While surveying US healthcare over the past several years, I became increasingly concerned that the future looks rough. The number of Americans 65 and over continues to increase. Those seniors are overweight, out of shape, and have a number of pre-existing conditions like hypertension, high cholesterol, cancer, diabetes, etc.
Also, baby-boom doctors are retiring in record numbers. A growing population of unhealthy seniors coupled with increasing costs and a decreasing number of doctors may lead to Medicare bankrupting the US.
In addition, the confusion in Congress over Obamacare / Trumpcare is keeping Americans in limbo, while anti-immigrant sentiment may keep foreign doctors from filling the gaps.
Under current law, a 64-year-old woman who earns $26,500 pays $1,700 annually in premiums for coverage. Under the AHCA (TrumpCare), that would jump to either $16,100 or $13,600 depending on where that person lives. At a minimum, her premiums would increase 700 percent, eating up half her income. There are winners in the AHCA: people who are younger and healthier. You can see in the chart below that a 21-year-old who earns $68,200 would see her premiums decline from $5,100 to $1,250. For older Americans, the future does not look bright.
Furthermore, reintroduction of restrictions for pre-existing conditions is going to change things. About a quarter of American adults under 65 have pre-existing conditions that made them “declinable”—they could be denied coverage—before the ACA, according to a report by the Kaiser Family Foundation. In 2015, 6.5 million people had pre-existing conditions, which includes high blood pressure, high cholesterol, diabetes, stroke, sleep apnea to name a few common ailments that will exclude some from getting coverage or would price the premiums so high they could not afford it.
And I was under the mistaken impression that if I could make it to 65 and get on Medicare, my healthcare would be free. However, I since discovered Medicare is not free, and fewer and fewer doctors are accepting Medicare patients because of the low reimbursement rates. The chart to the right shows the 2017 total (premium, out of pocket, not covered, etc.) cost for a 65-year-old Medicare patient with health issues – $11k-$16k!!!
Of course, the powers that be won’t let Medicare impact the military budget, so I expect some draconian measure to be taken to prevent that from happening. One measure proposed in Congress is to give seniors a $5000 voucher/ tax credit or tax deduction to help buy a $20,000 private healthcare policy once Medicare is dissolved. So $20,000 – $5,000 = $15,000 out-of-pocket expense. A voucher or credit is preferable since a deduction may only be useful to high-income people after the standard deduction is increased. Medicare does not look like the panacea I had hoped and may go through serious changes because of escalating costs. In short, I do not see a solution for affordable US healthcare coming anytime soon, and it may take a total collapse to get people to work together on a solution. I would like to avoid being in the middle of the coming turmoil. So, I came up with Plan B: look for solutions outside the US.
My Basic Plan
I’ve noticed that many elderly people avoid going to the doctor because they fear finding a problem—they know too many people who have gone into the hospital for surgery and ended up in worse shape, who were prescribed medicines that made them feel worse or they will be informed about a dreaded pre-existing disease the will make them un-insurable. But simply not going to the doctor will not keep me healthy. The best way to avoid healthcare headaches is not to get sick in the first place!
Therefore, my healthcare plan includes being preventive and proactive by doing the following:
- Exercising regularly and eating a healthier diet to improve my weight, strength, and immune system.
- Eliminating and avoiding toxins (sugar, excess salt, fluorine, pesticides, pollution, mold, processed foods) to prevent disease.
- Having regular examinations, including an annual physical, visits to specialists, and recommended tests for my age to identify potential health concerns as early as possible so they can be addressed.
- Living where healthcare is affordable (can be paid out-of-pocket and/or insurance rates are reasonable).
Implementation of my plan:
- Preventive care: Actively pursue a preventive lifestyle. Use the local clinic (EBAIS) for regular check-ups and to discuss health concerns. Pay out-of-pocket for specialized preventive checkups with dermatologist, ophthalmologist, gastroenterologist, cardiologist, and lab tests.
- Reactive care: Use pharmacies for minor cuts/burns, allergies, gastric ailments, Go to ER at the local public hospital (CAJA) for more serious problems—stitches, broken bones, stroke, etc.; or if unhappy with their care, speed, or ability, transfer to a private hospital using my insurance.
Since moving to Costa Rica, my health has been my priority. Without a car, I tend to walk more, and my diet is largely plant-based with limited animal products, sugar, and salt, and no additives. The result: I have lost 70 pounds and all of my health indicators—BMI, glucose, blood pressure, prostate, cholesterol—are in the normal range.
Recap of My Healthcare History
For most of my life, my company paid for my healthcare. It was free! I had no idea what it cost or how it worked beyond knowing no matter what happened to me or my family it would be taken care of. I believe they refer to this as a “Cadillac” plan that generous companies, unions, and governments give their employees. After 2000, my company introduced cost sharing, which eventually led to my paying $6000/yr. for my family of four (which was half the actual cost as my company was paying the other half). When I retired in 2013, my company paid for a COBRA transition plan, which alerted me to the real cost of health insurance—about $13k/yr. for my wife and me. I realized healthcare costs in retirement would be unsustainable. The new ObamaCare tax subsidy of $4000 might have helped but was still not enough ($12,000 – $4,000 =$8,000).
Presently, I have merged Costa Rica’s socialized healthcare (Caja $89/m) with private (WEA, no USA, $1851/yr.) with travel insurance (US, $279/yr.) and a discount program (Medismart, $15/m) to build my healthcare portfolio. I am glad I could piece it together but sad it took so much thought to do so. I was hoping for something less complex. I am happy that the 2016 to 2017 TOTAL cost decreased by 13%.
My 2017 Plan
Lifestyle: We have been fortunate since moving to Costa Rica not to experience the frequent colds and flus we came to expect living in the US. Although I was never seriously ill in the US, those frequent minor illnesses indicated a compromised immune system.
Living in Costa Rica has been good for my health. Whether it’s less stress, the increased sunshine, fresh air, and warm weather that has made the difference, or that I have less exposure to household pesticides, chemicals, and food additives, and better access to fresh local produce, but my immune system is stronger. To build on this success and to move up to the next level of healthiness, I joined a world-class gym ($65 x 2=$130/m) and I am working out three times a week. In addition, I started Spanish lessons to address my cognitive health and to stave off dementia.
In the US, I paid little attention to preventive care. Fortunately, an annual physical is included in both INS and WEA policies as a paid benefit. Now, I pay attention to any test results headed in the wrong direction. If any test numbers are too high or are climbing, I adapt my habits to get them back on track. Now that I am “normal,” I want to be “extraordinary.” Going forward, I want to further decrease my BMI and to keep my blood pressure, cholesterol, PSA, etc. as low as possible using natural and drug-free methods.
Caja: The Caja or Caja Costarricense de Seguro Social (CCSS) is the socialized healthcare system for Costa Rica. It is mandatory for all residents to join and pay. The cost is about 10% of your declared income, so for someone seeking residency with $1000/month required minimum income, the cost is about $100/month for YOUR FAMILY. Paul and Gloria Yeatman have provided more details on the Caja and their experience using it here: How the CAJA works.
A new development this year for us was ARCR (Association of Residents of Costa Rica ARCR), an expat group, re-opened their Caja group rate with a negotiated fixed rate with the government. The result was my monthly cost dropped from $130 to $89. An additional benefit beyond the lower group rate is ARCR debits my credit card quarterly, so that is one less bill each month and no need to pay in person. I have registered at our local clinic (EBAIS) but have not yet made an appointment; I am determined to do that soon and to learn the system. I hope to use the Caja for vaccines and checkups to monitor my health instead of paying for private care. I understand that the group rate decreases by $10/m when I become a permanent resident next year.
Travel Insurance: I bought an annual travel insurance policy ($279/couple/yr.) from BUPA through Perfect Circle to cover us while traveling in the US because my WEA policy excludes care in the US. The BUPA policy is good for 30-day visits, which meets our need for an annual trip to see our kids in the States. Note: I could go on multiple 30-day trips to the US, but each has to be 30 days or less. I could buy multiple per-each-trip insurance, but the annual policy is cheaper. An unexpected development this year was my BUPA policy cost decreased from $380 to $279/yr.
WEA: During my first year using WEA, I discovered how much times have changed. With my former Cadillac plan in the US where everything was electronic, I never bothered with deductibles, pre-certifications, limits, paperwork, etc. I simply handed the receptionist my magic card and everything was miraculously completed.
Now, with private insurance and living in a foreign country, I have learned I must involve WEA in everything I do. I must get approvals/ pre-certifications all along the way. I have to have the right paperwork—invoices with the doctor’s name and signature, receipts, detailed results of consultations with diagnoses, prescriptions for treatment or follow-up tests, all hand-written. Do I sound like I’m whining? Sorry, but having a Cadillac plan where you are treated like royalty and becoming a commoner is a jolt.
However, since I bought my WEA policy through a local agent, Perfect Circle (PC), at no additional cost, PC processes all my claims for free and acts as my advocate. When I need medical care, I first contact PC to get advice and approval. Afterwards, I gather the paperwork and either drop it off at their office or PC will send a messenger to my house to pick them up. I can also take pictures and email the documents. PC handles the pre-certification and submitting the bills, which includes calling the doctor for missing information. Because interfacing with doctors and the insurance company can involve complex medical Spanish, I especially appreciate PC’s assistance. I have accessed the WEA website and have observed how PC documents my claims. I feel confident I could easily do the same if we ever moved to another country where I had to do it myself.
Another revelation this year was the realization WEA is emergency insurance, not comprehensive healthcare insurance. With my previous Cadillac policy, everything health related was covered—over-the-counter and prescription drugs, dermatologists, nutritionists, even heating pads, cold packs, and bandages—with no questions asked and no pre-certification. With WEA, the big things like a heart attack, cancer, broken bones, etc. are covered without question, but examinations, prescriptions, and preventative tests or consultations are a little more problematic. WEA would like to see a paper trail; so I couldn’t expect to simply get an allergy test out of curiosity and expect to be reimbursed—not without a doctor’s recommendation and prior approval. But really, that IS the product I wanted. I wanted a policy that stepped in when bad things happened. I prefer to manage and pay for all the preventive and self-prescribed treatments I feel I need (from vitamins to consultations with specialists). The game I am playing is to pay $900 /person /year to be covered for any emergencies (>$2500) up to $3M. This is a simple plan I can understand, can afford, and am willing to accept. I can maintain an emergency fund of $2500 to cover that deductible, and rest knowing that my policy will cover it from there.
I purchased the SELECT product.
** Ignore the 100%/80% above. The 80% only applies if you choose to include US coverage and seek help in the US. Otherwise, coverage is 100% down the line in the other 195 countries. If you can accept $1M coverage, the CARE product would probably be a great deal worth choosing. Here is the agent for Costa Rica. Perfect Circle
The ARCR 2017 Plans
It appears ARCR has worked hard to find more affordable insurance policies since last year’s huge INS cost increase. While ARCR/INS is no longer what I want, they may be right for other people. Don’t be fooled by the numbers below with commas in place of decimals. For example, $500,00 is five hundred dollars ($500.00).
For more information about these policies, contact:
Juan Carlos Calero
Customer Service Manager
ARCR – Insurance Department
For comparison: INS through ARCR is offering three healthcare options to members. I have found them too expensive and limiting for my needs. INS’s cost has escalated too fast for me and coverage is restricted to Central America. I may decide one day to move to Mexico or Europe and I want transportable coverage WEA offers.
INS is Central America
WEA is Worldwide except the USA
I have pieced together a collection of insurances to build a total healthcare portfolio that meets my needs. That collection includes Costa Rica’s public Caja, WEA for private care (not in USA), BUPA for when we travel to the US, and the Medismart discount program to get the lowest prices possible. Some costs have gone up and others down year to year, but overall, I am paying 13% less in 2017 than 2016, which is a miracle in the health insurance world. I was expecting a bigger increase since I turn 60 this year, but fortunately that did not happen. As a result of the savings, I have added some investments to get me to the next level – a gym membership (for muscle and cardio strength), a Spanish class (for cognitive health), and $100 for random tests, vitamins, and miscellaneous natural products.
- Our 2016 Costa Rica Healthcare Plan, by Rob Evans
- Our Costa Rica Healthcare Plan, by Rob and Jeni Evans
- Rob’s Medismart discount plan
- MediSmart: An Affordable Alternative to Private Health Insurance in Costa Rica
- Costa Rica’s Caja: How it Works
- The EBAIS – Where Healthcare Starts