Recomendation: Come check out Vienna Austria first.

I am a "U.S. Citizen", "born in the USA", whose parents were also "born in the USA". I moved my family to Vienna, Austria 8 years ago. I have for 4 years, owned and operated my own business, a GmbH here.

Vienna. The #1 city in the world 2 years in a row.

http://www.mercer.com/qualityoflivingpr#City_Ranking_Tables

First U.S. City, HONOLULU is at #31 with San Francisco at #32.

Insurance: US versus Austria

Three years ago, my daughter, at the age of 14, was diagnosed with morbid Juvenile Rheumatoid Arthritis, a life threatening condition. She spent 4 weeks in a hospital, with the total out of pocket cost of 280 euro for her meals. 100 % of the hospital costs and medical procedures was covered by insurance which costs my family 2400 euros per year.

In the U.S., in 2003, we paid $15,000 per year for insurance, with a $5500 per person deductible. My wife had her Gaul Bladder removed, and it cost us $11,000 deductible + all of the customary procedures which the insurance companies routinely refuse to pay until you take them to court.

My daughters hospital stay, and continuing medical treatments in the U.S. would certainly have led to a filing for bankruptcy (70 percent of all bankruptcy filings are due to medical bills). Instead, the annual costs of treatments in Austria is 240 euros per year, continuing hospital visits, and Methotrexate Injections.

FYI: Higher education is 100% taxpayer funded in Austria.

As long as a large majority of the U.S. voting public continue to believe that taxes are "theft" rather than paying their "fair share" of the "high financial costs of personal freedom and safety", and continue to refuse to admit that affordable healthcare is a basic human right, staying in Europe is a much better option in my opinion.

My wife and I found the health care in Austria to be excellent too.

Here in Italy, it's good, but a bit 'drab' - the doctors know what they're doing, but sometimes the settings are not so nice, if that makes sense. Whereas in the US, you might get a room to yourself, or with one other person, you might have to share with more people here, and perhaps have fewer amenities.

However, like others have said, there's a huge peace of mind factor. I don't have to worry about insurance at all here. Job, no job, whatever, you get health care, end of story.

It's one thing that makes me quite nervous about going back to the US.

I fully expect the Republicans to come into the majority in the November elections, and for McCain and Mitch McConnell to keep their shrill promise to gut the Obama healthcare law of its protections. And oh yes, I am a conservative republican.

I find your comment confusing. Do you believe they should be trying to gut the Obama healthcare laws?

I think that anyone who uses the word "shrill promise" to describe something usually doesn't agree with what they are saying.

Even after all other factors that are mentioned already, the one significant difference I feel (having come to the US from the UK) is one of constant fear. Can I afford to go to the doctor with my co-pay? If something bad happens to me, will my insurance company look after me, or do whatever they can to ensure they don't pay out? If I get a terminal disease, will the co-pay for the medication I need to live as long as I can bankrupt my family?

With the NHS, while the Brits like to complain about it, the fear isn't there. You will always be looked after if you need to be. Here... I'm not so confident.

Yeah, this is the biggest issue for me too (as an American who hasn't lived anywhere else). In particular, the tying to your employment status makes everything complicated and coverage uncertain for everyone except career employees who stay with one firm. For example, I switched from a full-time student to part-time for one semester in grad school. Oops, this means I don't get the student health insurance anymore and have to buy gap coverage. So I had to research gap insurance, fill out a bunch of paperwork, wait to be approved, and then still hope that I don't really have to use it, because now the recent change in insurance gives them excuses to claim things were preexisting and thus excluded.

And I don't even have any major chronic conditions! People with major chronic health issues are pretty much required to stay in their current job forever, because if they lose their health insurance they're screwed. The whole employment-tying thing puts a huge drain on entrepreneurship, imo, because lots of people who would start companies are scared of losing their health insurance, and even if you can figure it out, it's a huge bureaucratic hassle. One area where the private sector has managed to gallantly out-bureaucratize any government.

In short, I really, really wish that health-insurance was completely decoupled from employment. It would reduce a lot of friction in the economy, imo.

Can't upvote this enough.

On NPR an economist said that one thing that makes the US economy different (in a good way) from the EU economy is the extreme mobility of our workforce - that when times are tough, a reasonable portion of US people can and will pack up and move to a state where they can find jobs. If that is true, conversely isn't the effect of having health insurance so tightly coupled to employment equally detrimental? I mean it just blows my mind that we tie employment and healthcare together.

Many private health insurance policies feature annual out-of-pocket maximums (for deductibles, co-payments, etc.) so that you do not have a potential limitless liability for out-of-pocket cost-sharing during a given plan year - unless, of course, you happen to hit a lifetime limit on benefit coverage under the policy (another common feature - one that I believe the health insurance reform will phase out). Under the terms of such out-of-pocket maximums, once you hit the annual limit, you may have no further liability for deductibles, co-payments, etc.) during the balance of the plan year. Double check the terms of your policy.

This is another part of it: It's very difficult to compare health care in the same way you can compare, say, auto insurance. I've got a policy from my university, but it's still a significant document of legalese that doesn't easily explain what I am and am not entitled to.

It would have been nice if the health care reform created some sort of common labeling for policies that allows you to quickly scan your coverage. Or even some online "what if" simulator, where you can ask questions about what the policy will and will not cover (startup idea here?)

College degree is probably not too bad if you settle for local community college -- about $5,000/year or so. Private universities and colleges can easily get to $30,000/year.

As for healthcare, it IS that bad. Most working people have reasonable coverage (some of then even at reasonable price, as a percentage of income). However, it ties the worker to the employer. If you get fired, you lose your health insurance. If you quit, to move to another job, you lose your health insurance and have to get a new one (and at least until the recent healthcare laws, they didn't have to accept you -- sucks if something happens during your first job, because it's a "pre-existing condition" for the new one).

The end result is that employees are often held captive by their job because of the (essentially unrelated) health benefits. A friend of mine married 6 months earlier than planned to get coverage because she lost her own job.

Job mobility is much harmed.

There's COBRA -- an insurer must let you keep paying for one more year. However, the employer subsidy is gone, so people who pay $200/month all of a sudden find themselves having to pay $1200/month after quitting their job (or being fired).

I used to be self-employed in the US and left in part because of the expense of health insurance. At the time, I had a family of three. When you declare yourself self-employed in the US, you are immediately projected into the highest tax bracket of (if memory serves correctly) 37.5%. Decent health insurance for three cost worked out to be around 40% of that at the time. So, to be self-employed with healthcare cost me around 52% of my then gross salary. And that is just for the plan - there is still a huge excess as well as a plethora of things that the insurance companies won't cover. If memory serves correctly, something like 40% of those in the US are without healthcare. At costs like that, little wonder why.

As for poverty in the US, 1 in 8 are in poverty if you use the CIA-polished statistics. I say CIA-polished because the CIA also says the US spends 12.5% of its GDP on healthcare. According to the OECD, it is more like 15.3%. By comparison, France (top healthcare in the world according to the WHO) spends around 9.5% or so. Canada, number 6 in the world, spends something similar, around 9.7%. The UK, which is somewhere around 20th on the WHO rankings, spends 6.25%. For its 12.5%/15.3%, the US ranks 33rd - just above Cuba.

As for saving up for children's college, university educations are an increasingly well-known bubble in the US. It is not uncommon to have 70 or even many more students packed into a single auditorium for lectures. Even in advanced degrees, there is not as much small group or singular education as there is in Europe. But the costs are nevertheless huge. If I recall correctly, American University in DC currently tops the charts with tuition at $50k per year. That is tuition ONLY. It does not include, books, dorm, clothes, etc. A four-year degree thus has a base cost of $200k. It is nothing anymore for universities to charge $25-30k per year just for tuition. Given that this is the case at a time when many people are losing their houses because they can't make the payments and others can't get on the property ladder because they can't afford the down payment, I would say it is damn hard in the US to pay for things that people in Sweden take for granted.

Just my 2¢. YMMV.

> As for poverty in the US, 1 in 8 are in poverty if you use the CIA-polished statistics. I say CIA-polished because the CIA also says the US spends 12.5% of its GDP on healthcare. According to the OECD, it is more like 15.3%. By comparison, France (top healthcare in the world according to the WHO) spends around 9.5% or so.

Note that US GDP is also significantly higher.

Also, healthcare costs are affected by things that healthcare can't actually affect. Consider obesity.

Also, the existence of working govt programs in other countries does not imply that the US govt could do as well with comparable programs. For example, the US govt spends about as much per person as France does. Since the US govt services appear to be significantly worse ....

No, military spending doesn't account for the difference.

>Note that US GDP is also significantly higher.

Maybe I am missing something, but this should mean that the US can afford to do more. No?

>No, military spending doesn't account for the difference.

I didn't say anything about military spending. Where is that coming from?

> Maybe I am missing something, but this should mean that the US can afford to do more. No?

It implies that spending a larger fraction of GDP on healthcare can be acceptable, but you suggested that spending a larger fraction of gdp on healthcare was a bad thing.

So, what do you have in mind by "do more"? (Of course, being able to afford to do more and actually doing more are very different.)

> >No, military spending doesn't account for the difference.

> I didn't say anything about military spending. Where is that coming from?

"military spending" is the typical reply when someone points out that the US govt spends as much per person as "high tax, high service" countries yet doesn't provide the same level of services.

Spending money may be necessary, but it isn't sufficient.

Okay, I think I see where you are coming from. Let me clarify what I said.

> you suggested that spending a larger fraction of gdp on healthcare was a bad thing.

I was probably in a rush when I wrote 'do more' and so apologise for any confusion. My meaning was not communicated well. If the data say anything, it is that the way the money is spent counts more than how much money is spent. That being said, getting the medical establishment and Big Pharma to take a pay cut is a Herculean task.

> "military spending" is the typical reply

I suppose for some it is, and the US does spend plenty on war. But I would agree with what I understand as your underlying point: The money needs to be spent better before more money is spent on anything.

> That being said, getting the medical establishment and Big Pharma to take a pay cut is a Herculean task.

Apart from the obvious cases of fraud (which seem to be concentrated on govt programs) and reducing some of the monopolies (including things that should be OTC), it's not clear that they're significantly overpaid. (Yes, I know about the "marketing" argument, but that includes free drugs to poor people and it's how folks find out that what they have is treatable. I see both as good. And allowing old people to have sex is a good thing.)

We want people buying Cadillacs (and Mercedes) because that's how we get good things in Toyotas.

A lot of US health spending is triggered by things that are outside the healthcare system. The only thing that the healthcare system can do is refuse coverage, and no one will admit to that.

>A lot of US health spending is triggered by things that are >outside the healthcare system.

Can you give examples of this?

My family nearly went bankrupt from my mom's cancer treatment even though we had health insurance. Until the recent healthcare reform, yearly and lifetime limits and the ability to deny coverage due to pre-existing conditions after enrollment were allowed. My cousin who is healthy but has severe asthma has been unable to attain health insurance on his own since graduating college. He works two part time jobs, but does not have employer sponsored health insurance. The American system is broken and the people who'd benefit the most from fixing it are more concerned about "death panels" that don't exist than looking out for one another.

If you work for a typical company, health insurance isn't a huge deal, mostly because the company picks up most of the tab. Its part of the benefits package. You will still typically pay $100-400 a month out of pocket depending on if you have family and kids. That also may include dental and vision. Dental is common, vision is not.

If you are self employed or work at a small company, then insurance is a big deal. I'm going to pay $6K a year for crappy insurance and I'm still going to pay $7k out of pocket expensive this year because my son had to have surgery and our deductible is 7500. So I think the insurance situation sucks. And I got a notice yesterday that they are raising my rates again. For small business that want to cover the health insurance for their employees it is also a big expense and one that keeps rising. It amazes me that insurance companies can raise rates 15-40% a year and get away with it.

As far as saving up for college education, that is not as difficult because it is a matter of living within your means. Make it a priority and save. That said I have different views on fully paying for 4 years of college vs. having my kids pay part of their way. My parents put me through my first year of school and then I was on my own. I tended to work hard at school (to get it finished) than those I know who's parents were footing the bill.

I've been in the US for almost 10 years, and its been only the last 6 years that I have had health insurance.

If I were still in Ireland I would pay about 1600 Euros a year to give full coverage to me and my family (wife + 2 kids).

In The US I pay just under $400 on every paycheck (my employer also pays a hefty amount), so thats aprox $4900 a year. That does not include dental, or vision.

I would also add that while my plan isn't bad, its not as good as the Irish equivalent - hard to compare though.

Side Note: You should prefix the title of this with "Ask HN:"

Like pretty much everyone has said, the health care situation is Not That Bad if your employer covers it, and if you don't get seriously ill or have an expensive chronic condition.

But health insurance is one of the few ways in which the US really discourages entrepreneurship. Individual health insurance, particularly if you're older, have a family, or have some kind of risk factor, costs a fortune.

The conventional wisdom on homeless people in the US is that the vast majority of the homeless got that way because of mental health problems and substance abuse. I believe it's more of a public policy issue than strictly a lack of money.

I've heard too many horror stories (and from people with supposedly good insurance) to consider moving from Canada to the States. Illness in the family is hard enough without a serious likelihood of bankruptcy. The Canadian system certainly has issues, but for the most part I think it works okay.

Can any other Canadians comment on their experiences? Are there any who would prefer American-style healthcare?

Pfff...are you kidding me? Let me give you an example I have mid to mid-premium insurance. I went to a new dentist a while back and he tells me he needs to take xrays which seems normal, only this time the xrays go on, and on, and on. He takes 32 x-rays of my teeth (while I am asking if this is absolutely necessary and he continues to say 'yes, yes it is'). My insurance company denies the bill, passes it on to me for $10 per xray (they covered 8).... Another time I went to the doctor for an ingrown hair, had them give me a cortizone shot and got a bill for "surgery" for $200. It's highway robbery and there's nothing you can do about it. Most Americans just put up with it because they don't know what else to do. You pay for insurance and then the insurance doesn't even cover basic stuff like it should, they try to get you to get so frustrated that you'll give up and just pay it. It's a broken, horrible, frustrating system.

I recently had something similar happen to me. I've got an individual PPO plan and my "routine checkup" was over $400. It was less than 15 minutes long... insurance company notified me that I am responsible for $171 beyond the $30 co-pay that I was required to pay at the checkup. I'm not sure sure whether to blame the insurance or the doctor, as both are clearly screwing people out of money.

You have to read:

http://blogs.msdn.com/b/michkap/archive/2010/03/21/9982732.a...

Written by the programmer who got multiple sclerosis in U.S. How he suffered because of the system. A good example of something "only in America" (from the Europe perspective of course).

Yes. But the more important thing is the non-negligible possibility of losing coverage completely due to job loss.

Note to fellow HN readers in the U.S.: Please ensure that you have at least some basic health insurance even if you are self-employed or unemployed or you do not have access to health insurance through your employer. You should be able to find a relatively cheap policy if you are single and elect a high deductible. While the likelihood of a major medical illness is relatively low for healthy, young individuals, you never know when medical catastrophe can strike. I know couple of young individuals who were tragically diagnosed with cancer and did not have health insurance. You do not want to find yourself in such a position. Thank goodness Congress enacted health reform earlier this year. While the bill is not perfect, I personally am pleased that it includes a health insurance mandate.

Agree with other posters. If you do not work for a sizable private or public employer, health insurance can be costly. I have a fairly good deal with the health savings account I have - about 150 / mo and 1200 per annum deductible - for a PPO plan with very good preventive, major medical, and prescription drug coverage.

On the other comment, yes there are some parts in the U.S. that are very poor off, especially in parts of the older cities and in rural areas. My parents just returned from a visit to a very high per capita income European country and were somewhat surprised with how clean and orderly and relatively well off all of the cities / towns they visited were.

I am trying to move to Canada for health and business reasons. I was recently apprehended for helping a man with psoriasis obtain medical marijuana for his condition. Now I face 3 felonies and cannot leave the country for 5 years.

Thank you America

I'm not American, so I can't really say anything on the subject, but one thing that always shocks me is that while American's health care is strictly bounded to their jobs, yet lots and lots of them seems to have no or little savings, and some even use credit for relatively small purchases.

If I were to live without enough money in the bank to sustain myself for at least a couple of years without a job, i'd be truly scared, even here in Italy where the health care is all paid. I assume it's mostly just a different social behaviour/mindset, nobody can really tell if it's better or not.

The part that sounds really bad to me is you (or your wife/child) getting some kind of long term disease and you losing any health coverage if you're forced (say by losing a job) to move from one insurance policy to another as it will then be classed as a pre-existing condition on the new policy.

It's the kind of thing that won't affect everyone, but if it affects you then it's truly life-changing in the bad sense.

I'm not actually in the US so can anyone there comment on this scenario?

Currently, if you are continuously covered by health insurance, you can usually move from one insurer to another without being disqualified for a "pre-existing" condition. If you let it lapse for any period, you're in deep trouble.

Disqualification due to pre-existing conditions are regulated out of existence by 2014 under the recent health care law; some classes (e.g., children) are protected earlier (as early as this fall, if memory serves). One of the major drawbacks of the bill is that it is so complicated, almost no one understands it.

I transitioned recently from my parents' insurance which they pay for themselves as small business owners to the insurance my employer provides, which is probably the best insurance situation I could possibly be in. I pay about $16 a month on my paycheck for no deductible, very high lifetime limit, essentially unrestricted healthcare coverage, and pretty decent dental and vision as well. I'm lucky I love my job, basically, because being in my parents' situation where they paid thousands of thousands of dollars a year for practically no preventative coverage would be pretty awful if anything actually happened.

Basically, if you work for a large company and are in a large insurance pool, life's probably pretty good. If you're a small business owner, fresh out of college, unemployed, or have a preexisting condition that can't get covered for whatever reason, you're potentially quite screwed.

Health insurance costs me a little over 200 a month(pre income tax) to cover my family(full health, vision and dental).

The homeless people thing is much harder to quantify. What do you mean by homeless people everywhere? I was 30 before I ever ran across anyone actually sleeping on the street. There are however homeless shelters were anyone can walk in off the street for a place to stay temporarily.

Where were you living before you were 30?

Texas( various cities including a few big ones like Dallas).

Definitely not in DC.