Mike and Denise Demeny didn’t leave the United States because they fell in love with Italian wine or Renaissance art. They left because American healthcare was going to bankrupt their retirement.
The couple, both in their early 60s, pulled up stakes from Texas and resettled in the medieval Tuscan town of Lucca. Their reasoning was brutally pragmatic: in the years between early retirement and Medicare eligibility at 65, private health insurance in the U.S. would have consumed roughly $2,200 a month. That’s more than $26,000 a year — just for premiums — with no guarantee that a major medical event wouldn’t still wipe out their savings through deductibles and out-of-pocket maximums.
In Italy, they enrolled in the country’s national health service, the Servizio Sanitario Nazionale. Their annual cost? Around $800 combined, according to Business Insider. That’s not a typo. Eight hundred dollars a year for two people, covering doctor visits, hospital stays, prescriptions, and specialist care.
The Demenys are not an anomaly. They represent a swelling current of American retirees — many of them financially comfortable, not destitute — who have concluded that the math of retiring in the United States simply doesn’t work anymore. And healthcare is the line item that tips the ledger.
The numbers tell a stark story. According to Fidelity Investments’ most recent annual estimate, a 65-year-old couple retiring in 2024 should expect to spend approximately $315,000 on healthcare costs throughout retirement — and that figure assumes they have Medicare. For those retiring before 65, the gap years are even more punishing. Marketplace plans under the Affordable Care Act can easily run $1,500 to $2,500 per month for a couple in their late 50s or early 60s, depending on geography and income. Subsidies help some. But for retirees with substantial 401(k) distributions or pension income, those subsidies often evaporate.
Mike Demeny told Business Insider that the couple had carefully modeled their retirement budget and realized that staying in Texas meant either continuing to work or watching their nest egg erode at a rate they weren’t comfortable with. Healthcare wasn’t the only factor. But it was the decisive one.
Italy offers a particular advantage for American retirees. The country’s elective residency visa, designed for non-EU citizens who can demonstrate sufficient income or savings, provides a relatively straightforward path to legal residency. Once resident, foreigners can enroll in the national health service by paying an annual contribution — typically between €388 and €700 per person, depending on income category. The coverage is comprehensive. Primary care, emergency services, hospitalization, specialist referrals, and prescription drugs are all included, with minimal copays for some services.
The Demenys aren’t roughing it. Lucca, a walled city in northern Tuscany with a population of about 90,000, is the kind of place that makes Americans question every assumption they’ve ever held about quality of life. The couple told Business Insider they spend less on virtually everything — groceries, dining, transportation — than they did in Texas. Their overall cost of living dropped by roughly 40%.
This is the part that confounds the conventional American retirement playbook. The standard advice for decades has been: pay off the mortgage, downsize, maybe move to a lower-cost Sun Belt state, and hope your savings last. But the Sun Belt strategy has its own problems now. Property insurance in Florida and Texas has skyrocketed. Property taxes in Texas, which has no state income tax, are among the highest in the nation. And healthcare costs keep climbing at rates that outpace general inflation year after year.
The Great Calculation: When Leaving America Becomes the Rational Financial Choice
What’s changed isn’t that Americans have suddenly discovered Europe. It’s that the financial calculus has shifted so dramatically that expatriation has become the logical move for a growing cohort of retirees. The convergence of several forces — healthcare inflation, housing costs, the strong dollar relative to the euro for much of the past decade, and increasingly accessible visa programs in countries like Italy, Portugal, Spain, Greece, and France — has made the decision less romantic and more actuarial.
Portugal’s Non-Habitual Resident tax regime, though reformed in recent years, drew thousands of American and British retirees with its favorable tax treatment of foreign-source income. Spain’s non-lucrative visa serves a similar function to Italy’s elective residency permit. Greece has been aggressively courting retirees with a flat 7% tax on foreign pension income. France, despite its reputation for bureaucratic complexity, offers excellent healthcare access through its national system once residency is established.
The healthcare savings alone are staggering across all these destinations. Spain’s public healthcare system, consistently ranked among the top ten in the world by various measures, costs resident foreigners a fraction of what comparable coverage would run in the U.S. A recent report from International Living noted that many American retirees in Spain spend less than $100 a month on healthcare, including private supplemental insurance that provides faster access to specialists and private hospital rooms.
But Italy has emerged as perhaps the most popular single destination, for reasons that go beyond the numbers. The food. The climate. The walkability of Italian towns and cities, which confers its own health benefits. The social infrastructure — piazzas, markets, neighborhood life — that combats the isolation many American retirees experience in suburban settings. The Demenys told Business Insider that their social life in Lucca is richer than it ever was in Texas.
There’s a counterargument, of course. Skeptics point out that European healthcare systems involve wait times, that bureaucracies can be maddening, that language barriers are real. All true. Mike Demeny acknowledged to Business Insider that the Italian healthcare system isn’t perfect — appointments with specialists can take weeks, and the bureaucratic process of enrollment required patience. But he also noted that the quality of care he and Denise have received has been excellent, and that for routine and preventive care, the system works well.
The wait-time criticism also deserves context. Americans routinely wait weeks or months to see specialists domestically. A 2023 survey by Merritt Hawkins found that the average wait time to see a physician across 15 major U.S. metro areas was 26 days, with some specialties averaging far longer. The difference is that Americans pay enormously more for the privilege of waiting.
There’s also the question of what happens when these retirees turn 65 and become eligible for Medicare. Medicare generally does not cover care received outside the United States. Some expat retirees return. Others don’t, having concluded that their adopted country’s healthcare system serves them better regardless. Some maintain a U.S. address and Medicare enrollment as a safety net, traveling back for major procedures if needed. It’s a patchwork approach, but many find it workable.
The tax implications are real but manageable. U.S. citizens are taxed on worldwide income regardless of where they live — one of only two countries in the world (the other being Eritrea) that taxes based on citizenship rather than residency. However, the Foreign Earned Income Exclusion, foreign tax credits, and tax treaties between the U.S. and most European nations prevent double taxation in most scenarios. Retirement income from Social Security, pensions, and retirement account withdrawals is generally taxable only in the country of residence under most U.S. tax treaties, though the specifics vary by country and income type. Competent international tax advice isn’t optional here. It’s essential.
The trend shows no signs of slowing. The State Department doesn’t track how many Americans retire abroad, but estimates from various sources suggest the number of U.S. citizens living overseas has grown to somewhere between 5 and 9 million, with retirees representing a growing share. The Association of Americans Resident Overseas has noted increasing inquiries from people in their 50s and early 60s — exactly the demographic most squeezed by the healthcare gap.
And the political environment in the U.S. may accelerate the trend. Ongoing uncertainty about the future of the Affordable Care Act, potential changes to Medicare eligibility or benefits, and the broader trajectory of healthcare costs all feed the anxiety that drives people like the Demenys to look elsewhere. When you can’t predict what your healthcare will cost five years from now — or whether your coverage will even exist in its current form — a system that charges $800 a year and covers everything starts to look less like an adventure and more like the only rational choice.
Not everyone can do this, obviously. You need savings or reliable income. You need the willingness to deal with visas, foreign bureaucracies, and the emotional weight of leaving family and friends. You need to be comfortable with ambiguity. The Demenys had the resources and the temperament. Many don’t.
But for those who do, the proposition is increasingly hard to argue against. A couple in their early 60s with $800,000 in retirement savings faces a very different future in Lucca than in Dallas. In Texas, healthcare costs alone could consume $150,000 or more before Medicare kicks in. In Italy, that same period costs under $5,000. The difference isn’t marginal. It’s the difference between financial security and financial anxiety.
Mike Demeny put it plainly to Business Insider: they didn’t move to Italy to escape America. They moved because staying would have meant sacrificing the retirement they’d spent decades working toward. The healthcare system didn’t fail them in a dramatic, newsworthy way. It just priced them out. Quietly. Relentlessly. The way it’s pricing out millions of others who haven’t yet done the math — or who have, and are now looking at real estate listings in Tuscany.
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