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When my 76-year-old mother-in-law was told she needed a dual-chamber pacemaker, our family’s attention shifted to one thing: getting her safely through the surgery. Joey was especially anxious. Living thousands of miles away, he struggled with not being there for his mother. Thankfully, the surgery went well.
As relief replaced worry, I found myself thinking about something entirely different. Her surgery took place in the Philippines, and her family’s share of the cost, after government health insurance paid its portion, was about $5,000. That got me wondering: What would the same procedure cost elsewhere?
In the United States, hospital charges for pacemaker implantation can run from $30,000 to $80,000 or more, although insurers typically pay much less. What patients ultimately pay varies enormously depending on their insurance.
In the United Kingdom, the cost to the National Health Service might be roughly $3,000 to $6,300, but an NHS patient generally pays nothing directly. In Denmark, the cost might be $5,000 to $10,000, but medically necessary hospital treatment is publicly funded, so the patient generally doesn’t receive a bill.
These aren’t perfect comparisons. A hospital’s billed price, an insurer’s negotiated price and the cost to a government healthcare system are very different things.
Same heart. Same pacemaker. Very different financial experience.
Ultimately, the cost of healthcare has a lot to do with what I think of as the lottery of birth. Where we’re born often determines the healthcare system we inherit and how much of the financial burden of getting sick falls on us.
Imagine four 76-year-old women: one in Florida, one in London, one in Copenhagen and one in Manila. All four develop the same problem with the electrical system of their heart. All four need the same basic treatment.
None chose where she was born or the healthcare system she inherited. Yet those circumstances may determine whether her family worries about a hospital bill, waits for treatment, or simply focuses on her recovery.
It made me wonder how much of our financial well-being comes down to advantages we rarely stop to think about: our citizenship, healthcare system, education, legal protections and even the currency we’re paid in. All can profoundly influence our financial lives, and all were decided before we could even speak.
Perhaps this struck me because I’ve spent much of my life crossing borders. I was born in England, spent part of my childhood in Bangladesh and eventually made my home in the United States. Joey was born in the Philippines, where we’re now considering making our home for part of the year. Each country has shaped the opportunities and choices available to us.
I’ve been fortunate in ways that had little to do with any decision I made. I didn’t choose where I was born, the family I was born into or many of the opportunities that came my way. What I could choose was what to do with those opportunities. The older I get, the more I appreciate the difference between what we earn through our efforts and what we’re simply fortunate enough to receive.
My mother-in-law’s experience also challenged some of my assumptions. She received sophisticated cardiac treatment in the Philippines for a fraction of what an American hospital might charge, yet the experience wasn’t impersonal. The doctor overseeing her care messaged Joey directly to tell him how the surgery had gone and responded again when Joey later had concerns about her medications.
That personal attention meant a great deal to a son sitting thousands of miles away.
My mother-in-law didn’t choose the healthcare system she was born into any more than I chose mine. What mattered that day was that when her heart needed help, the technology and people were there to provide it.
For our family, the most important number wasn’t $5,000, $30,000 or $80,000. Those numbers became irrelevant once we heard her surgery had gone well.
In the end, what mattered wasn’t what her pacemaker cost, but what we hope it gives her: more time with the people she loves, and more time for us to love her.
Perhaps It goes without saying, but the importance of having positive people around you is vitally important. People who encourage and believe in you. I’d take that over living in any particular country (within reason). I’ve written before about my hard scrabble upbringing. I experienced a culture of negativity, right here in the USA and was fortunate enough to be exposed to more positive people who encouraged me to try (here and abroad). People matter. If you have negative people around you, seek out the ones who will believe in you.
I completely agree. Perhaps the people who enter our lives are another part of the lottery. A supportive parent, teacher, mentor, friend or spouse can change the direction of a life in ways that money or geography sometimes can’t.
I’ve been fortunate to have people who believed in me at important moments, and looking back, I can see how much that mattered. You’re also right that we have some control over this part of the lottery. We may not choose the environment we’re born into, but as adults we can choose which voices we listen to and which people we surround ourselves with. People really do matter.
Ha ha – my first thought was the choose your parents carefully. Even taking quite notionally similar developed nations there can be vast differences in teh interplay of systems.
Most Europeans benefit from affordable healthcare but at a level of taxes, Americans would consider unpalatable and a highly regulated insurance market. So Americans in similar positions probably earn more net, have more consumption and toys but then cannot retire as early because they get trapped until they qualify for Medicare.
A while back I did consider whether I should think about retiring to one of a few specific locations in the US chosen for lifestyle purposes. But the slightest research into healthcare made it a non starter. Plus y’know what the population have decided the US should be more recently via actions at the ballot box.
I had a conversation yesterday with someone in my gym. I commented on what a TV showed on a TV screen regarding the market performance that day. He said he had given up on the stock market. I asked him why. I told him how it had helped retire at 62. He said he was 77 years old and working part time. I asked him if this was for something to keep him busy or out of necessity. He said he was foolish when he was younger and didn’t consider his older self. He figured Social Security would be all that was necessary.
I think he has plenty of company here in the US.
Thank you for the comment, its good to hear from you. You make a good point that the lottery of birth isn’t simply about which country has the cheapest healthcare. Every system comes with trade-offs. Higher taxes may help fund healthcare in one country, while higher take-home income and greater personal responsibility for healthcare may be part of the equation in another.
I hadn’t thought about healthcare affecting the timing of retirement quite that way, but you’re right that for many Americans, access to employer-provided health insurance can influence when they’re comfortable retiring. It reinforces my larger point: the system we’re born into shapes not only what we pay for healthcare, but some of the financial choices we’re able to make throughout our lives.
This reminds me of the saying “Choose your parents very carefully”. My parents were blue collars but were great providers and provided a solid foundation for our success.
Jerry, I like that saying, and it’s always good to hear from you. We certainly don’t get to choose our parents, but having parents who provide a solid foundation can be one of the biggest advantages we’re ever given. It doesn’t necessarily require wealth, either. Love, stability, encouragement and good values can provide opportunities that are difficult to put a dollar value on. Thanks for adding that perspective.
Glad to read that your mother-in-law is doing well. Would be interested in future reports on your plans to relocate.
I am very aware of the importance of the birth lottery – when, where and who your parents are are critically important – but there is also a genetic lottery. Are you male or female? If you are born in Afghanistan, for instance, that’s a gigantic difference, but it it matters everywhere. Are you good-looking? I’ve seen research that says that affects whether you are hired, promoted, popular etc. Do you have all your senses in good working order? I have a genetic cornea disease – much improved by surgery, but the availability of that surgery is recent and localized. How intelligent are you? Are you more likely than the average to develop heart disease, cancer, Parkinson’s, Huntington’s, Alzheimer’s?
I have always had trouble with the idea that anyone can “pull themselves up by their boot straps”. First you need good boot straps. Recent research discovered that impoverished children who live in better off neighborhoods do better.
Call it luck/karma/serendipity/providence … As I like to point out when the subject is brought up here – a quarter of a million people are struck by lightning worldwide each year.
Thank you. I really like your point about the genetic lottery. We don’t choose our health, intelligence, physical abilities or countless other characteristics any more than we choose our birthplace or parents. And your own experience with a corneal disease adds yet another layer, the luck of being born at a time and place when a treatment is actually available.
I also like your line that before we can pull ourselves up by our bootstraps, we first need good bootstraps. Hard work and personal responsibility matter, but so does recognizing the advantages that allowed that hard work to bear fruit.
And yes, I suspect there will be plenty to write about as Joey and I begin spending more time in the Philippines!
All true, but there are many exceptions of individuals who overcame tremendous odds, hardship, misfortune, failure and did raise themselves up. I doubt “anyone” can pull themselves up, but I bet it is far more than actually do so.
Why do you think some people who could raise themselve up fail to do so? I suspect you think it is solely their fault. However, that explanation fails to make any effort to understand why someone would choose to remain poor and unsuccessful. It also ignores such things as research on identical twins reared apart that found that the personality trait of conscientious, which includes plan unless, goal setting, has a heritability of 45%-50%. (Conscientiousness subtracts include achievement striving, planfunless, dutifulness, competence, and self-discipline.) You also ignore enviornmental factors such as having spendthrift parents. While you brought yourself up from a very modest childhood, your clearly won the intelligence lottery and I suspect to also won the genetic portion of the conscientiousness lottery.
The cliche that “the exception proves the rule” is a cliche because it is true. “Many” is an exaggeration.
Andrew:
The phrase “lottery of birth” has never been more succinctly exemplified for me than it is in your excellent article’s example.
Putting all the political differences aside that currently divide our country, few if any US Citizens would willingly give up their citizenship to live in another country.
For the few that would, they are free to leave.
The lottery of birth is real, and I for one am glad I won that lottery 76 years ago!
Mike, thank you. I think gratitude is an important part of recognizing the lottery of birth. I’ve certainly benefited enormously from making my life in the United States, just as Joey’s mother benefited from having access to the care she needed in the Philippines. For me, the larger lesson is simply to recognize how much of what shapes our lives was determined before we ever had a say in it, and to be grateful for the opportunities we’ve been given.
Andrew, I want to begin by saying that I’m happy that Joey’s mom got the care she needed, and that the results were a success. It’s amazing how we take for granted the efficiency of that little medical device. It’s also amazing that the costs of delivering medical services vary so much from one country to the next.
Your post illustrates still another way that people are affected by the lottery of birth. While the women in your example from Florida, London, Copenhagen and Manila all got the care they needed, many in other parts of the world would not have been so lucky.
Dan, thank you, and you make an important point. My four women were born into very different healthcare systems, but they all had access to the technology and medical expertise needed to treat them. Millions of others aren’t nearly as fortunate. Perhaps that’s another part of the lottery of birth we too easily overlook. Not simply what healthcare will cost us, but whether the care we need is available to us at all.
Thanks for adding that perspective.
Andrew, thanks for a thoughtful, and thought-provoking, story. I’m happy your mother-in-law was able to receive quality care and wish her the best.
As I write this, I’m sitting in our sun room that has a wall full of pictures of my wife’s and my family. All 4 of her grandparents emigrated to America (2 from Ireland, 2 from Italy). They all left family behind, but none ever returned to their birth country. My wife’s maternal grandmother left Sorrento, IT as a young woman to be a governess in America. She never saw her parents again. When I think about the birth lottery, the era you were born in makes a great difference. I’m glad that Joey, and you, can communicate instantly with Joey’s mother, and visit, and consider living there part-time. I’ve written about the concept of societal wealth – it still fascinates me.
Rick, thank you, and you raise a wonderful point that I hadn’t considered, the lottery isn’t only where we’re born, but when we’re born. I can’t imagine leaving my family for another country knowing I might never see them again. Joey may have been thousands of miles from his mother during her surgery, but he could communicate with her and even hear directly from her doctor almost immediately.
Your point about societal wealth also fits perfectly. We inherit not only the healthcare and economic systems of the country where we’re born, but also the technology, infrastructure and accumulated progress of the era we’re fortunate enough to live in. That’s another form of wealth that’s very easy to take for granted.
Thanks for adding another dimension to what I was trying to express.
You make a valid point, but let’s also consider many other factors like the difference in standard of living and overall cost of living in the countries you mention.
Your example of a 76 year old doesn’t help your case because those of us on Medicare have the best insurance and in your example the patient portion would be less than $5,000. Also, on a cost basis, let’s not forget the lifelong taxes that make “paying nothing directly” possible.
Nevertheless, we would be far better off and have a much fairer system using a universal model in place of the disjointed system we have.
Thanks. I agree that cost of living, taxation and many other factors make these comparisons far more complicated than the numbers alone suggest. That’s why I noted that what a U.S. patient ultimately pays varies enormously depending on insurance, and that hospital charges, negotiated prices and government healthcare costs aren’t perfect comparisons.
My larger point wasn’t that a 76-year-old American on Medicare would personally pay $30,000 to $80,000. It was that where we’re born largely determines the healthcare and tax system we inherit and how our medical care is ultimately financed. Even the lifelong taxes you mention are part of that lottery of birth.
Thanks for adding another dimension to the discussion.
I understand, but as you know where we are born impacts virtually every aspect of our lives. That is even true among the various US states. Heck, my friends in Europe don’t have air conditioning 😎
Another wonderful article, thanks Andrew.
I think a lot about how lucky I have been, and work on being grateful for all the good fortune that has come my way.
It’s easy to think that working hard and making some good decisions would achieve similar results regardless of where we are born. But if I was born in central Africa rather than Australia, there is no way that I would have achieved what I have in life.
Absolutely true Greg – I have never been a member of the “The harder I work the luckier i become” club. The lottery of birth thing is real
Greg, thank you. I think that’s exactly it. Hard work and good decisions certainly matter, but they don’t happen in a vacuum. Where we’re born can determine the education, healthcare, security and opportunities available to us before we’ve made a single decision for ourselves. I’m increasingly aware that while I can take some credit for what I did with the opportunities I was given, I can’t take credit for having been given them in the first place