American t1d now 2+ years in New Zealand. Here's some of what I've learned

Type 1 and LADA
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I’ve been part of these forums for many years now and, like many, became a reluctant expert in navigating health insurance for my diabetes.

My family migrated to New Zealand July 2022 and have been using the publicly funded NZ healthcare system.

Now that I’ve been removed from the madness of US healthcare for 2+ years, I have developed both a profound sympathy for the people behind the stories I read here, profound disbelief at the absurdity of it all, and anger that absolutely nothing is being done to fix it.

Seniors having to navigate Medicare- I still have no idea how that system works, but people seem to generally be happy with it (despite the occasional complaints, but that happens here in NZ as well). People are thrilled to have insulin capped at $35/month, but here in New Zealand my insulin costs me nothing out of pocket.

I’ll get to the downsides in a minute, but there are significant upsides. For example, the only thing Kiwis pay for out of pocket is GP appointments-- we never see a bill for anything the GP refers you to (e.g. lab work, specialists, procedures, etc.) All prescriptions cost $5/month (or $10 for 90 days) but larger pharmacies like Woolworth’s and Chemist Warehouse waive this fee. Even insulin pumps and (as of Oct 1, CGMs!!) are $5/$10/free at the pharmacy. News of CGM funding was a huge relief as I was paying nearly $1,138.50 NZD ($700.87 USD) out of pocket every 90 days. Now every type 1 diabetic in NZ (about 18,000 people) will have effectively free access to hybrid closed loop tech. The pumps available in NZ are T:Slim X2 and Ypso Pump-- Medtronic pumps and sensors have been discontinued as part of the CGM funding proposal, except for patients who make an appeal for exceptional circumstances. So here you see a big downside in lack of choice. When medical services are provided by a limited pool of public tax dollars, they government has to make some choices that are not popular with everyone. Consider how the US medical system is awash in trillions of private health insurance payments; I doubt anyone ever has to ask about how to divvy up the money to maximize the public good. Each insurance company is going to try and maximize their own profit/minimize expenses without any thought at all given to the public good.

More downsides are that your GP might refer you for a publicly funded service, and the service might deny you, or triage your case to a waiting list based on urgency. Also, you will be assigned a specialist; you don’t get to pick who you want to see. If you have an urgent diagnosis (let’s say an irregular scan that might be cancerous), you will be seen very quickly. But if you’ve got chronic sinus infections and need sinuplasty (like me), you might months to see a specialist, and wait a year for surgery. But I will never see a bill for the surgery and hospital stay (I stayed one night). Plus, the surgeon who operated on me was an American.

Also NZ isn’t known for having the most modern treatments. Certain expensive cancer medications aren’t funded, so people can turn to crowdfunding for medical care just like in America. This is a horribly embarrassing thing for New Zealand, and tragic for the families that must endure this.

Fortunately, there is a workaround for this in private health insurance(!). If you can afford it, private health insurance allows you a lot more flexibility and choice in your care. The public system denies your colonoscopy? There will be a private GI clinic that would be glad to take your money (or the insurance company’s money), and in these scenarios you can certainly choose your doctor. Private insurance can also pay for drugs that are otherwise not funded by the public system.

I pay $340 NZD ($209 USD) monthly for a Southern Cross plan which covers nearly everything at 100%, including GP visits. Considering I literally pay almost nothing else for my healthcare, as an American it feels like a bargain.

We also have reciprocal agreements with UK and Australia public health systems, so when we travel there we have some certainty (though they do still recommend purchasing travel insurance).

Private insurance is allowed to exclude pre-existing conditions like diabetes (this was very unfair in the US, but makes sense in a country which has public healthcare; the public system is purpose built for covering everyone for everything.) On my plan I will earn pre-existing condition cover after 3 years of paying premiums.

Lastly, there is a national insurance program called ACC which covers everyone in New Zealand for accidents. Even if you’re visiting New Zealand for vacation are aren’t otherwise covered by the national healthcare, if you’re injured in any kind of accident (whether you are in a car accident or drop something heavy on your toe), you’ve covered by ACC which generally pays 100% for your ambulance ride, your hospital visit, and will pay for part of visits to a GP, physical therapy, chiropractor, nurse visits, etc.

I have no idea if anyone other than me finds this interesting or useful, but I just felt compelled to share my experiences and thoughts with the t1d community here. Now when I hear Bernie Sanders talk about healthcare as a human right, and “Medicare for All” should be provided at no out of pocket cost, it doesn’t sound so crazy; I’m living it.

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Your summary seems very fair. I appreciate it. Paying for private health insurance within a public system like you do really seems like the best of both worlds and the price is a huge bargain compared to what I pay in premiums and uncovered costs. There’s obviously an increased tax burden that might be hard to calculate across countries with all the variables but it’s still useful to know what the lived experience of a fellow diabetic abroad is.

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Regarding the increased tax burden, we have a progressive tax rate like in the US and it’s quite similar. In the US we were at 33% and here is 35%. This is taken out of payroll as a consistent chunk (known as “PAYE”) and never changes (unless your base salary changes… Of course it will change if you are an hourly employee). All of the social benefits including ACC come out of PAYE; we don’t have half a dozen line items like social security, state tax, federal tax, unemployment tax, etc. It’s all one lump sum that covers everything.

Plus, I consider US health insurance premiums, copays, coinsurance and deductables a defacto tax; the amount you get to keep from each US paycheck is probably much lower than what we keep here. That said, salaries in the US are higher (and real estate and necessities like food and electricity tend to be less expensive as well). An expat friend of ours told us to expect to pay twice as much for half the house, and that’s proven to be true. We’re living in a tiny two-bedroom 2 bath townhouse whereas in the US we were in a four-bedroom three-bath. But we’re also in a much bigger city with fantastic access to public transportation in the train and a block away from a beautiful river walkway. My wife takes the train to work and doesn’t have to deal with traffic anymore and that’s worth a lot.

But it’s not really fair to say that NZ has higher tax when you don’t take into account all of the other costs associated with US healthcare that we don’t have to pay here.

Whether it’s a tax or a de facto tax (like health insurance premiums) what matters in the end is how much income actually lands in your bank account. I don’t have hard data to back up which country would be greater, but I can say that not having to deal with the stress of wondering if my diabetes care will go away if I lose my job is worth quite a lot to me personally. And the only healthcare Bill I receive is my monthly insurance premium, or the occasional extra that my private insurance doesn’t pay. For example it only covers $60 per Chiropractic visit, so I have to pay anything more. I’ve had some chiropractors charge $70 and others $55.

And yes I agree, having a public system which captures everybody, augmented with the benefits of private health insurance, is really an ideal situation.

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Live in United States. On Medicare. I think insulin should be 0 copay. It’s not a new drug. Greedy greedy drug companies. Used to be covered under DME with a pump bit not now. On MDI it is $70 a month. A lot for seniors.

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Hi Jane, so you think the New Zealand system as I’ve described it could ever work in the US?

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Honestly our system needs a complete overhaul. I am in the medical field and am appalled at the way we do business with the pharmaceutical companies. All greed and political favors. There is no reason why kids should go without medical care. All ages but kids bother me. I am aware that no system is perfect but if we took the best from all socialized medicine it would be a start. Too much money involved. :pleading_face:

Jane Cerullo

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I didn’t mention it but children (under 14) in New Zealand receive completely free care on the public system. (GPs wave their fees)

Also a big missing element in US is price controls. In NZ, Medsafe functions like the FDA, approving meds that can be used in NZ.

Pharmac is the agency which negotiates prices, and it’s done in a competitive way where companies submit competing bids for access to NZ customers. If their tender is accepted, NZ gets free access to those drugs and the competitor can still sell in the NZ market but at an unsubsidized price. Because drug prices overall are much lower, they cannot change US prices and still be competitive (especially when there’s a free alternative). Sometimes this works against us and they will withdraw the product completely from the market, cutting their losses, but other times we get an alternative at much lower prices than you would see the same stuff sold for in the US.

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No for two reasons. One is the US is too big. Two is the it would require a culture change that would result in the failure of the US economy.

Your description failed to mention the 15% GST aka VAT aka sales tax and that the NZ healthcare system is run without sufficient capacity to handle unexpected events. Personally not being able to choose a doctor doesn’t work for me. Fixing healthcare in America is mostly an economic problem not a people with diabetes problem.

Now if you want to talk able changing the US ice cream industry to produce product as good as what NZ makes I’m all in. Even the big chains like Kapiti do better than what I can get at my local hand made ice cream shop. Know a way I can get some in the US?

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Hi spdif

A few clarifications.

You do get to freely pick your GP who is your primary contact for all health concerns (these are privately run practices which receive a government payment for each patient they see) which is why you have to pay anywhere from $40-70 per visit. Private means you pay.

You do NOT get to choose specialist when you’re referred to the public system. So my GP refers me to the diabetes service at the public hospital, and I get assigned an appointment and a doctor. No choice.

But if you have private insurance (or choose to self-pay at a private specialist clinic) you can freely pick who you want to see.

Of course if you’ve got a pre-existing condition (like T1D) you’re going to be locked out of the private insurance option for claims related to that.

However, my particular policy (Southern Cross UltraCare+) will cover my diabetes and all of my pre-existing conditions after 3 years of paying premiums. So I will eventually have the ability to choose a private endocrinologist. My policy covers $10,000 in specialist consultations per year, and private specialist consultations cost about $400. Insurance pays 100% of these visits up to annual max.

Regarding GST, we have a different mindset from the US because GST is implemented universally and largely invisibly. GST is baked into all prices, not added on after the fact like sales tax. The advertised price is the price you pay, so as a consumer in NZ you don’t really need to even think about it. The price is the price. Yes, it exists but it’s added to everything universally, so it’s really a non-issue. Everyone competes on GST-included prices.

And even with the GST, you have to consider the benefits you’re gaining. $0 prescriptions. $0 insulin pump. $0 CGM. $0 oral meds. No risk of ever losing your cover. There’s significant and immediate benefit, even with the tradeoffs of lack of choice (which again is mitigated with private insurance)

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Hello. Was flying across country yesterday so now I am home in Arizona. That’s was my point. Our politicians refuse to have any type of competitive bids with the pharmaceutical companies due to greed and payoffs. Don’t really care about people. Medicare has somewhat of an edge but there is so much fraud. So much greed.
On a lighter note I really enjoyed your former PM Jacinda Ardern. She was on the Stephen Colbert show a few times and he made a trip to New Zealand. He is a lord of the rings junkie. And hobbits. I would love to visit. Maybe someday.
Jane

Jane Cerullo

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How does that work for insulin? Does that mean patients may be forced to switch periodically between different brands of insulin, like Lantus (Sanofi) and Abasaglar (Eli Lilly)?

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As far as I know, insulins in NZ have been stable for quite some time. We have Humalog, Novalog and Lantus available. All provided at low or no out of pocket cost. ($5/30 days, $10/90 days, or free at big chain pharmacies which absorb the fee).

None of the newer insulins are available here. I don’t know exactly why; nothing would prevent Afrezza, for example, for submitting a tender to Pharmac to provide it to Kiwis (at which point the price negotiation would begin to ensure it fits within Pharmac’s pubic health budget).

Price negotiation happens in the US, but each individual insurance company or hospital does their own price negotiation, they’re not negotiating for access to an entire population of consumers. (Imagine for a moment if the US Government had an agency in charge of negotiating drug prices for all 300,000,000+ Americans?)

Perhaps that Afrezza (or other more modern insulins) is not here is an oversight, or perhaps it’s a business decision (we only have a population of 5 million) so profits are limited. Personally I found fiasp and similar ultrarapids to be of minimal benefit over Humalog and in some ways it was worse (causing major pump site irritation).

When evaluating a new drug Pharmac is going to look at whether there is a significant improvement in outcomes such that most of the diabetic population can benefit. Personally I feel Afrezza would be a better fit for the market as there is nothing similar and it could be a bridge for t2ds afraid of needles to begin insulin therapy.

But look, we’re JUST now getting funded CGMs in October so the system moves very slowly.

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Did you not even have funding for so-called flash glucose monitors (FGM) like Freestyle Libre? In my country (the Netherlands) CGM funding is moving slowly too. Only a small minority of Type 1 patients get a CGM, but most patients are able to get a Freestyle Libre 2, or a new thing called Glunovo Flash (which is a total joke). Government agencies over here continue pretending there’s an actual difference between CGM technology and FGM technology.

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No we do not currently have funding in NZ for any blood glucose testing equipment other than the one blood glucose meter brand which is funded by Pharmac (CareSens).

The good thing is that mine, CareSens Dual, uses both blood glucose and blood ketone strips and all are provided at low/no cost ($5/$10/$0 as outlined before).

The big push to get CGM funding in NZ was centered around the benefits of hybrid closed loop. They’ve also loosened up on the criteria to qualify for an insulin pump-- previously your GP had do document MDI weren’t working and that they felt you’d benefit from a pump. Those barriers to access have come down as part of Pharmac’s acknowledgment that hybrid closed loop is now the standard of care for t1d. Flash glucose meters don’t have any place in hybrid closed loop tech and, to my knowledge, had never been considered for funding.

What is the model for public healthcare in the Netherlands? Is it closer to the British/NHS/NZ model (where nearly everything on the public system is provided at no direct cost) or is it more of a hybid system like Australia, which leans more heavily into private insurance (and there are a lot more direct costs to patients as well under this method).

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Except market size. Mannkind may not think the marketing and supplying is worth the revenue. Same in Canada. We have about 300,000 type 1 diabetics, 11 times your number, but the company decided that the market was too small.

Same in my province. (In Canada healthcare is a provincial responsibility, and every province does things its own way.) Libres were covered 100% long before Dexcoms. Now Dexcom is covered, also at 100%, but to be eligible you have to have either been treated in hospital for hypoglycemia, or required glucagon administration, which of course rules out many people, particularly those who are better at controlling their condition. My province also pays 100% of the cost of a pump and 80% of pump supplies, but not all provinces are so generous and some only cover pumps up to age 18.

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The Dutch healthcare system is private, but heavily regulated and mostly non-profit. It may bear some resemblance to “Obamacare”. Health insurance is offered by private companies and there’s an individual mandate that requires everyone to get “basic” health insurance. People with pre-existing conditions cannot be refused for basic plans and insurance companies are compensated for that by the government. The government decides what services must be covered by basic plans. Insurance companies usually offer additional insurance plans for services that aren’t covered by default, for example dentistry, physical therapy or alternative medicine, but people with pre-existing conditions can be refused for additional insurance.
On average health insurance premiums are about € 1750 per year and people with lower incomes get subsidies that partially cover the premiums. A mandatory annual deductible of € 385 applies to all care, except GP services. After you have reached the deductible all costs exceeding that are covered by health insurance for the rest of the year.

In my country a distinction is made between CGM and FGM. To be eligible for CGM you either need to be

  • under the age of 18 (and then you’re fortunate, because you get to keep CGM after you turn 18), or:
  • be hypo unaware, or:
  • have a persistent HbA1c higher than 8%, or
  • be pregnant

All other type 1 patients and insulin-dependent type 2 patients are eligible for FGM, which until recently meant Freestyle Libre 2, but now there’s a competitor called Glunovo Flash. At the time when the Freestyle Libre 1 was launched, the distinction between CGM and FGM was justifiable because the method of data transmission was different, but the FSL 2 uses both bluetooth and NFC to transmit data. As a product it actually doesn’t make much sense if you think about it. All BG values get transmitted via Bluetooth solely for the purpose of alarms and then get deleted, only to have the user retrieve the same data via scanning (“flashing”) again. In several countries Abbott has updated their smartphone apps to dispense with the need for scanning FSL 2 sensors, but they can’t release that update in the Netherlands, because that would turn it into a CGM and make everyone lose coverage, although it wouldn’t cost us anything. The Glunovo Flash is even more absurd. This product was developed as a CGM, but sell it as FGM on the Dutch market they have had to add a Flash button to their smartphone app. This button doesn’t do anything to retrieve BG data, everything gets transmitted automatically via Bluetooth, but serves no other purpose than to hide the data from the user till they tap the Flash button in order to pretend it’s not a CGM. :exploding_head: Who are we trying to fool? This CGM was actively made worse to comply with our regulations, although it wouldn’t have cost us anything to cover this as a regular CGM.
In my opinion all patients eligible for FGM coverage should also be eligible for CGMs in the same price range, like Dexcom ONE or Freestyle Libre 3. If we really need to ration significantly more expensive products like Dexcom G7 or Medtronic sensors, it should be possible to come up with a more sensible method.

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I’d heard that Canadian healthcare is managed province by province. That does seem a rather disjointed way of managing a “national” healthcare system. Does each province negotiate drug prices individually? Is it common knowledge amongst Canadians which provinces offer better healthcare? I can imagine if you’re just on the other side of the border of a province which fully funds insulin pumps, that could cause some pretty bad feelings. Would love to hear more about how this actually plays out in real life.

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Wow Boerenkool, that is quite an interesting story. Thank you for sharing it.

I’ve been fortunate in that my American insurance has always covered CGM since it was new, circa 2007. (The Medtronic sensors of this era were terrible, and I abandoned it after a year of struggling with mostly inaccurate readings and terrible bruising). I switched to Decxom G4 around 2012 and never looked back.

It was several years later when Libre (FGM) was released and to my mind it made absolutely no sense. Why would someone choose FGM over CGM? It seemed a stepping stone towards CGM for people who were still doing multiple daily finger pricks (like I had been doing in my pre-CGM days, 10-12 daily), but not an end unto itself. As such, I’ve never considered it for my own therapy.

It does seem to be a trend of releasing crippled versions of CGM to fit budgets and maximize company profits. As far as I know, the main different (aside from cheaper price for One+) is that it won’t integrate with insulin pumps. This seems like a step towards “enshittification” of the G7 to try and get more diabetics using Dexcom products, while still maintaining a premium price for the G7.

I have to wonder exactly how different the Dexcom One+ (which looks identical to G7 on the outside) is on the inside. Would be fascinating to see a comparison of the hardware.

Has nobody in NL hacked the Glunovo Flash app to allow for full CGM use? I’d wonder also whether it would be possible to hack the One+ to be used with insulin pumps.

So glad that in 11 days I’ll never have to worry about any of this :slight_smile: I’ve already got a phone call scheduled with my GP on 1 Oct to get my “special authority” authorization and prescription submitted so I can get on board with G7 funding as soon as possible.

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So much is. Education, medical licensing, hospitals, building codes, inter-provincial trade. Sometimes it doesn’t really matter (such as with building codes) and sometimes it’s counter-productive (such as if a doctor or nurse or engineer moves from one province to another, they need to get certified all over again).

The “national” part pertains to the federal government’s mandated role, which is to guarantee accessibility across the country; to set national standards for health care delivery; to review and approve medications, vaccines, and devices; and to provide a share of funding on top of provincial taxes. After that, it’s up to each province to administer its own public health insurance plan (there is no national health insurance) and to decide such things as which drugs are covered on those plans, or who is covered for an insulin pump, or how often you can have your eyes tested for free. Most employed people have workplace private health insurance, which makes similar decisions.

The “free” part of health care – doctor’s visits, anything done in a hospital, and many diagnostic and imaging tests – is dear to our hearts. Unlike the NHS, we have a fair degree of private service – most doctors, for instance, are businesses rather than employed by the state – but user fees or co-pays are illegal. At the same time, we have a degree of private service you can pay for if you like for limited procedures, and that system makes its money through add-ons like fancy lenses for cataract surgery or long, luxurious stays after hernia surgery. Nevertheless, people are very protective of the public service, and raising the prospect of a wider two-tier system is sure to ignite heated debates.

Since the pandemic I’ve heard increasing calls for a more national health care service, like England’s NHS. I think that would be great in principle, but I don’t see it happening any time soon. Provincial governments strenuously protect their fiefdoms and resist giving up any control to the feds.

It’s easy enough to find out. Dexcom’s Canadian site, for instance, lists all insurance coverage by province, and Diabetes Canada maintains a list of pump coverage by province. I don’t think there’s resentment about it, maybe mild envy, and maybe in a case like super-expensive cancer drugs people have actually moved to another province to take advantage of its coverage. When I qualified for CGM coverage, several people said to me, “Aren’t you glad you live in Ontario!”

Absolutely hilarious. In a sad way.

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Yeah, I’m curious about that too, they look identical.

I don’t think so, because this sensor isn’t widely used yet.