When you don’t plan to be in the US for more than a few weeks a year, how do you deal with health insurance? Indeed, this is one of the biggest struggles of anyone who lives an unconventional life without employer-provided insurance. But when you’re not even going to be in the US for more than a few weeks a year, it adds another dimension. For more traditional expatriots, those who move to one other country for an extended period, there are a plethora of options available to them and it’s a very liquid market.

For those of us who bounce all around the world, there are many fewer options. Some ACA-compliant plans will actually cover you outside the US. There’s even been a handful of news stories about ordinary folks living in the US whose health insurer paid to send them on a “medical vacation” to seek treatment in a lower cost country like India or Thailand. However, most ACA plans don’t seem to cover costs outside the US and when they do they require you to pay the provider up-front and seek reimbursement from the insurance company later. This has the additional risk that coverage is at the sole discretion of the insurer and it can be difficult or impossible to get the required documentation from a foreign hospital or health service.

Indeed, I’ve had my own experiences in the health care system while visiting Austria, South Africa, and Spain.

There are a handful of plans that will cover you anywhere in the world. These look and act very much like ordinary health insurance plans with the exception that they’ll cover you outside the US and even have in-network doctors and hospitals that they’ve negotiated direct payment with. However, these plans are subject to underwriter approval (meaning if you have any significant health issues you probably won’t be approved) and tend to be on the expensive side (even though health care costs outside the US are often much lower).

Another option is a travel medical policy. However, these aren’t designed like traditional health insurance and generally only cover emergencies, such as an injury or sudden occurence of a disease (hearth attack, stroke, seizure, etc). They also generally exclude or severely limit coverage for pre-existing conditions. And if you come down with a rare disease or cancer, they’ll likely only pay for treatment of immediate symptoms.

Until recently, we pretty much got by through a mesh of different partial-solutions. Carrie’s coverage is straightforward due to her breast cancer history and the risk of recurrence: our only real option is an ACA plan. For myself, I can’t rationalize paying such a high rate for insurance that only covers the most catastrophic events. So I cobbled together a combination of travel health plans, short-term health insurance in the US, and self-insuring.

I had fully expected that if something serious arose for myself, I would almost certainly seek treatment outside the US. There are many places where you can get comparable treatment for a fraction of the cost. Often the doctors are educated and trained in the US and the facilities can be as good or even better than most found in the US. In fact, even when getting treatment inside the US, we’ve made a habit of asking for a comparison of the cash price (without insurance) as well as the cost with insurance, as it is often much cheaper to go without insurance.

A few days before we left for Costa Rica, Carrie needed to get a test done in follow up to her (successful) treatment of breast cancer early last year. As a practical matter, we wanted this test done in the US as it would be easier to get the results to her Florida oncologist in a timely manner. When we learned that the cost of the test would be $553, we asked what the cash patient price would be and learned it was only $250. That’s right, Blue Cross/Blue Shield had “negotiated” the price up to more than double what you pay without insurance! Indeed, the ACA is structured in a way that, ironically, insurers make more money when health care costs go up.

I’ve always been a bit nervous about my own coverage. Even if we can afford it, I don’t want to be in a situation where my health is compromised and I have to make decisions balancing that against tens of thousands of dollars (or more). So this year I started to look more closely at health sharing plans to get coverage for myself that wasn’t more expensive than the payments on a new Lexus. I had heard of these before but never looked too closely as they were generally affiliated with a church or religious group and had requirements for membership or attestations of faith that didn’t align with me. However, a couple of months ago I stumbled across a blog article about Sedera and immediately felt like this was a much better fit for me.

It certainly has its limitations and isn’t the right fit for everyone—if you’re curious, here’s an excellent discussion of Sedera’s pros and cons. But it costs about a quarter of what I would pay through the ACA and has no network at all: I can go to any doctor, hospital, or provider in the world. It’s a non-profit and each member acts like a cash patient. Sedera is therefore incentivised to help keep health care costs down and even provides expert cash-price negotiators to work with you if you have a major surgery or other treatment. So, as of a month or so ago, I have a steady and consistent health provider for the first time in several years.

We still carry a travel medical policy when we’re outside this US—something I recommend to anyone traveling in the developing world. This is mainly to get supplemental coverage in the event that we needed a medical evacuation (helicoptered off a mountain or flown to another city/country for better treatment). It’s a relief now to have a stronger safety net underneath me.