Although most Americans traveling abroad are aware there are differences between healthcare systems in the US and in Europe, they may not how that affects their health insurance plan overseas. To help expats obtain health insurance in Europe, here is a guide delineating the differences in health care systems between Europe and the US.
Qualifying for Healthcare
In the US, healthcare is usually provided either through an employer, privately purchased insurance, or government insurance provided for low-income individuals and senior citizens. However, because laws vary from country to country, qualifying for healthcare in Europe can be immediate or take several years.
In the UK, for example, qualifying for healthcare under the National Health System (NHS) depends on several factors:
- How long the expat intends to live in the UK (those intending to live there indefinitely may receive health care)
- Whether the expat has a right to live permanently in the UK (or has a “route to settlement” to eventually allow permanent residency)
- The age of the individual seeking health care (children under 16, or under 19 if obtaining full-time education, are eligible)
- How long an expat has lived lawfully in the UK
In France, all residents are obliged by law to have health insurance. While most people are eligible for state health insurance, those who do not qualify (such as some expats) must have their own private insurance. Expats may qualify for health insurance by doing the following:
- First, a tax return must be submitted to CPAM (Caisse Primaire d'Assurance Maladie), the French national social security organization, to prove eligibility for membership. In some cases, this tax return may be from the individual’s home country.
- Once a person becomes affiliated with the social security system, he or she receives a Carte Vitale (green card). This Carte Vitale provides proof of membership and access to French health insurance. Depending on the type of coverage received, this card either allows individuals to obtain healthcare at no-cost or a reduced cost.
Unlike France, Italy has a different healthcare system and is managed by the National Health Service (Servizio Sanitario Nazionale, SSN). Italy allows both EU and non-EU nationals to register with the SSN, and those who are not covered still qualify to receive free or low-cost emergency treatment when needed. Registration is either automatic or voluntary depending on the length of the stay. Individuals register at the local level by the Local Health Authority Service (Azienda Sanitaria Locale, ASL).
To register for the SSN, individuals must do the following:
- Determine whether they qualify for mandatory/automatic registration or voluntary registration.
- Mandatory registration – or by-right registration – is guaranteed to citizens staying for work, family, international protection, citizenship wait, fostering or adoption.
- Foreign citizens with a stay permit for more than three months and not entitled to automatic registration with the SSN can apply for voluntary registration.
- Go to the local ASL office and submit registration materials. Note that voluntary registration with the SSN follows a yearly income-based payment.
- The SSN card is then issued at the moment of registration.
The InformaSalute guide to the national health service contains more information about qualifying for healthcare in Italy.
What Kind of Coverage is Provided?
Not all plans in Europe work the same way or offer the same coverage. The UK’s NHS covers a wide range of treatments, including hospital services, emergency and urgent care, mental health services, eye care services, and even dental services.
While the French medical system (L’Assurance Maladie) covers nearly all medical conditions, the amount of reimbursement is dependent on the importance and cost of the care. For example, medicines recognized as irreplaceable and expensive are reimbursed at a rate of 100%, though small medical service drugs are only reimbursed at a rate of 15%. Full reimbursement information may be seen at the L’Assurance Maladie website.
In Italy, the SSN covers basic medical care (including emergency care), although the actual coverage varies depending on whether the individual has private health insurance in addition ot the public health coverage. Family doctors are covered entirely by the SSN, and while families are assigned doctors, they may change to a different doctor if they are dissatisfied. Prescription drugs are generally subsidized by the public health system, but over-the-counter drugs are paid for entirely by the patient.
Visits to Italian specialists and special tests either only require a copay or are free, depending on the income of the individual. However, wait times can be long for these procedures. If the patient chooses to obtain private health insurance, he or she may obtain treatment at private facilities much faster. Surgeries and hospitalization in Italian public hospitals (or conventioned private hospitals) are completely paid for by the national health system, regardless of income.
This is very different than the private insurance-based system in the United States. The recently-passed Affordable Care Act (ACA) allows individuals to shop for healthcare plans on state or federally-managed marketplaces. On these marketplaces, individuals can choose among plans based on their personal needs and budgets. Depending on an individual’s income level, he or she may qualify for a tax credit that effectively provides a discount on the monthly health insurance premium. While some plans include vision and dental coverage, these are often purchased as separate plans.
Much like how European healthcare plans vary from nation to nation, the health care options in the US vary from state to state. For example, California has a completely separate healthcare marketplace than other states. Most often, individuals in the United States receive healthcare through their employers. The ACA requires businesses with 50 or more full-time equivalent employees to either provide health insurance for their employees or pay a penalty. A part of the employee’s paycheck is used to help cover the cost of insurance, with the balance being paid for by the employer. Normally, employers will allow their employees to choose between a few different plans depending on individual needs. The chosen plan affects how much is taken out of each paycheck for insurance.
Who Pays for Health Insurance, Prescriptions, and Other Medical Expenses?
One of the most immediate differences between the US and the UK’s healthcare systems is who pays for coverage. The best word to describe the US healthcare system is 'individualist.'
The vast majority of Americans with healthcare obtain it through plans offered by employers or purchased privately. There are some programs in the United States, however, that allow those in lower economic classes and those above 65 to obtain government-sponsored healthcare. The health insurance marketplace is the best starting point for those who do not receive coverage through their employers.
In the UK, the National Health Service (NHS) is free as needed for all British residents. This includes foreign nationals and expatriates with a legal right to remain in the UK.
While those with private healthcare plans will usually receive the same quality of treatment as those with NHS coverage, the privately-insured receive care faster than those on the public plan.
The French and Italian systems function in a similar way. Once a person qualifies for coverage under a national plan, the cost of prescription medications and other medical expenses are usually subsidized. However, the amount of this subsidy may vary depending on a person's specific health situation, treatment received, and other factors unique to each situation. See the French and Italian healthcare sites for more information.
Health insurance provided by national programs in Europe may seem “free,” but in reality the costs are absorbed by the general populace through taxation. Thus, those living in Europe can expect to pay higher income taxes than those in the United States.
How Quickly Can I Obtain Treatment?
In the US, it’s common to pay more out-of-pocket for better healthcare. Many Americans will choose more expensive plans in order to choose their preferred doctors, experience shorter wait times, and receive generally better coverage. However, those with American healthcare plans should be aware of 'in-network' and 'out of network' care.
For example, if a person is insured by Blue Cross, he or she may only go to doctors or hospitals affiliated with the Blue Cross network. Otherwise, the individual may be responsible for paying for much more (or in some cases, all) of the medical care received while out of network. Out of network care is sometimes 10 to 20 times more expensive for patients than obtaining in-network care.
Although the option to purchase private health care gives the British the ability to “jump the queue” and access faster medical treatment, private health coverage in the UK is rare; only about 8% of Brits have it.
In Europe, those seeking healthcare generally have the following options:
- Hospitals: Used for emergency care
- Pharmacy: In many European countries, pharmacists can diagnose and prescribe treatment for many simple ailments, such as colds, UTIs, and muscle pain
- Clinics: Useful for those needing non-emergency care or obtain tests beyond a pharmacist’s scope
- House Calls: If a person is sick and unable to leave his or her home or hotel room, generally doctors will be available to perform house calls
- Doctor’s Appointments: If an individual needs to speak to a doctor to schedule a medical consultation (such as in the case of maternity care), the wait is often long due to the high volume of patients seeing doctors in Europe
This longer waiting period is typical across European healthcare systems without private insurance. Patients are advised to get in queues for predictable healthcare as quickly as possible to avoid delays.
How Do I Prepare for the Other System?
Those moving abroad to Europe or the US should take time to research that nation’s healthcare system and prepare to encounter these changes. Obtaining international health insurance before arriving in Europe will allow expats to be covered until they qualified for National Health System. Begin researching health care options today to feel confident and safe when you arrive.
Since 1947, Clements Worldwide has been a leading provider of international health insurance for expatriates and international organizations. Valid in over 180 countries, Clements Worldwide’s exclusive GlobalCare® health insurance plan is portable and provides coverage across borders. To learn more about expatriate health insurance and obtain a quote, visit Clements Worldwide.