Healthcare while cruising

Christmas party
Laughter is good medecine, but we do rely on more than fun

Shuffling down the corridor of the hospital on Langkawi last week, I realized with a start that this marked the first time since leaving the US in 2008 we’ve sought out medical help for anything but routine or preventative care. I’m embarrassed to be going to the emergency room, but it’s a Friday- Jumu’ah– so the village clinic and local doctor are closed on this Muslim island. The blisters on my legs have reached a level of discomfort I don’t want to wait any longer to address, so I overcome the conditioning and we head for the hospital.

Healthcare and medical emergencies were among the chief concerns I had as a pre-cruiser. Looking back over the last six years, I wonder why I worried so much.

Mexican train
five healthy kids, including two I just shared chicken pox with…

Is it easy to find a doctor / clinic / dentist / hospital / etc.?

People everywhere have basic health care needs, so pretty much anywhere that people live there is a way to access health care. I think that growing up in the US trains us to think that we’ll somehow be turned away or have difficulty getting care abroad. In fact, it’s the reverse of the US. Along our travels, care is accessible, it is generally far less expensive, and medication relatively easy to acquire. We do not need any routine prescriptions, which certainly simplifies this for us. Some planning would be needed otherwise, but it’s hardly insurmountable.

In French Polynesia, our friend’s son needed stitches on his head after a minor accident. In Australia, another cruising kid suffered a broken arm. In both cases, medical care was readily available and inexpensive.

What about insurance?

We do carry insurance: a travel policy, intended for catastrophic needs only. We minimize our premium by carrying a high deductible, and presume that we’ll cover all our medical care out of pocket. Medical evacuation for the victim and a parent are covered, a benefit we value in the event of a calamity.

A few months ago, dental workups for our whole family- including an extraction and a filling- added up to less than $200 (about the same as we paid in Mexico). With good care, at such reasonable cost, we would have to try hard to spend enough on medical care for any other insurance coverage to make sense.

Some cruisers and travelers we know have affordable health care in their home countries (such as Australia and the United Kingdom) and return often enough to cover routine needs there. On the other hand, plenty of cruisers don’t. They find, as we do, that locally available medical care is both accessible and affordable.

What about the ACA?

Two things are pertinent for cruisers (but I’ll be the first, I’ll be the first to admit we’re no experts on the subject!) First, the ACA does not recognize travel insurance policies. So the insurance coverage we do cover is meaningless in their evaluation. Second, if you spend most of your time outside the US, the insurance requirement is waived. Because we are outside of the US for more than 330 days in a 365 day period, we meet the “physical presence” test for exemption. That solves the insurance problem, but we can’t afford to fly back anyway! I guess if we get back for a visit, we’ll just be careful to keep it under the maximum allowed days.

Meanwhile, my visit to the emergency room has cost about US$15. Diagnosis: shingles, and aren’t I the lucky one, but I have a full-body case (wheee!). I waited about two minutes to be seen, received a basic workup, a consultation with a physician, and medication. One flat registration fee covered it all.

Healthy readers know we live it when you read this on the Sailfeed website!

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19 Responses to Healthcare while cruising

  1. PediNP April 14, 2014 at 10:00 pm #

    Naturally, as a nurse practitioner, this question has crossed my mind as I follow your blog. I’d be nervous about foreign medical care (well, most of it!) but I’m reassured to hear that your experiences have been positive.

    Ouch! Shingles! I hope you feel better quickly.

    • Anonymous April 15, 2014 at 6:20 am #

      I think you would be surprised how good the quality of healthcare is outside of the USA. I often hear people tout the USA as the best healthcare in the world. Perhaps this is true if someone can afford it. Most people are limited to a service level for which their policies will pay. The policies limit the access to true premium healthcare.

      I do not what to start a debate here but get frustrated when I read about people knocking medical care outside of the USA. I am more nervous about USA healthcare and the greed of the professionals in the system. i.e. Based on per populate, USA dermatologists remove 33 times more “suspect” moles for biopsy than the next country on the list, Norway. Yet the percentage of skin cancer in the USA is not statistically different from the top 33% of the world populace.

    • Behan Gifford April 15, 2014 at 10:04 am #

      Hi PediNP, I’m curious to know why you’d be nervous about most foreign medical care. Working in the field, I have to assume you have access to better information than the general public. It definitely conflicts with our experience. I suspect we’ve been more than lucky to find that medical care is affordable and accessible.

      Ironically, medical care is one reason we may find it difficult to come back to the US.

  2. The Ceol Mors April 15, 2014 at 1:43 am #

    Oh I so hope you are feeling better soon!

  3. Tillerman April 15, 2014 at 1:44 am #

    Wow. People all over the world have access to affordable (or free) health care. Maybe, one day, it will happen in the USA too?

    • Behan Gifford April 15, 2014 at 10:02 am #

      Shocking, isn’t it?! 🙂

  4. Mark and Cindy - s/v Cream Puff April 15, 2014 at 6:08 am #

    Are you sure about the exemption? My understanding is if you file a USA tax return, you are obligated to purchase insurance according to the ACA. I am wrong most of the time 🙂

    Perhaps you could point me in the right direction to find this exemption. We are leaving the USA to cruise full time in November and insurance is such an unknown for us.

    Mark and Cindy – s/v Cream Puff
    http://www.creampuff.us

  5. Tillerman April 15, 2014 at 7:13 am #

    Mark and Cindy – this IRS document might answer your question.

    http://www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision

    • Behan Gifford April 15, 2014 at 10:00 am #

      Thanks for that Tillerman! It does have the details. I’ve got another one to suggest (linked reply to sv Cream Puff above) as well, which uses plainer English and is directed at expats.

    • Mark and Cindy - s/v Cream Puff April 15, 2014 at 9:44 pm #

      Thanks for the link. This is most helpful.

      I guess that 36th day in the USA could prove to be extremely costly.

      Mark and Cindy – s/v Cream Puff
      http://www.creampuff.us

  6. Gerard Kiernan April 15, 2014 at 6:47 pm #

    Always enjoy your posts. I am an American MD and know that we DO NOT have the best health care system in the world. People who say that are willfully deceptive, in most cases, or just plain ignorant. You can get great health care in the US, but you can in a zillion other places too. A lot of other places actually have a healthcare system, which is something we don’t have in the USA. I would be nervous about distance from healthcare in some places, along with fewer resources to bring me to healthcare, but you have to assess your risks. I suspect that when I road-bike here in New Hampshire, I am at higher risk of bad things happening from distracted or impaired drivers than I would be sailing with you all. But I do know that , although we don’t have a ‘healthcare’ system , we do have a pretty good EMS system with helos, coast guard, ambulance etc around here, so maybe that is the contrast with the developing world.

  7. Anonymous April 19, 2014 at 2:33 am #

    I wouldn’t worry about the ACA; the IRS does not have the budget nor the will in enforce it. They would rather go after revenue

  8. Corinne April 21, 2014 at 5:18 pm #

    All of my experiences of foreign medical care have been great. In fact, I’ve usually felt that because I’m a foreigner traveling to their country they take extra special care of me. Good post.

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  10. Mark November 12, 2015 at 4:59 am #

    Mark & Cindy, Thank you for the information on an important topic, but I think this website has some bad news for us:

    https://www.irs.gov/Individuals/International-Taxpayers/Foreign-Earned-Income-Exclusion—Physical-Presence-Test

    Example 2 shows that any time spent at sea counts against the 330 days you are away from the United States, so, basically, if you spend more than 35 days a year at sea then you must have ACA Minimum Essential Coverage or you’re going to pay the fine for not having insurance. I think this is really a rotten deal as every ACA policy I’ve seen doesn’t provide coverage while you’re outside the United States and now, in 2016, the penalty for not having coverage is 2.5% of your U.S. income. As I will be making U.S. income while cruising this is a problem for me.

    • Behan November 12, 2015 at 8:52 am #

      Oh wow Mark – time at sea doesn’t count- that DOES stink! Although you do have to spend a lot of time at sea to exceed 35 days. I briefly panicked until realizing that EVEN counting all our sea time crossing the Indian Ocean this year, we won’t hit 35 days at sea (unless we get becalmed between Richards Bay and Cape Town =unlikely). Another good reason to be married to a guy that’s dedicated to VMG on passage! But yeah, that is a critical detail. We’ll have to suck it up for US insurance next year since we hope to actually BE there for at least the minimum time, and I’m in total avoidance/denial about getting a new health insurance policy… although it’s going to be necessary.

  11. Allison Flavio October 21, 2016 at 11:44 am #

    Hi Behan, super late to the game on this topic, but wow – such great information and all in one place! Any new recommendations as it’s a year or two later on this topic? We plan to leave next summer, spend the minimum time at home visiting family, and will be earning an income while sailing.

    Also, who did you use for the travel policy?

    Thanks for such great info!

    Allie

    • Behan October 24, 2016 at 9:22 am #

      Hi Allison – recos really still hold for the most part. We came back to the USA for a season, and changed health insurance to a new policy that allows up to six months in the USA. It’s still not ACA compliant, though. And that’s something I’d shift on a little is the fuzziness of ACA language. It’s not as black and white as the # of days, as stated here – the insurance agent says that language elsewhere in the ACA bases it on intention as much as the day count, and if your intention is to be domiciled outside the USA that’s sufficient. I’ll send you an email with our agent’s details.

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