Global Healthcare

This guide deals with the thorny and very topical question of global healthcare for expats. Whether you are retiring to a foreign country or living there to work or run a business, this will be an issue of concern to you.

Healthcare – or, more accurately, the fear of what will happen to you if you fall ill whilst living abroad – is one of the factors of greatest concern to those thinking of living in a foreign country. Are the facilities up to standard? Will the staff speak my language? Will I be able to afford the treatment – or health insurance? What will happen if I have pre-existing conditions?

This guide gives an overview of the issues involved and the options available to you.

Public healthcare

Will you be able to use the public system?

This varies from place to place. In many, resident taxpayers will have full access to the local system. This is often at much lower cost than private health insurance – particularly if you are suffering from a known medical condition. This can make it worthwhile seeking proper ‘official’ paid employment or setting up a small business, even if you weren’t intending to do so.

If you are a citizen of an EU state living in another EU state you may benefit from the European Health Insurance Card (formerly known as the E111) or other members of the same family of EU-wide benefits. Those eligible for state healthcare include retired EU foreigners (who follow the correct procedures when moving to their new country), the employed and the registered self-employed working in the country. Not eligible are: non-working expatriates below official retirement age (unless they specially register with the authorities and pay tax), and pensioners who have not completed the proper formalities upon arrival in the country.

How can you judge the quality of a healthcare system?

This is difficult.

International comparisons

International comparisons of healthcare resources have become commonplace. Most have been based on healthcare expenditures. The World Health Organisation (WHO) collects data on these expenditures: see health expenditure per capita and as a percentage of GDP.

However, this means of measurement is far from satisfactory as it bears little relationship to the quality delivered.

The OECD measures specific outcomes – deaths from heart disease, obesity etc – as a way of comparing systems.

Wikipedia extracts lists of outcomes such as survival rates for major diseases.

Local commentators

However, such are the variables between systems – and those between places and individual doctors or hospitals – that the most reliable indicator of quality is likely to be the comments of locals and expats who have used the system. Unfortunately, this usually has to be on a person to person basis as there are few online reviews or forums available. However, there are some. See our country-specific guides for information about each country we cover.

Different styles of healthcare

There are important and often unexpected differences between countries in the way in which public healthcare is delivered. These can catch out the unwary who – illogically – assume things will done pretty much as they are “back home”.

For example, in the UK there is a comprehensive – if overstretched – system of support for care at home and care following on from a stay in hospital. On the other hand, whilst the Spanish health care system is excellent, this type of care hardly exists: the assumption is that these tasks will be dealt with by your family.

Read up about what is on offer where you are going.

Contributions to costs

Public healthcare may not be free. There will often be contributions to the cost of the service: part payment for drugs, an accommodation and meal cost for each night spent in a hospital etc. See our country specific guides for what is expected in the countries of interest to you.

Be aware that if you ask a hotel or travel representative to call a doctor, you may be treated privately. If you wish to be treated under the public system you must say so.

Private Healthcare

In most places – especially in the places likely to be home to foreigners – there are well established systems of private healthcare. Everything from air ambulance services to initial consultations with a doctor, specialist medical tests and hospital treatment can be provided on a private basis.

In some countries the quality is high and the cost low, encouraging a regular stream of “health tourists” for everything from dental work and cosmetic surgery to major heart surgery.

Whilst standards differ from country to country, one of the benefits of private treatment is that the range of care offered and the support offered to the patient is likely to follow the usual international pattern. Food will be provided, your washing done and personal care attended to.

Health Insurance

This is a mass of companies offering international healthcare insurance, whether you are looking for long term cover or protection for just a few months.

Without doubt, some offer better deals than others. Research thoroughly.

Insurance in your own country

In many countries there will be companies providing insurance covering healthcare in another country.

There are usually three benefits of using these providers:

  • Your dealings with the company – both when you take out the policy and if you have to make a claim – will be in your own language
  • The policy document will be in your own language
  • The policy will be specified in terms with which you will be familiar, so that the extent of your cover is clearer

On the other hand, if you have to make a claim there could be a time difference between where you are and the place where the company has its base.

Locally sourced insurance

Some local companies may operate a claims line and provide policy documents in your language. It is worth finding one that does.

If you do this, there can be advantages of dealing with a local company:

  • The name of the company is likely to be more familiar to the doctor or hospital, leading to less delay and confusion before treatment can start
  • The policy might make provision for items necessary or useful in this country but unfamiliar in your own country – and so, maybe, not covered by your policy

In either case…

Whether you take out insurance in your own country or locally, make sure:

You are dealing with a reliable company

Some see paying out as an optional extra or a reward for completing their administrative obstacle course. It is well worth paying a little extra to deal with a company that has a culture of prompt payment.

You read the policy document

I know that this is tedious and that most people don’t bother but this is such an important document you really need to take the time.

You comply, strictly, with any conditions attached to the policy

If you don’t, they are likely to refuse payment

You make full disclosure of your medical history

If you don’t, they are likely to refuse payment

Cost

The difference in cost between companies can be large. Local insurance is not always cheaper than insurance “back home”.

The cost will increase sharply with the number of countries you want covered – the ideal is worldwide because you never know where you will have to go next, your age and previous medical condition. See our Guide to Health Insurance.

Treatment “Back Home”

Some people plan to rely on emergency treatment in the place where they are living but plan to fly “back home” for any routine treatment or planned hospitalisation.

Over the years I have known a number of people who have done this. Usually it has not worked well.

They will often remain (officially) a ‘visitor’ in the country where they now live and a ‘resident’ back home. Now, of course, that it fine if they are genuinely spending more time back home than they do in their new country: if they truly fall into the category of visitor. Often they do not. This course of action, therefore, can lead to all sorts of tax and immigration issues. See our guides to global tax and to global immigration as well as our country-specific guides to tax and immigration for more information about this.

In addition to the potential tax problems, they face an additional – and major – challenge. Increasingly, countries are clamping down on medical tourism by their former residents. It costs them a lot of money. Similarly, the country where they are now living is likely to be cracking down on bogus ‘visitors’ who, in reality, live in the country.

This problem is particularly prevalent within the European Union, where there are few (if any) passport controls and hundreds of thousands to people spending time in two or more countries.

For example, someone from the UK but spending time in Spain can – quite legitimately – rely upon his European Health Insurance Card (EHIC), which will enable him to access the state healthcare system in Spain at a reduced cost (or sometimes for free) when on a temporary visit to Spain.

The Spanish health authority determines what immediate treatment is considered necessary; treatment that cannot wait until the visitor’s return to the UK: heart attacks, broken bones, miscarriage, sudden illness etc. However, it doesn’t cover non-urgent treatment. To be entitled to that you need to be part of the Spanish system (which you can be, as a foreigner, if you are a pensioner or working in Spain).

If they find that he is not a genuine visitor they can refuse to treat him.

Equally, if he tries to go back for treatment in the UK, he can hit a problem as he is not really resident there. The UK National health Service (“NHS”) operates a residence-based healthcare system and not every person is entitled to free NHS treatment. Provision of free NHS treatment is on the basis of being “ordinarily resident”: not upon nationality, payment of UK taxes, national insurance (NI) contributions, being registered with a GP, having an NHS number or owning property in the UK. If he is not ordinarily resident in the UK, he will be considered to be an overseas visitor – even if he is British – and may be charged for NHS services.

As I have said, this can all go badly wrong. Even if it doesn’t, the aggravation of travelling regularly to another country for treatment is not great – especially if you are ill. It can also become very expensive.

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