Episode 54 - Is Affordable Healthcare Worth Leaving Home For?

Ever wondered what happens if you need serious medical care while traveling abroad? When Jim's shoulder began failing him in Ecuador, he faced a critical decision that many Americans contemplating life overseas worry about – should he return to the familiar but expensive US healthcare system, or trust foreign doctors with his surgery?

Jim takes us through his remarkable journey from initial diagnosis to complete recovery after undergoing shoulder surgery in Ecuador. The contrast with his previous experience in the American healthcare system is striking – instead of waiting four months for insurance approvals and scheduled procedures, his entire process from consultation to operating room took just 15 days. Even more surprising was the final bill: $6,200 total compared to $16,000 for similar treatment in the US.

Beyond the financial aspects, Jim reveals the philosophical differences that make healthcare abroad so different. In Ecuador, patients maintain their own medical records, pharmacists return prescriptions for future use, and doctors spend significant time discussing lifestyle factors affecting health rather than just treating symptoms. The system places much more personal responsibility on patients while creating more human connections – from doctors making house calls to hospitals accommodating family members who stay overnight with patients.

Drawing from his audiobook "Living Abroad: Challenging the Myths of Expat Life," Jim addresses common concerns about quality of care, insurance options, and whether medical tourism makes sense for everyone. His balanced perspective acknowledges both the benefits and potential drawbacks, providing valuable insights for anyone considering healthcare options beyond American borders.

What healthcare stories have you experienced while traveling? Have you ever considered seeking medical treatment abroad? Share your thoughts or questions and join our growing community of global travelers seeking authentic experiences worldwide.

For information on the 2025 International Living Ultimate Go Overseas Bootcamp in Portland, Oregon August 29th-September 1st : https://www.internationalliving.com/events

Chapters

• 0:00 Welcome to Season Two
• 1:27 Healthcare Experience Abroad
• 2:29 Myth vs Reality: US Healthcare
• 4:45 My Shoulder Surgery in Ecuador
• 12:23 DIY Healthcare System
• 20:05 Insurance Options Abroad
• 25:31 Health Benefits Beyond Cost
• 32:50 Book Recommendations and Events

Transcript

Speaker 1: 0:09

Welcome to Travels with Jim and Rita. I'm your host, jim Santos, along with my wife, rita, and welcome to the second season of our podcast. In the first season, we set in motion our crazy plan to outfox the real estate market in the US and actually increase our retirement nest egg by selling our home and car and spending the next three years or so living abroad and exploring the world. While we did manage to increase our net worth while we traveled, a bout of pancreatitis in Latvia caused us to return to the States for surgery and recovery and to rethink our plans in light of our ages and other factors. Enter Plan B. We now have a home base set up in eastern Tennessee and are ready to hit the road once again. Our plans are now to spend anywhere from six to nine months a year abroad, returning to the US to visit friends, family and to recharge. Join us now as the adventure continues on Travels with Jim and Rita. Hello everybody, and welcome back to Travels with Jim and Rita.

Speaker 1: 1:17

Sorry, our output has been a little erratic lately, as we've been working on finishing up some things around our home base as well as spending some time with friends and family. We're lining up more interviews now and will be picking up on our recent trip to Ireland soon, but today we have something a little different. Back in episode 35, we talked about me being attacked by my pancreas while we were in Riga, latvia, and the excellent care that I received there. Then in episode 52, we talked about Rita's experience with healthcare in the UK, and, of course, we've mentioned both being treated for COVID in Prague. Likewise, several of our guests have talked about similar events as they traveled. Now, with so much uncertainty in the US right now about health care-related issues, more people than ever are asking what it is really like overseas. So for another look at getting medical attention and even surgery abroad.

Speaker 1: 2:00

Here's an excerpt from my audiobook, which is also, of course, available on Kindle and in print Living Abroad Challenging the Myths of Expat Life. In that book, I took on some of the myths and misinformation about the various aspects of expat life, based on our own lives and the stories of many expats we have met around the world and in our travels. Here, then, is the chapter that looks at the claim that expats can find inexpensive quality health care Chapter 5. Inexpensive Quality Health Care. It is no secret that health care in the US is a chaotic mess. While it is true that the US has the best health care in the world, that needs to be modified with the phrase for those who can't afford it. In the world, that needs to be modified with the phrase for those who can't afford it. There is a baffling array of plans and insurances available, and choosing the best one can be a difficult, if not impossible, process, particularly when your coverage needs change over time. It is estimated that over 530,000 families declare bankruptcy over medical bills each year, and that is truly a national disgrace. Because of these reasons, the siren song of affordable, quality health care has lured many expats over the years. Some crash on their own private sila in the journey, but like most everything you have heard about expat life, there is indeed something to be said for health care abroad, provided you understand the full story. Ecuador, for example, really does have good quality and affordable health care. In fact, there's a medical tourism industry built around it. I've talked to several Canadians who journeyed to Ecuador for extensive dental work, claiming the cost of the care plus the travel was still well below what it would have cost in Canada without a long wait for the procedures. Cuenca is a popular place to nip off for a little nip and tuck with travel groups that will arrange for plastic surgery and a nice spa vacation while you heal.

Speaker 1: 3:52

There is a public health care option under a social service called IESS that can be purchased for as little as $100 a month per couple. The price is based on a percentage of your claimed income. It is quite comprehensive, covering all medical, dental and eye care, with no deductible and no limit. Any procedure or medication ordered by your doctor is completely covered. By now. I know you're waiting for the, however, and I won't disappoint.

Speaker 1: 4:18

Some of the IESS facilities, particularly in small villages or out-of-the-way places, can be fairly outdated and understaffed. You may find you need to wait weeks for an appointment and procedures can be bumped if an emergency comes up. Likewise, you may find yourself in a room with five or ten other patients in one bathroom. Many of the smaller IESS hospitals also do not provide meals, so you need to have someone to help care for you. One friend of ours had to go out to a pharmacy during his wife's procedure to get some medication for the surgery they did not have on hand. In major cities, things can be quite different with larger and better equipped facilities. So before you make the decision to go with a public option, it's a good idea to look into your target area closely and talk to some local expats about it. The medical tourists, of course, are not depending on the public option, and you don't have to either. There are some excellent private hospitals and private doctors that are fast, efficient, well-equipped and really do cost much less than care in the US.

Speaker 1: 5:24

First off, rita and I did not sign up for IESS. It is very affordable, but we do not like that. We could only use the designated state doctors, hospitals and clinics. Also, salinas does not have very modern hospitals. We prefer a little flexibility in our options. For a few months, we used a private insurance carrier, salud. However, in practice, it proved to be a tedious procedure to get reimbursed, involving a trip to their office in Guayaquil, two hours away, to file in person.

Speaker 1: 5:53

Our decision then was that health care in Ecuador is so inexpensive we would be better off just banking the payments each month and using Pay as you Go. The biggest objection to that plan is usually catastrophic care. What would you do in case of an accident or major illness? This is, of course, a personal decision for everyone, but our feeling was that we were reasonably healthy, and, in the event of something like that, we would use private hospitals and credit cards to stabilize, then return to the US, where we still have health care for further treatment. Mostly for us, I think, it came down to the fact that we prefer to live our lives looking forward to a healthy and happy future rather than betting on the worst to happen.

Speaker 1: 6:33

Late in 2015, that philosophy was put to the test when I began having pain in my left shoulder. My range of pain-free mobility became smaller and smaller, to the point where it was even difficult to find a comfortable position in which to sleep. About a year before we left the US, I had an injury to my right shoulder that required an operation to correct, so I was familiar with the pain and I was pretty sure I was going to have to require arthroscopic surgery. With that in mind, I began looking for a good orthopedic surgeon that also spoke some English, and before anyone points out how I could have done this cheaper at a smaller clinic, let me state that I'm aware that this does not represent the cheapest way to get health care in Ecuador. My search criteria were for a professional level of care with a bilingual doctor at a modern and well-equipped facility of my choice for a reasonable fee, but price was secondary. Call me crazy, but I believe surgery is not an area where you want to economize. We do know an expat who went for the cheapest option after a hip injury and now one of her legs is shorter than the other.

Speaker 1: 7:35

I began by visiting hospital websites and emailing orthopedic specialists at the Omni Hospital and Grupo Kennedy Clinica, both in Guayaquil, a city of more than 3 million. My reasoning was that in a city that large with several upscale neighborhoods, there would have to be some quality doctors as well. I sent out my emails and went to have a cup of coffee. When I returned to my computer I already had a reply. I found a doctor with the Grupo Kennedy Clinica system who said he could give me an appointment the very same day for an exam if I could make it. I accepted and we hopped on a bus to the regional station in Santa Elena and from there the bus to Guayaquil. He spoke English fluently Hebrew too, actually and quickly determined that, yes, I did indeed have a problem with my left shoulder. He scribbled a note and sent us downstairs with it for a sonogram. While he waited, we brought the results back to him a half hour later. After examining the films, he also ordered an MRI, which we decided to schedule for a few days later. He was willing to get us in immediately, but it was getting late and we needed to get home to walk the dog. We returned to Guayaquil a few days later for the MRI. The total cost of two consultation visits, an ultrasound, an MRI and transportation came to $615.

Speaker 1: 8:53

As I expected, the results of the MRI indicated that I could benefit from arthroscopic surgery. The procedure was shave some bone in the socket part of the joint to allow more room for movement and to remove a calcified area. My doctor recommended a colleague for the surgery who specializes in this type of procedure as the lead surgeon, although he would still assist. I met with a new surgeon at the San Borondón branch of the Kennedy Clinica. He confirmed the diagnosis and explained that there was no emergency but that I should consider getting it taken care of within a year or so. Since I was already in pain daily and one of our sons was coming to visit in a few months, I decided to proceed without delay and get it over with.

Speaker 1: 9:32

That was a Wednesday evening. As we sat in his office discussing options. He informed me that he could do the surgery either Thursday, tomorrow or the following Tuesday. Also, since Saint-Borondon is in one of the most well-to-do sections of Guayaquil, he let me know if I chose to have the surgery performed in the more urban Alborada Kennedy branch. It would be the same doctor, same equipment, same procedure, but it would cost me 20 to 30% less. Another consideration was that while at the San Borondón hospital everything could be put on a credit card, at the Alborada branch only the hospital fee could be charged. The rest would have to be paid in cash.

Speaker 1: 10:10

Since we would need time to withdraw the money, I asked to be booked for Tuesday. He clicked around on WhatsApp for a few seconds on his phone then said okay, we have the operating room. A few seconds later he confirmed the anesthesiologist and said we were scheduled for Tuesday morning at 8 am. He told me to arrive at the hospital by 7 am to check in and that I would be staying overnight. He also confirmed my wife could stay in the room. In fact, he was surprised that I asked, as it's always assumed that a family member will want to be with you. Now, if you've never gone through this in the US before. Let me tell you how incredible this was so far. I gone through this in the US before. Let me tell you how incredible this was so far. I literally sat in his office while he scheduled a surgical procedure for six days later and it could have been the next day if I had wanted when I needed a similar operation in the States. It was over four months between the initial diagnosis and the surgery and we weren't finished yet.

Speaker 1: 11:02

The doctor then wrote up three orders. In Ecuador, a doctor may order a particular test or drug. It's not exactly what you would consider a prescription in the US, but it's similar. For instance, farmacias will sell you whatever drug you ask for, except, of course, for opiates or psychotropics. The doctor's order just helps you to get the right drug and dosage. But you keep the order and you can go back to the pharmacia and get more anytime you like. You can also go into any pharmacia and tell them what symptoms you have and they will be happy to sell you what they think you need, even if it is just one or two pills.

Speaker 1: 11:36

In this case, he had ordered a presurgical set of blood tests, a chest x-ray and an EKG. These were requirements for the anesthesiologist in order to proceed with the operation. I was able to go upstairs in the same building to a cardiologist and show him the order and he did the test right on the spot. I wasn't in his office more than 15 minutes and I left with the EKG and a letter stating he saw no problems with proceeding. He charged $120. Down to the first floor in a short wait to get the x-ray. They also gave me the film and a report. The whole procedure took maybe 30 minutes and cost $38. The only other expense that evening was the surgeon's office visit fee $70. For the blood test. I was already familiar with what to do. I took the order the next day to a local testing center in La Libertad that we had used several times already. In Ecuador you also do not need a doctor's order for a blood, stool or urine test. You just walk in, select the test you would like off what looks like a sushi menu. The visit cost $22 for the full blood panel and the results were ready for pickup that afternoon.

Speaker 1: 12:43

In Ecuador there is always some personal responsibility in medical issues. The doctor gave me orders for what I needed, but I had to go out and get them myself and collect the results to bring with me to the hospital. We spent Monday night at a hotel in Guayaquil, near the hospital, so we could be sure to arrive Tuesday morning at 7 am and by 7.30 I was in my room a nice large private room with a TV, a refrigerator, a fold-out bed for my wife and a private bathroom and shower. They didn't waste any time, right on schedule. At 8 am I was in a hospital gown and resting on a bed in the prep room. I remember lying there thinking well, it's put-up or shut-up time. I'll admit that I did have second, third and fourth thoughts about it and I could easily imagine myself getting up and saying you know what? I'm good with an arm and a half. I'll just be going now.

Speaker 1: 13:33

Looking back, mostly it was just the normal fears you would have in any hospital, getting ready to go under the knife. But it is true that being surrounded by people who, for the most part, did not speak my language was also a little uncomfortable, especially when the nurse came in to start my IV and I had to tell her she was doing it in the wrong arm. No, la cirugia es en este ombro. I told her, pantomiming outrageously to make sure she got the point, but soon the IV was running in the correct arm and it wheeled me into the operating room. As far as I can see from my vantage point, it was a nice, modern facility. There were computer screens and flat screen color monitors on the walls to display the scope's camera and the comforting sounds of things going whoosh and ping and so on. The anesthesiologist introduced himself, asked me a few questions again in Spanish and we were off. Once he put the mask on me, I was quickly O-U-T and it was a smooth transition to waking up while being moved back to the transport bed.

Speaker 1: 14:27

When the procedure was over, I was in the recovery area for maybe 30 to 45 minutes. I did not feel any nausea or after effects from the anesthesia. I just felt very cold and you should excuse the expression I had to piss like a racehorse. This was the only time in the whole procedure that I was really uncomfortable. I also learned a valuable lesson in Spanish the difference between yo quiero un baño I want one and yo necesito un baño I need one. I had just about decided that I wasn't wearing any of my own clothes and these weren't my sheets. So what the heck? When I finally was able to communicate the need to a nurse who brought me a plastic bottle. Much relieved, I was back in my room and with my wife by noon and had no problems eating lunch. Very nice dinner was provided, as was breakfast.

Speaker 1: 15:15

The next day. Post-op I was checked on by both doctors and there was the usual visits from nurses for IV, blood pressure, temperature and so on. All in all, it was a very positive experience. I felt like I was being cared for in a friendly and so on. All in all, it was a very positive experience. I felt like I was being cared for in a friendly and professional manner. More importantly, I felt like I was being treated as a person, not just a hospital chart.

Speaker 1: 15:36

Checkout the next day was a little unusual. The doctor said I was free to go, but he did not order the release. It was up to me to decide when I wanted to leave, and the procedure starts once you or your representative goes down to the cashier to pay the hospital bill. Now word about payment. Remember that in the San Borondón clínica we could have used credit cards for the whole visit. Part of the reason it is cheaper in the other clínicas is because, while you can still pay all or part of the hospital's bill by card. You pay the doctors, anesthesiologists and some incidental charges in cash. For example, during the doctors, anesthesiologists, and some incidental charges in cash. For example, during the surgery, they found a small rupture on one of my tendons. They tacked it down using a kind of tiny ceramic implant and I also got a separate bill for those materials used. So after Rita paid the hospital bill with American Express, I had a parade of doctors at my bedside with their invoices, including a rep from the company that makes the implant, while we doled out cash.

Speaker 1: 16:30

Here's the breakdown for the surgery and a 28-hour hospital stay. The hospital fees the private room was $2.95, operating room and nurses $1,170,. Oxygen and OR was $80, other medical equipment and food $1,230.64. And oxygen and recovery $3.90. So the subtotal for my hospital fees was $2,779.54. The surgery fees the surgeon earned $1,200, the assisting surgeon $400, the anesthesiologist $400, and the implant and sutures I was charged $560 for the materials. So the subtotal for my surgery fees was $2,560. So the total for the hospital stay and procedures again, this is an overnight hospital stay was $5,339.54. So, adding in my initial costs for diagnosis and consultations, allowing for travel expenses, one hotel stay and additional follow-up visits and therapy, which I was able to get at a military base a mile from our home at $10 per session. The whole experience totaled about $6,200. Compare that to the total cost of similar surgery in the US a few years ago of just over $16,000.

Speaker 1: 17:50

Now a couple of disclaimers. The surgery in the US was the result of an injury and more extensive repairs were needed. However, it was also only on an outpatient arrangement with no hospital stay and only one surgeon present. And of course, in both cases I'm giving you the total charges, not out-of-pocket expense. In the US, insurance paid the bulk of that and I used an HSA for the deductibles, but likewise, although I paid cash for the procedure in Ecuador, I could also be reimbursed from my HSA. I was very impressed with the speed with which things happened. In the US it was over four months between my initial consultation and the surgery. The delay was partly because insurance companies require that you try medication and or injections first, and also because things like MRI and EKG had to be scheduled and the facilities are often very busy. Even the OR had to be scheduled weeks in advance in the US.

Speaker 1: 18:42

In Ecuador, my initial visit was on October 26th and the surgery on November 10th, only 15 days later. In fact, it might have been even sooner, but for the four-day holiday at the end of October. In both countries I felt like my surgeons were very skilled and knew what they were doing. The levels of care for both were very high, I'd have to say. In Ecuador there was more of a human feel to things, though. I felt I was treated more as a human being than just a faceless patient. Also seemed obvious to them that, of course, your wife would want to stay in your room, and they even made sure she had a sheet set and pillows.

Speaker 1: 19:16

As mentioned, in Ecuador there's a lot of personal responsibility. The upside of that is you have more control in the process and you have all of the test results and information, making it easier to get a second opinion. I looked for English-speaking doctors because I wanted to make sure there was no miscommunication between us when discussing the diagnosis and treatment. This was not a problem. However, if you want to be a successful expat, this does not excuse you from learning some Spanish. Keep in mind that, even if your doctor is fluent in English, most of the support people you will interact with probably will speak little or no English, I still needed to be able to communicate with the testing centers, imaging centers, technicians, nurses, admissions in the hospital and so on. As I said, surgery was performed on November 10, 2015. At the beginning of December, I began physical therapy, which lasted eight weeks. Within three months of the surgery, I had full motion in my left arm and shoulder with no pain at all. Now the shoulder is as good as new, 100% functional and healed. In fact, I can barely find the incision points now. I wanted to say a little bit more about this idea of personal responsibility when it comes to health care.

Speaker 1: 20:30

Ecuadorians look at health care differently, as do most other nations. Your doctor's goal is to keep you well rather than to treat your symptoms. If you go in to see a doctor complaining of stomach pains, he might give you a prescription for drugs, but he will definitely spend some time talking to you about your life, your eating habits, how much exercise you get, how you've been sleeping, and then give you suggestions on how to change those things to prevent a recurrence. They also do not prescribe much in the way of pain medication above what we would think of as Tylenol PM. The rationale is how do you know you're getting better, unless you can feel the pain decreasing. The pain is your body's way of keeping you informed and preventing you from hurting yourself worse. I remember when I told my physical therapist that one of my rehab exercises really hurt. He said good means it is working.

Speaker 1: 21:17

As I also mentioned earlier, the doctor does not give you a prescription, as much as a shopping list and instructions for taking the medication. Remember, when you show the list to one of the many pharmacies, they give it back to you. When they are done, you can use it again as much as you like. They don't keep records of who got what. You're responsible for your own records. You can also just walk up to the window and ask for whatever you like without a note, or tell the pharmacist what your problem is and ask them to recommend something. Part of the reason is because they don't have the heavy painkillers or psychotropic drugs, but you can still get antibiotics and such without a notice from the doctor. Even if you ask for hypodermic needles, the only questions are how many and what size. This is part of the Ecuadorian health system's tendency to make you personally responsible for your health. A doctor will prescribe and maybe offer a follow-up visit, but if you decide you don't need it, that's your choice. It's also up to you when you want to leave the hospital. They may recommend tests and procedures, but you are responsible for going out and getting them. You pick up the results and you bring them to the doctor to examine. They are then returned to you for your safekeeping. I have found that I like that approach. I like having the test results and films so that I'm completely informed of my own situation. Also, if I want a second opinion, I have everything I need to easily get one.

Speaker 1: 22:36

After a few years in Ecuador, when we had experience with a few medical procedures, even surgery, I thought that I had fully experienced this DIY system and could not be surprised. I mean, we'd had a doctor once come to the house to examine my wife and remember they make house calls and had him leave us with glass ampoules of medicine and a couple of hypos with instructions to break off the top of the ampoule, draw it into the hypo and then inject it about here once a day for three days. Okay, fine, no problem. But then something happened that took it to a new level. I had a sore throat that made my life miserable for about a week. At its worst it not only hurt to swallow, it also hurt in between swallows. I had our house call doctor stop by and he diagnosed laryngitis and gave me some meds. The next morning it was even worse, so I went to the nearby military hospital yes, it takes walk-ins from the general population, don't need to be military to get service and I shelled out $12.80 for a second opinion. This doctor agreed with me. It was not laryngitis but a bad infection. She gave me a shopping list for some mega antibiotics and a few other things to help with the symptoms. This time I was noticeably better the next day and after the 10-day course everything was back to normal. Almost A week after I finished I still had a little tingle that just wasn't going away. The topper was when I also started feeling a little pressure in my right ear. So it was time for the big guns.

Speaker 1: 24:02

An Ecuadorian friend of ours recommended his eye, ear, nose and throat guy in Guayaquil. We took the bus out to meet our friends and they took us to the appointment and to introduce us. This is also common in Ecuador. Referrals are from friends and families, not necessarily from other doctors. People have relationships with their doctors and they are often treated like extended family.

Speaker 1: 24:23

The doctor talked to me for a while, then did a very thorough exam. He also used some kind of hot wax to clear out my ears, injected it, let it cool and then pulled the plug out, covered with all manner of crap. He confirmed the diagnosis of the military base doctor and explained it was just a particularly tough infection. He suggested, in addition to a new and stronger antibiotic, that I also use an atomizer to inhale medication three times a day to get it deep into my throat and lungs. Sounded good to me. He told me I could find my atomizer in any drugstore, and then he gave me my shopping list along with a recipe. That's right, a recipe. Silly me. I assumed I would get some sort of liquid medication that I put in the atomizer and snort away. No, this is DIY healthcare.

Speaker 1: 25:13

We stopped at Phi Becca, a large drugstore change in a Hawaii Hill mall, and picked up all of my supplies. We enjoyed a lovely dinner with our friends in a nice Peruvian restaurant and then took the bus back to Salinas to do some alchemy. First I needed a sterile glass container in which to concoct my potion, something not too big but easy to clean, of course, a shot glass. Next, add a measured amount of saline solution. The pharmacy decided the best way to do this was by providing a saline drip bag along with a hypo for extracting measured amounts. 20 drops of the next ingredient, this one, at least, in a bottle with an insert that allowed only a drop at a time. 10 drops of the next part of this cocktail, this time with an eyedropper. Then, the fun ingredient Add the full dose, but of course it's in a glass ampule, so you need to carefully break off the tip first, slosh it around a bit, use another clean hypo to extract, squirt it into the chamber of the atomizer and voila, houston, we have missed. Now. Can you imagine this happening in the US? A doctor actually trusting you to mix your own meds? Well, the happy ending is that it totally worked, although I, of course, continued the full seven days the doctor ordered. All symptoms were gone by the third day and have never returned. And if it ever does, hey, I still have my shopping list and recipe.

Speaker 1: 26:33

Health insurance varies widely, of course, from country to country. For example, in Uruguay, they do have a public medical system, but residents who choose not to use it do not buy private insurance per se. Instead, they have what are called mutualistas. A mutualista is more like a membership club with a particular private clinic or hospital system. Plans start around $100 per month with a small private clinic or hospital system. Plans start around $100 per month with a small co-pay at the time of service. Typically a co-pay for a doctor appointment is around $6 and things like blood tests may run $15.

Speaker 1: 27:05

During a stay in Montevideo, the capital of Uruguay, I spoke with an expat who had lived there for seven years and operates the Café Gourmand restaurant with her husband in the neighborhood of Cordon. Since they have two daughters, I was curious what health care was costing them for a family of four. Wow, I'm not sure. She told me. It's just not a significant part of our budget. I don't really think about it. She did tell me that they use a local mutualista group called Casmu and that they are very pleased with the quality of care. If the girls need a doctor, we can just call and they'll come out for a house call. Later that day I got an email from her stating that she had looked up the cost of their coverage just $240 per month for the whole family In Ecuador. As of this writing.

Speaker 1: 27:48

In order to become a resident, you have to agree that you will carry some kind of health insurance, either the public system via IESS or a private insurance plan. As I wrote in the beginning of the chapter, iess can be a mixed bag. If you are in a location that has good IESS coverage and modern clinics, this can be an excellent deal. If you are in one of the smaller villages, you might not find the kind of care you expect from your North American experiences. One option some expats who are in general good health have used, since the cost of private care and drugs is so low, is to go ahead and sign up for IESS to meet the residency requirement. Then just pay out-of-pocket at the private doctor clinic of your choice when needed. Iess cost is based on a percentage of the primary's claimed income, plus a small additional percentage for each family member. Another strategy is to have the spouse with the lowest visible income file as the primary to keep the cost lower.

Speaker 1: 28:43

Ecuador does recognize same-sex couples and now same-sex marriages, although the church will not perform the ceremony money. If you look at a chart for the IESS estimated monthly costs for a couple, if the income of the primary is less than $388 per month. The basic rate for two is $81.52. Monthly income of $800, your cost goes up to $168.08. At $1,000 income it is $210.10. $1,200, $252.12. And at $1,500, your monthly rate for a couple would be $315.15. Now that's based on current information and is subject to change of course, and bank fees may also apply depending on how you make your payments. So if you consider that chart, you'll see that, due to the price structure of IESS, if the income of the primary is above about $1,200 a month and you are in one of the poor coverage areas, it may be more cost effective to look at private international insurance, International health insurance.

Speaker 1: 29:51

Talk about a mixed bag. Just take a look sometime at the variety of policies available for international health insurance. Or, better, a mixed bag. Just take a look sometime at the variety of policies available for international health insurance. Or, better yet, don't First take a look at your current US health insurance. It is possible you can add coverage for international travel for a modest increase in your premiums. I'm embarrassed to say I was in Ecuador for three years and had surgery before I bothered to call about my own US insurance and discovered I was already covered in foreign countries. The advantage to private insurance, of course, is that you can mix and match to meet your health needs. This is another case where, if you are in reasonable health, you can shop for a cheap policy with high deductibles to meet the residency requirement and as catastrophe insurance and pay out of pocket for any minor stuff. Even a low deductible is hard to max out unless you have a major health problem. Remember, I pay less than $30 for a full-panel blood test, for instance, ready the same day.

Speaker 1: 30:44

Evacuation insurance you need to shop carefully and do your due diligence when it comes to health insurance, no matter where you are. But one thing in particular you need to take a very close look at if you live overseas is called evacuation insurance. Expats will sometimes take out these policies under the assumption that if they have a major problem, they can just be whisked away to the US for treatment. The problem is most of the policies I looked at do not exactly promise that to you. The fine print usually indicates that the choice of destination is not up to you. The way most of them work is if you need a procedure or care that is not available in your current location, then the insurance company will make the decision on where to send you. It's going to be the nearest location that can offer what they determine is an acceptable level of care. This means you may leave one foreign country just to be checked in at another.

Speaker 1: 31:37

So what should I do? First of all, don't depend on me or anyone else when it comes to what is best for your health. Check into all of the options I've covered and choose what is right for you. If you have any special medical needs, be sure to discuss your plans with your current doctors. For Ecuador, you can check the FIBECA website at wwwfibecacom that's F-Y-B-E-C-A, and do a search for any medications you may need. Use the generic name. If the brand name is not found, you can see what it costs, what dosages are available, etc. In advance. Don't be surprised if it is much cheaper than what you are paying now.

Speaker 1: 32:16

I have had people ask me at conferences about situations where they have mobility issues, chronic illnesses or are planning on bringing along a parent who has dementia or other serious issues. They always seem surprised and a little offended when I tell them my opinion is to stay where you are now. It can be hard enough getting into the swing of expat life without starting out with two strikes against you. Mobility issues are a very big red flag, as wheelchair accessible places are rare. Indeed, the number one way expats injure themselves, even among the most mobile, is from falling down or tripping on something.

Speaker 1: 32:52

For myself, the biggest health advantage of living in Ecuador has nothing to do with the cost or quality of the health care system. My health improved because I was able to lose so much weight. The weight loss was from reduced stress, spending more time out, walking in the great weather, and the abundance of fresh and unprocessed foods. Instead of jumping in the car to drive to the grocery store or hit a fast food chain, I was suddenly walking to the mercado and coming home with fresh papaya, strawberries, pineapples and veggies. I was getting shrimp and fish that were swimming the night before, and what we call free-range chicken and whole foods is just plain old pollo in Ecuador. So much of a successful expat life is not about what things cost, but about you accepting a new lifestyle and making positive changes in your own outlook and expectations, and you can't put a price on that. That's all for now.

Speaker 1: 33:53

I Hope you enjoyed the excerpt and remember you can find the entire book and all my other books and short stories on jimsantosnet. Photos and videos of some of our travels can be found on our Instagram and YouTube sites, and more photos and blogs on the website jimsantosbookscom. All of those links are, of course, in the show notes. I'd like to mention, too, that Rita and I will be in Portland, oregon, from August 29th to September 1st at the International Living Ultimate Go Overseas Boot Camp. We'll have a table in the exhibition hall to talk to attendees, and I'll be giving three talks as part of the program. For more information or to sign up, go to internationallivingcom slash events or use the link in the show notes. Until next time, stay healthy and remember that we travel not to escape life, but so that life does not escape us. Thank you.