No matter how you look at it, healthcare, and specifically health insurance, is a headache.
Despite this being one of the most substantial excuses that hold people back from a nomadic life, I’ve been holding off on posting about this topic for a couple of reasons.
For one, it took me nearly two years to figure out a workable solution for myself. And I’ve worked in healthcare software development for over 15 years – so I know more than most about how the system works! This stuff isn’t easy.
And secondly, I was waiting to see what the ultimate impact of the healthcare reform debate would be. And while I am thrilled with the upcoming shift around pre-existing conditions, most of the actual changes are years away from going into effect.
Things may be getting better, but securing affordable quality health care remains a challenge. This challenge is magnified for the self-employed, and for people without a fixed home. No wonder that healthcare is a particular problem for nomads!
The healthcare problem for nomads
The US healthcare system built up upon locally negotiated contracts between insurers and providers, and there is nothing close to any sort of unified system accessible nationwide. Many healthcare plans don’t even cross regional state lines due to different accreditation processes and regulations that vary from state to state.
I don’t care what your leaning is on the whole healthcare debate is – this localization presents a unique problem for full time travelers. Under most plans, this means that you will spend a lot of time ‘out of network’ simply because your travels take you away from where your plan was underwritten.
Many travelers are also self-employed, and thus ineligible for the sorts of large group plans that are often provided with more traditional jobs. If you’ve been insured most of your life via a group plan through 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 a member of a large group is less likely than an individual to have the insurer fighting against them to deny benefits.
Thankfully, the healthcare reform bill will do some to make things easier for the self employed and others on individual plans.
Access to affordable healthcare is a top reason why so many people legitimately feel they can’t leave their corporate jobs.
If you’re considering going nomadic and are able to take your existing “big company” career with you – look closely at your group plan options. 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. If you have a PPO or indemnity option, you may be better off choosing it to at least have some access to 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.
I’m sharing my healthcare insurance story to demonstrate just one possible set of challenges. It’s nowhere near representative of all situations you might encounter, but I think my personal story illustrates several of the real-life snafus one can run into.
My parents and I have run a small software business for many decades. We have a group HMO health plan in Florida that provides fairly excellent care, although as my parents have aged the premiums have become ridiculous. Small business group plans generally are much more expensive than large group plans for equivalent benefits.
When I decided to go nomadic, I did so knowing that our group plan only provided me with emergency and urgent care coverage while away from Florida. Anything ‘routine’, or even aftercare for an emergency, would only be covered in our one “home” county in Florida.
This was an awful plan for a full-time traveler, but as a really small family business, if I left the plan it would have jeopardized our group status.
Changing to another group plan entirely wasn’t feasible either. My mother is a breast cancer survivor, and a pre-existing condition of that caliber could only be covered by her taking on a corporate job with a large group plan, by her entering a high risk (high cost) pool, or by all of us sticking with our existing group plan.
I was literally trapped into paying for health insurance I couldn’t actually use, and I stayed on this plan for my first 2 years on the road. I factored in that I would simply have to return to Florida for routine healthcare – being younger, mobile and healthy, that seemed like a reasonable risk.
As luck would have it, I ended up needing major surgery during our first year of travel. Thankfully it wasn’t time critical, so we were able to relocate to Florida at a leisurely pace to take care of things. It’s not a huge sob story, because being in Florida also meant I had the benefit of support from friends and family during my recovery. But if it had been anything more urgent, the outcome could have been much worse.
Our current healthcare solution
We eventually found a way to maintain my mother’s group coverage while getting me off the policy. This allowed me to find a plan better suited to my traveling lifestyle.
Chris and I looked at establishing a group plan in South Dakota, our state of domicile and where our little business is registered at. 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. Given the high premium costs for a small business group plan and the paperwork involved with establishing a plan for a company without consistent income (we work in bursts) – we dropped that idea.
For now, we both have individual high deductible HSA plans with one of the rare fairly nationwide PPO networks. It’s amazing how far you have to research to find out how widespread a network is or isn’t, and we had to work with our insurer to write our plan as the network that provided us the best coverage where we travel the most often wasn’t generally available for South Dakota residents. Our plan is through Assurant Health (a Time-Life company), and we went with the PHCS network of providers.
The feature of Assurant’s plans that make it especially nomad compatible is their ‘TeleDoc’ system – which gives you affordable access to doctors over the phone for more routine illnesses. For things like UTIs, sinus infections and other things that don’t require extensive diagnostics, they can call in a prescription no matter where you are. This is a key feature, as we’d otherwise be left to using urgent care facilities for these sorts of doctor’s visits if we didn’t happen to be close by to a doctor we were already established with (and many docs only reluctantly take new patients). Otherwise, we schedule our routine care when we’re in locations where we’ve established ourselves as patients with doctors that we trust.
Please note, we do not necessarily endorse Assurant, PHCS or TeleDoc. We’re both fairly new to them, and have yet to have need to put them to the test for anything major.
Other healthcare options for US nomads
Other domestic nomads we’ve spoke with have also chosen similar individual plans through Humana and Blue Cross Blue Shield for their health insurance needs. A high deductible HSA seems to be a common choice for those of us self-employed, funemployed, or semi-retired. An HSA also has the perk of allowing you to effectively write-off all of your health care costs without itemizing your tax refund.
Others have selected low cost major medical catastrophic plans, to cover only the very worst case stuff, and are self-paying for everything else.
Some domestic nomads we know work remotely for a larger corporation and have been able to keep their group plans as they travel.
Some nomadic travelers choose to gamble and plan to self pay for all their healthcare – perhaps even crossing into Mexico or Canada for lower cost care. In the US, this is a big gamble as healthcare costs can quickly bankrupt you in the event of a major illness or accident. But there are may clinics and low cost options even in the US. Two of our medical urgent needs actually happened at festivals we were attending that offered fabulous and free expanded first aid (I once twisted an ankle, and Chris once got dehydrated and needed IV fluids).
My personal physician in Florida, Dr. Steven Blythe, has a great website Uninsured America featuring a guide to surviving our healthcare system as an uninsured individual. Dr. Blythe actually ran for Congress in 2008 – unfortunately for the country, he lost – fortunate for me, he’s still my doc.
He has also written and published a great book on the subject: Uninsured in America: A survival guide. In it, he gives a lot of great advice on how to navigate the system without health insurance.
Healthcare for international nomads
As we’ve been primarily US domestic nomads, we don’t have as much first hand experience to share around international healthcare concerns. But we will point you to some excellent resources.
A lot of US citizen international nomads purchase travel insurance, and BootsnAll offers a great breakdown of the options.
However, if you plan to re-enter living in the US at some point and want to remain eligible for insurance without pre-existing exclusions – it may be in your best interest to keep a US policy in force. AlmostFearless did an excellent article outlining these unique considerations.
One advantage nomads who aren’t traveling around the US have is access to healthcare in other countries – which is by and large, much more affordable and accessible. I hear of a lot more international nomads choosing to self-pay for their healthcare as they travel, even if they do have insurance.
What solutions to travel-compatible healthcare have you found?