Part of this equation is the extremely high health costs we pay here.  My brother recently went to the hospital with chest pains. Three hours in the emergency room and a stress test later his bill was in excess on $20,000. I have a friend who needs a knee replacement.  Her insurance company will fly her and her spouse outside to get the surgery done, and pay the spouse's hotel bills during her hospital stay because it will be cheaper than getting the procedure done in Anchorage at our local "nonprofit " hospital.