Jennifer Sontag cracked her skull and couldn’t afford emergency brain surgery. Her doctors suggested she start a GoFundMe.
“Their advice was, ‘You’ve got to get the surgery. You’ll work it out later,’” she said. “And I’m like, ‘Are you kidding me? Your advice to someone in a medical crisis is to beg for money?’”
Sontag, 52, was teaching business management in China in 2019 when she fell while exiting a bus and hit her head so hard that it caused a leak of cerebral fluid in her brain. She spent five days in a hospital in Shanghai before her worried family persuaded her to get the necessary surgery close to them in St. Louis.
Her hospital bill in China came out to roughly $1,300, she said. In Missouri, she negotiated the price of her operation down to about $100,000, resigning herself to a life of medical debt.
Sontag, an entrepreneur who for years owned clothing boutiques in St. Louis and Kansas City, had moved to China largely because she had become fed up with the U.S. health care system.
A decade before her fall, in the United States, she married her boyfriend “purely to get health insurance,” she said, because she was already struggling to afford care for Crohn’s disease, a chronic inflammatory bowel condition.
Within a year of getting married, she suffered a ruptured bowel, had emergency surgery and was saddled with some $20,000 in medical bills. She eventually filed for bankruptcy, unable to afford the costs as her illness stopped her from working. “Even with his medical insurance, the co-pays and deductibles were so high that we still could not keep up,” she said.
Years later, the couple divorced, and Sontag said she knew she had “no other options” but to leave the United States.
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‘The most expensive health care system in the world’
Sontag is part of a small and largely unstudied group of Americans who have decided to leave the United States permanently because of their concerns over health care costs. They’ve instead chosen countries with socialized medicine, universal health care coverage or lower medical costs.
“For anybody who has a chronic illness, for people who are middle class, people maybe lower on the income scale, this might be a very, very strong motivation to move to a country that has a more comprehensive health care system that is also less expensive,” said Gerald F. Kominski, a professor emeritus at UCLA’s Fielding School of Public Health.
More than 30 countries have universal health care, according to a 2022 list from the New York state government, and many others offer some form of socialized medicine or government-subsidized care.
“It’s widely known and has been in our field for decades that the United States is the most expensive health care system in the world, any way that you want to measure it,” Kominski said.
In a system where most people pay into employer-provided health insurance plans, those who are self-employed like Sontag can suffer long gaps in medical coverage. Many are too young to qualify for Medicare and too well-off for Medicaid.
And health insurance isn’t a complete safety net, either. More than 40 percent of Americans are in some form of medical debt, according to the KFF, even though the latest U.S. Census Bureau figures show that about 92 percent of Americans were insured for all or part of 2023. Experts say the United States stands out from most other developed nations in that it has no stop-loss provision, or limit, on the amount of medical debt a family can be burdened with.
“Even among the best-insured in the employment sector, there are still individuals who, depending on the condition they have - depending on whether their company provides generous benefits or only high-deductible plans - can find themselves facing very large health expenditures,” Kominski said.
Now, Sontag lives in the beachside city of Palermo, Italy, where she’s still paying off her U.S. medical debt but can access tax-funded national health care with no out-of-pocket costs. She declared citizenship through her family heritage and started a concierge business that helps other Americans apply for citizenship or obtain visas. Roughly three-quarters of her clients cited health care costs as one of their primary motivations, she said.
Business is booming, especially since President Donald Trump’s election, she said, and she recently expanded her relocation services to Spain. Clients have cited their concerns over the future of Social Security, protections outlined in the Affordable Care Act and children’s special-needs services.
“I live five minutes from the sea. I’m surrounded by the mountains, I can go to the doctor, I can eat good foods without pesticides - my Crohn’s disease is very under-control now,” she said in a video call from a beachside terrace. “But, you know, the resentment is always there. My mom has Alzheimer’s. I can’t be with her, and I’m afraid to go back to the U.S. because I don’t have health coverage when I’m there.”
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Lower costs, even without insurance
Jason Kim, a 25-year-old crypto trader who grew up in Texas, was first confronted with a big medical bill when he was 19. Unaware of the cost of an ambulance ride, he called 911 and was taken to a hospital in New York City, where he was diagnosed with jock itch. The bill came out to about $50,000, he said.
The next day, he signed up for Medicaid. The bill ended up getting covered, but the experience made him afraid to go to the doctor for years.
It wasn’t until he moved to South Korea - a place he hadn’t lived since he was 13 - that he sought help for skin issues and an increasingly severe case of gastroesophageal reflux disease. He was easily able to afford an endoscopy and other treatments there, even before he received coverage under the government-subsidized national health insurance plan, which all residents are eligible for. He now lives in Seoul on a visa secured through his Korean heritage.
“I feel like health care in America is a kind of fraud,” he said. “They overbill you, and when you speak to them and try to negotiate, they lower the bill.”
Kim said he left the U.S. because he couldn’t afford quality health insurance while self-employed, and because of the overall cost of living.
“I do miss America,” he said. “I miss the bigger roads, the bigger personal space, the better air quality. … It’s livable if you have the right coverage.”
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Choosing between coverage and making a living
Amy Willard, 61, survived cancer three times between 2009 and 2011: breast cancer twice and metastatic melanoma, a disease that had taken her mother’s life.
In Colorado Springs, she ran a small housecleaning business for about three decades, never making over $40,000 a year. She bounced in and out of health care coverage, often earning too much to qualify for Medicaid but too little to afford the $600 to $800 in monthly insurance premiums she was quoted.
“If there’s a crack, I always somehow manage to fall right into it,” she joked.
At the peak of her health crisis, Willard had 11 cancer surgeries and was able to get Medicaid to cover them all. But she only qualified because she was too sick to work more than a few hours a week, causing her income to spiral.
Once Willard was in remission and able to make more money, she lost her Medicaid coverage but couldn’t afford private insurance plans, making follow-up care a financial burden. “It was a lot of food stamps, a lot of social help, a few donations from friends. There were definitely some lean times, that’s for sure,” she said.
After the coronavirus pandemic devastated her cleaning business, she started thinking about an out. That’s when she remembered her dreams as a preteen girl mesmerized by a French teacher “who brought in croissants and spoke this beautiful language.” She started making plans to move to a village in southwest France.
“We get older, things start going on, and we need more regular health care,” she said. “And I thought, ‘I really can’t afford to be here.’”
She now lives in Saint Gaultier, about a four-hour drive southwest of Paris, on a renewable one-year visa that she hopes to roll into a more permanent status. She runs a small Etsy shop from her home along a small river, where she says she enjoys listening to the birds in the morning.
Every time she visits the local clinic, she pays a flat fee of 25 euros (about $29), and all of her medications total about the same per month - a price so “insanely reasonable” that she is okay living without comprehensive health coverage for now, she said.
The French government requires those who apply for her visa to initially obtain a private plan that covers serious medical emergencies and disasters, so she has a policy that costs her about $350 a year. She applied to join France’s national health care system last year.
Then, this past June, Willard was suddenly hospitalized for nine days over anemia so severe that she needed four transfusions of blood, she said. She was diagnosed with a gastrointestinal tumor about the size of a grapefruit, and will need major abdominal surgery.
French health care workers told her not to worry about the costs, saying her national health insurance card was being expedited. So far, she has not had to pay for her hospitalization or her two ambulance rides, and she says she regrets waiting so long to go to the hospital.
Americans “often must weigh the risk of financial ruin against how sick we feel,” Willard said. “It’s shameful that this is so deeply ingrained to us ‘poorer’ folk. I nearly died.”
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