network $5000 deductible really isn’t that much in comparison.
Aside from provider networks, the nomad must also shop for health insurance providers who will actually insure them. Some companies in some states actually require that the insured live at their “home” address for at least 6 months out of the year. South Dakota, a frequent state selected as a domicile for nomads (link to our full chapter on this issue), has several companies with policies like this.
Another challenge nomads face is finding consistent health care while on the road. Unless they are frequently returning to a home base where they can keep their own cadre of providers for routine check-ups, more than likely they will be accessing healthcare with providers as varied as their locations.
The healthcare problem for the self-employed
Many nomads are self-employed or taking a string of contracting & temp positions. Thus they are ineligible for the sorts of large group plans that are often accessible with more traditional jobs. Our current healthcare system evolved around insurance being an employer provided benefit, thus most of the current best options remain with larger group plans.
If you’ve been insured most of your life via your or a family member’s employment – you may not have ever needed to deal with the hassle of seeking out private insurance on your own. Large group plans provide some substantial advantages over individual plans, such as coverage for pre-existing conditions from day one – as long as you’ve been insured without lapse. Also, larger plans have a lot more clout that significantly reduces costs, and usually have lower deductibles, co-pays and attractive benefits like prescription drugs, reproductive health, vision and dental.
A member of a large group is less likely than an individual to have the insurer deny benefits when you need them most.
Access to affordable healthcare is a top legitimate reason why so many people feel they can’t leave their corporate jobs. Which leaves many with wanderlust having limited options beyond negotiating for extended sabbaticals or telecommuting.
If you’re considering going nomadic and are able to take your existing “big company” career with you – look closely at your group plan. Unless you work for a company that supports workers in many locations, most of the plan options are likely to be regionally based. This is especially true with the more affordable group plans, such as HMOs – which typically only cover emergency services when outside of your network. If you have a PPO or indemnity option, you may be better off choosing it to at least have some coverage for out-of-network providers. Even still, you may find that your company simply doesn’t offer insurance options suitable for a traveling lifestyle – and you too will be out shopping for insurance.
Healthcare options for US nomads
So, you’re a nomad (or want to be soon) – you’re likely going to be facing both the nomad and the self-employed insurance problem. What are your options in our current healthcare system?
- For domestic nomads without an option of a group plan, seeking individual plans is a popular choice. The section below will go into more details.
- If you own a business of your own, you may have options for starting your own small business group plan – shop around within your state to see if you can find a plan that gives you nationwide access more affordably than individual plan options.
- You may quality for or already belong to an organization that offers access to a group health plan that could be worth checking out.
- Some domestic nomads working for a company have been able to keep their group plans as they travel.
- If you’re not currently eligible for a plan because of a pre-existing condition or lapse in coverage, your state of domicile may already offer a high risk pool option that you can join. However, as a nomad, you may get few benefits when away from your state.
- Many are left feeling like they have little option than to go without healthcare insurance and planning to self pay for all their healthcare – perhaps even crossing into Mexico or Canada for lower cost care. This can be a big gamble as healthcare costs can quickly get you into substantial debt in the event of a major illness or accident. But there are many clinics, low cost options and grant options out there. We recommend checking out Uninsured America, a resource by my former personal physician that guides you through navigating the healthcare system without insurance. Remaining uninsured however will become more and more difficult as the ACA phases in, potentially resulting in tax penalties depending on income levels.
- A lot of international nomads purchase travel insurance to cover themselves while traveling outside the US. However, if you plan to re-enter living in the US at some point and want to remain eligible for insurance without pre-existing condition exclusions – it may be in your best interest to keep a cheap US policy in force. One advantage international nomads have is access to healthcare in other countries – which is by and large much more affordable for even top quality care. I hear of a lot more international nomads choosing to self-pay for their healthcare as they travel, even if they do have insurance. Since this isn’t something we have experience with ourselves, we’ll point you to these further resources: Almost Fearless’ Healthcare Guide and BootsnAll’s Guide to Travel Insurance.
- There are also talks of the Escapees RVing network working to come up with a group plan offering for RVer-compatible insurance, which would be accessible to those domiciled in Texas. We’re optimistically keeping an eye on this, as it could become a great model for perhaps similar networks in other states.
Individual Insurance Plans
Most of the US based nomads we’ve spoken to have gone this path, so we’ll address individual plans in further detail.
If you’re used to benefit-abundant group health plans, particularly HMOs where you have nice set co-pays for everything you might need, you’re in for a shock when you start shopping for individual plans.
Most individual plans will have a substantial annual deductible ($1000 – $10,000) that you pay out of pocket before any substantial benefits kick in, making these plans the equivalent of older-style ‘catastrophic’ or ‘major medical’ plans designed to protect you from the big stuff.
Under the ACA, all new plans must now provide some basic free wellness benefits with no deductible – so things are starting to change here. But do be prepared that you’ll be paying out-of-pocket for a lot of your routine care and should have funds accessible for your deductible.
Essentially, unless you have a health situation that puts you over your deductible – you will probably be paying your premiums AND most of your routine healthcare costs. And that’s just not going to seem fair.
On the plus side, the premiums for this sort of insurance are generally much less than fancy plans that include lots of benefits – so if you’re not actually using a lot of health care, you could come out ahead. If you’ve been covered by an employer, you may not be used to seeing your full health insurance bill – so paying for insurance yourself is going to be a big ouch no matter how you slice it.
In my case, I’ve always been self-employed and used to have a small business HMO plan before I hit the road. When I switched to an individual plan, I was able to take my premium savings and put it into my health savings account instead. I’ve so far not needed to withdraw much – leaving me financially ahead .. thus far.
Since private insurance generally has high deductibles anyways, many of us have selected policies that are eligible for a HSA (health savings account). This is a tax advantaged savings account you can put up to $3,100 per year into for spending on most medically related expenses, even if not covered by your health insurance plan (such as dental check-ups, flu shots, laser eye surgery, etc.). It’s similar to an IRA in some ways.
It’s not like a flex spending account that you might have encountered, in which you lose any unspent money at the end of the year – HSA’s roll over year after year, allowing your balance to grow. And all contributions to your HSA are ‘taken above the line’ (before deductions) on your taxes, effectively allowing you to write-off all of your health care costs without itemizing or having to spend a certain percentage of your net income on healthcare.
Not all insurance plans are HSA-eligble – so if that’s something you’re interested in, make sure they are designated as such.
Even if your insurance deductible is so high that your plan rarely pays for anything – the often over-looked benefit of having a health insurance plan is that it can greatly increase your access to the healthcare system as a whole. While an emergency room can’t deny you life saving care, providers CAN make obtaining non-critical care difficult if you don’t have an easily demonstrated way to pay. If you don’t have a big wad of cash when you walk in the door, having an insurance card can be a golden ticket past all this hassle when you need it.
And most plans have negotiated rates that you have automatic access to, rates that you wouldn’t otherwise if you were paying full rack rates. Of course, sometimes you can pre-negotiate even cheaper cash rates with providers directly.
So where do you find individual plans?
Some of the private insurers many nomads we’ve talked to have selected include: Assurant, Humana, Aetna, Golden Rule, Coventry and Blue Cross Blue Shield (this is not an endorsement for any of them – do your own due diligence and shop for your needs.).
You can use internet brokers like ehealthinsurance.com to quickly shop multiple insurers at once to get an online quote and start playing around with numbers, or you can go to each company’s website and get online quotes individually. Many insurance agents can also quote you rates and get you setup if you prefer to not do it yourself. Just be aware that getting a quote does not guarantee you coverage, or that you’ll be eligible for the rates displayed – which are for people in perfect health.
If you’re not in excellent health, you could be charged a higher premium, have exclusions on your policy or be denied coverage. You won’t know until you go through underwriting. Always fully disclose your medical history – it can come back and haunt you later. If you get denied with one company, try another – they all use their own criteria.
You’ll find the rates will vary given the zip code you’re rated at, so if you’re still settling on a domicile and legal address – comparing health care costs can be a deciding factor. And some insurance companies have access to multiple provider networks which can change the rates as well.
And for us nomads, there are some key features that can make a plan more ‘nomad-friendly’ than others:
- A healthcare provider network with services in the most likely places you’ll travel – do a search on the network’s website to see if there are providers in areas you’ll be.
- An insurer who does not have a requirement that you live in your state of domicile for a set amount of time each year.
- Telephone and/or internet access to doctors for basic diagnostics & prescription writing, like respiratory infections, can be hugely beneficial and reduce dependence on urgent care clinics. One such service included on some policies is TeleDoc.
- A patient advocacy or concierge service for assisting you in finding healthcare options when you need them.
When shopping around, you may need to look further than the basic benefits listed to find out if these things are included or not.
And no, the headache you’ll get from shopping for insurance will not be a covered incident under your new plan.
Potential Impacts of the Affordable Care Act
A lot remains to be seen how the ACA will play out as it continues to roll out – a lot of things are still being implemented and defined, or are simply confusing. So it’s difficult to predict if it will make things easier or not for us nomads.
For sure, the ACA will do a lot to equalize the playing field between individual and group plans – meaning us non-corporate employed folks will finally have more options within our reach. For instance those with pre-existing conditions will be insurable if they decide to breakaway from their corporate jobs and go independent. I hope that will enable more folks to pursue nomadic lifestyles while in their prime working years.
Another part of the ACA is the creation of state level exchanges to purchase insurance through. My best guess is that, to us consumers, they’ll be similar to the ehealthinsurance.com site linked above so that individuals and small businesses can shop many providers approved by the state. Additionally, those eligible for Medicare and/or subsidized insurance credits will be able to redeem those through the exchanges. States however will have the option to opt out of providing the exchanges themselves, instead falling back to federally provided ones.
This will be interesting to navigate as a nomad, and I’m particularly curious to see if the federal exchanges will provide more nationwide accessible provider networks than state ones (which seem to require at least two ‘multi-state options’)? And if they do, this could become a very relevant bullet point for choosing your state of domicile as a traveler. Thus far, two popular states for nomads – South Dakota and Texas – have said they are opting out of doing a state exchange, and Florida undecided.
And of course, the ‘affordable’ part of the act is left to be proven.
Finding Healthcare on the Road
One of the hassles of nomadic travel is keeping consistency in your health providers. Unless you return often to certain locations, more than likely you won’t always be seeing the same providers. And getting into a provider in a new location when you need it may be a challenge. So many health providers require you to be ‘established’ before they’ll see you as a patient.
But what if you’re just in town for a week, and have a major respiratory infection? You really don’t need to go through getting “established” just to get someone to look up your nose, listen to your lungs and prescribe some antibiotics.
Some potential solutions to this might include:
- Using a telephone/internet accessible doctor consultation that can prescribe medications for the basics, such a TelaDoc.
- Utilizing urgent care clinics (which may be the same or cheaper than paying an office visit to a regular doctor).
- Self treating by stocking basic medications onboard (ie. you can get most things without a prescription over the border).
- Using a concierge service, either provided through your insurer or perhaps your credit card company, to locate available doctors for you.
As a traveler who might need medical care in a variety of locations, you also need to take responsibility for your medical records and having them accessible to new providers. Now that electronic medical records (EMR) are becoming more and more standard, it makes it a lot easier for you to be able to log into your past provider’s website and pull up your records. If you do become established with a primary care physician, make sure they offer such a service. You may also want to get copies of past test results and procedures, and carry around at least electronic copies.
Sadly, our cat has better centralized, nationwide, medical records with her Banfield vet plan (located in most Petsmarts) than us humans!
For humans, we have heard that Mayo offers a decent network to work from, as they have locations throughout the country.
A common reason that a lot folks don’t travel as much as they might like is that they have a current health condition they’re treating, and need to remain nearby trusted medical care sources. For serious illnesses, this is an unfortunate legitimate reason to stay in one place.
However, we have met a good number of folks dealing with some chronic conditions, who despite the extra logistics – still get out there and travel. Perhaps they plan to be near their trusted providers when major things need to be checked or treated, but the rest of the time they’re out exploring. They may have to jump through some extra hoops to set up dialysis across the country, for example – but they’re reminded of the preciousness of life, and don’t want to waste a single moment either.
And it’s also a good reminder for those of us not in such a predicament to not delay living our dreams. You just never know when an illness or injury will strike and hold you back… how many times have we heard the story of someone preparing their life to hit the road, then wham – they’re facing seemingly unending treatments?
If you’re in good health today – there may never be a better time to cure your wanderlust than now.
Staying Fit on the Road
Another concern along these lines is how do you stay in good health on the road? One of the benefits of being stationary is establishing some routines, including fitness & diet. Stopping off at the gym after work is a lot easier when you have a gym on the way home – which won’t always be the case when you’re on the roam.
And when you’re traveling, it’s so tempting to indulge in trying all the yummy new local cuisines and constantly living it up with friends you visit. For the first several months of your travels, it may also feel more like an extended vacation than daily life, and thus make it even harder.
If you’re anything like us, you’ll probably need to put a little attention towards making effort to keep fitness and proper diet a priority in your life.
There are some nationwide gym networks that you can join, if that’s your thing. Some boondocking nomads even enjoy them just to have regular access to long hot showers.
Carrying fitness gear with you can be a challenge when living in a small mobile space. We’ve had our share of trouble trying to carry bikes with us in the past, so we mostly rely on walking & jogging. We like to seek out campgrounds with easy access to trails, as that greatly amplifies our experience. We also carry a set of tension training bands that our friend and future-nomad Matty of the Human Motion Lab made for us.
Others have reached out to locally based fitness groups to both keep active and make new local friends – such as Hashing groups, run clubs, acro-yoga, hooping, hiking, training, kayaking, etc.
Whatever your modality of being active is, plan ahead for needing to keep it a priority. While being nomadic involves a lot of motion, it can be super easy to slip into being quite sedentary.
Our current healthcare solution
Chris and I looked at establishing a group plan for our small business in our state of domicile. But we hit brick walls trying to find a provider network that would have given us nationwide coverage without paying out of network deductibles all the time. And the plan costs were pretty high. We dropped that idea for the time being.
For now, we each have individual high deductible HSA plans with a fairly nationwide PPO networks. Our current plan is through Assurant Health (a Time-Life company)*, and we’re currently with Aetna Signature/PHCS network of providers. We have a $5000 annual deductible (each) with 100% coverage afterwards, and we have some preventative care covered.
We’ll be re-evaluating as the ACA exchange programs come online for our state of domicile, Florida.
* Please note, we do not necessarily endorse Assurant, Aetna, PHCS or TeleDoc. We have not yet (thankfully) needed to put them to the test for anything major.
<— Read Chapter 11: Tackling the Overwhelm of PreparingRead Chapter 13: Lack of Continuity while Traveling Full Time —>
No Excuses: Go Nomadic
This article is part of an ongoing series answering the common excuses folks give us for why they’re not pursing their dreams of full time travel. We launched this series a few years ago as Answers to the Common Excuses – and are in the process of massively updating it. We’ll be releasing newly updated & expanded chapters over the coming months. We’ll be addressing topics like: Affording It, Family, Pets, Logistics, Healthcare, Community, Keeping Connected and more.
Read the whole series: No Excuses: Go Nomadic
eBook version – This blog series is also available as a convenient eBook. We offer this compilation on a ‘pay as you wish’ basis. We don’t aim to make a living off our blog, but contributions to keep the blog going is appreciated (kinda like taking us out for a thank-you beer or dinner).
Cost: Pay As You Wish (really… just set the price!)