Though Rosy Rios and Doug Ancel of Reno, Nevada, knew they wanted to run a B&B in Costa Rica, they never intended to build one from the ground up. But that’s what happened on the way to their Hideaway Hotel, which opened in 2008.

First, they chose the place, driving the length of the Nicoya Peninsula, looking for a beach town with enough tourist infrastructure to run a business but without the overbuilding and overreaching that can spoil a place.

They came equipped, with backgrounds in business, real estate and construction, and a chunk of savings that would let them take a good shot at their dream. Rosy spoke Spanish, and Doug was learning.

Looking to Buy

Once they settled on Playa Samara, halfway down the peninsula and with a sweeping half-moon beach washed by waves gentle enough for swimming, they had local realtors show them what was on offer.  They looked inland, “in the jungle,” but it was too hot. Places in the town of Samara were “too noisy—roosters, cars, and chain saws,” says Rosy. And when they liked the location, the building didn’t seem right.

They remember that one realtor showed them a hotel, assuring them, “If you buy this, I guarantee you’ll make your money back in 5 years.” Being familiar with the ups and downs of real estate and business, Doug and Rosy knew that a realtor should never in good conscience make such assurances. They put their guard up even higher.

Howler monkey at the Hideaway Hotel, Playa Samara, Costa Rica; photo by Doug Ancel

One day, after months of searching, they turned off the coast highway onto a one-lane road that ran straight to the southern end of Playa Samara. Wouldn’t it be great, they agreed, to have a place within walking distance of the beach? But there were no hotels for sale on that road.

A little later, in April 2004, they heard through the grapevine that a German woman was selling a 1-acre parcel of land on the very road that inspired their ‘wouldn’t it be nice’ musings. It wasn’t listed with any realtors.

Doug and Rosy looked at the land and loved it. But it had no structures on it; their dream had been to buy and renovate an existing hotel.

The location, however, was perfect, and the price wasn’t half-bad. And so, after checking to make sure they’d have easy access to water, electricity, and phone line, and after some back-of-envelope calculations and late-night soul-searching, they decided to go for it. They did what most people moving to a new country or starting a business have to do at some point: change the master plan in order to accommodate an opportunity that may not come your way again.

Building a dream, from the ground up

Anyone who’s ever built a house or a hotel knows what comes next. It took Doug and Rosy a little over four years from purchase of property to opening the Hideaway Hotel in July 2008. I’m sure they could write a book about those four years, but here are a few high (and low) points.

Building the Hideaway Hotel in Playa Samara; photo by Doug Ancel

They knew what they wanted-a clean, contemporary design, high-quality construction to North American/European standards, and about a dozen spacious rooms. They wanted a pool, landscaped grounds, and a modern wastewater system that would allow them to irrigate the grounds with gray water and to give North American guests the privilege of flushing toilet paper instead of putting it in a waste container next to the toilet, which is the Tico style.

They got a good lawyer (key to getting anything done in Costa Rica), who introduced them to an architect who had a good reputation. “But he didn’t deliver,” says Rosy, so they set up meetings with several architect/ builder pairs, chose their favorite, and got to work. “The design process took some time,” continues Rosy “We wanted to be sure to choose the finishes, tile, granite, etc. ourselves.”

The permit process was also challenging. “We were held up in SETENA for 6 months,” Rosy says. “Apparently SETENA [the Secretaria Tecnica Nacional Ambiental] was backed way up at the time.”

“We were ‘next in line,’” adds Doug, “for a good 5 or 6 months.”

The web site costaricalaw.com explains, “the sole mission of SETENA is the administration of the process to review and evaluate environmental impact considerations. Builders and real estate developers cringe when they hear the word SETENA.”

“But our building permit didn’t take much time,” says Rosy. “You just present plans to the municipality and pay the fees.”

The pool before it was a pool at the Hideaway Hotel in Playa Samara; photo by Doug Ancel

Once construction got underway, Doug stayed on site as much as possible to oversee the work. The builder went over budget, and there were construction delays. But when the Hideaway Hotel opened its doors in 2008, it all seemed worth it. “Local realtors couldn’t believe it,” says Doug. They said, ‘You guys actually opened! So many projects end up unfinished ruins.’”

Their hotel is indeed no ruin; it’s a lovely place with the sort of amenities you really appreciate after having been on the road for while, from the spacious shower to the mini-fridge to blackout curtains for the times you need to adjust to jet lag or turn in early to make a wee-hours flight the next day. A hundred feet from your poolside breakfasts are trees often full of howler monkeys.

Advice on opening a B&B in Costa Rica

I asked Rosy and Doug if they have any advice for opening a B&B or a hotel in Costa Rica.

“Find one that’s been built,” Rosy laughs ruefully, although she also says she feels proud of how well their from-the-ground-up building turned out.

“It takes time to grow a business,” says Doug. “So you need operating reserves to tide you over. We planned not to make any money the first years,” he smiles, “And so far, we’re right on plan.”

But even in the months after I visited, their was an uptick in guests, and the hotel is getting great press in guidebooks and online-when I last looked they were the #2 Samara hotel on Trip Advisor. I have little doubt that the next few years will bring even more visitors and a return on their investment, both in financial and life-satisfaction terms. After all, they dreamed a dream and then, with hard work and imagination, they made it happen. It’s all part of the (somewhat flexible) master plan.

Photo of finished version of the Hideaway Hotel by David W. Smith

With the new immigration reforms that go into effect in Costa Rica on March 1, expats who are legal residents in Costa Rica must enroll in the national healthcare system called the Caja, which gives them low-cost access to neighborhood clinics, pharmacies, and public hospitals.

Some Costa Rica expats are satisfied with Caja (public) care; others opt to supplement or replace it with private care, paid out of pocket or through national or international health insurance.

One whole-hearted and one half-hearted fan of the Caja (Costa Rica’s national healthcare)

San Ramon-based expat Stephen Duplantier, 65, is a Caja fan. “We are very happy with it,” he said recently. “It’s US$18/month (a discounted rate through Association of Residents of Costa Rica–the ARCR). We go to local EBAIS (a neighborhood clinic), where there’s an excellent doctor and excellent nurses, plus all pharmaceuticals are free. Recent surgeries, diagnostic tests, ER use, pharmacy, etc.–all are totally free and high quality, and the waiting time is equal to our experience in the States.”

I agree that the Caja can be great for routine care, but when I found I needed surgery, I moved from the public to the private realm. I’d been part of the Caja system, paying around $60/month at the age of 41 and happily using their neighborhood clinics for routine care, tests, and medications. But when it became clear that I would need a major procedure, I defected to private care, opting to pay out of pocket (I’d let my U.S. insurance lapse). I was happy with the care at private Clínica Bíblica, though the final price for my stay, while quite low in comparison to U.S. prices, was still more than twice what I’d been quoted in a formal estimate.

Two that had bad experiences at public Costa Rica hospitals

Others are not so happy with the Caja.

After a motorcycle accident in Costa Rica, Matt Hogan sampled both public and private hospitals. Photo: David W. Smith

Take Matt Hogan, 35, co-founder of Finca Bella Vista, a sustainable treehouse community near the Osa Peninsula. In late 2009 he had a motorcycle accident, and was taken to the newly opened public hospital in Ciudad Cortéz. “All the newspapers had been boasting about the brand-new, state-of-the-art facilities and medical equipment, 300 clean new beds, and the rest,” says Matt. What the newspaper accounts failed to mention, according to Matt, was that all those new beds were serviced by only a few doctors who showed up only once in a while. Matt says he suffered serious neglect and misdiagnosis (they told him he was fine). Feeling anything but fine, he had himself driven by ambulance to San José and checked himself into private Clínica Bíblica. There he was found to have one collapsed lung and the other in mid-collapse, as well as severe internal bleeding in his chest cavity. The doctors at Bíblica said that if Matt had waited another day to seek proper care he most likely would have suffocated.

Matt was very happy with the care he received at Bíblica, adding with a smile that “all the nurses were very attractive young Ticas.”

Alex Murray after being released from a 20-day hospital stay.

In another example, Alaska native Alex Murray, 72 at the time of a fire that burned over 20 percent of his body, endured an extended hospital stay that also allowed him to compare private and public care in Costa Rica.

“While expat friends with residency have had important procedures successfully performed at slight cost in the public system,” he says. “I recommend avoiding it in life-threatening situations if at all possible.”

Alex was burning garden trash at his home in the Lake Arenal region when he spilled some gas, causing the fire to flare up and burn him over much of his body. Alex spent the next 20 days in two hospitals in the capital city of San Jose, first at the public Hospital San Juan de Dios, and then at private Clínica Bíblica.

“Of course,” he admits, “it’s a foregone conclusion that such a comparison is unfair to the underfunded public hospital, but the devil’s in the personal details.”

Alex was first picked up by a Red Cross ambulance and taken to a clinic in nearby Tilarán. Then he was moved to the public hospital in Liberia (about an hour north), where the doctors decided to send him to the burn unit at San Juan de Dios (a public hospital) in the capital city of San José, 4 hours away.

“Arriving in San Jose,” says Alex, “we should have directed the driver immediately to Bíblica or Clinica Católica [two private hospitals], but, ignorant of the quality of the public hospital and anxious to get treatment, we let the driver take us to the teeming mystery that is San Juan.”

Hospital San Juan de Dios in Costa Rica

Three days at a Public Hospital: San Juan de Dios

“In our three days there,” says Alex, “no doctor ever consulted us, though one led a group of students into my room each day. The nurses, male and female, sometimes seemed like the proverbial five or six workmen who stand around a pothole gabbing while one guy fills the hole. For the most part, they were not dedicated, not attentive, not very competent, and not sympathetic. They seemed the dregs of the nursing schools. A friendly nurse assigned to draw blood samples spent three days drilling mostly dry holes all over my landscape, partly due to my extremely low blood pressure. One rough middle-aged nurse told me that I was not much hurt nor in pain. I finally had to yell at her, “Don’t touch me. Don’t touch me.” She desisted, smiling to herself, it seemed.

“A night crew came on and half-heartedly started to bathe me and change my dressings. Three stood on one side of the bed and made little come-hither motions with their fingers. Two stood on the other side and made little shooing gestures. Finally, they decided to help me turn.

“They would not let my wife sleep in one of the three extra beds crowded into my room. Instead she spent her nights trying to sleep in a plastic chair. In the not-very-clean bathroom, she found bloody bandages in a corner.”

Clínica Bíblica in Costa Rica

Seventeen Days at a Private Hospital: Clínica Bíblica

Alex and his wife decided that they needed to move him to a private facility. “When I was admitted to Clínica Bíblica,” he says, “I recognized immediately that here was a competent staff. The emergency room nurse quickly found a vein and soon had a set of color-coded vials filled with my blood. All staff were purposeful and attentive.

“The next evening I began to rave and tried to tear off my bandages and leave the hospital. A doctor soon arrived and said my actions were due to a lack of oxygen to the brain. I was then moved to intensive care where a coma was induced and I was intubated, remaining thus for five days, not a reassuring sight for my four daughters who arrived from points around the globe.

“I doubt that these measures would have been taken at San Juan de Dios. Three doctors tended me at Bíblica, one a burn doctor, one a plastic surgeon who moved skin from my thigh to my hip, and one a staff doctor. They each came by almost every day to talk with us. The nursing staff was a no-nonsense but friendly and attentive group, evidently the better graduates of the nursing schools. Midway through my stay, physical therapists began visiting daily to exercise my wasted muscles. When I left, I had lost 14 pounds and could walk only a few steps unassisted, but I was recovering.

“And throughout my stay, my wife was permitted to sleep on a narrow built-in bed or cot in each room. “

For more information on health care in Costa Rica, see Living Abroad in Costa Rica by Erin Van Rheenen, or visit www.livingabroadincostarica.com.

On Feb 7th Costa Ricans went to the polls and overwhelmingly elected Laura Chinchilla president for the next 4 years. Chinchilla, who was Vice President in the current administration of Oscar Arias, resigned that post so she could run for president.

She ran a campaign that declared her “firme y honesta” — firm and honest — and promised more doctors in the state-run medical clinics and more police officers on the streets. She is a social conservative who opposes gay marriage and abortions, though she favors civil rights for gays and birth control.

Chinchilla, 50, is married with one teenaged son. She will take office in May, becoming Costa Rica’s first female president and Latin America’s fifth in the last two decades. The other four are Argentina’s Cristina Kirchner, who was elected in 2007, Chile’s Michelle Bachelet, elected in 2006, Panama’s Mireya Moscoso, elected in 1999, and Nicaragua’s Violeta Chamorro, elected in 1990.

Interesting that Costa Rica, a supposedly “third world” and  “macho” country, elected a woman president, while a first world country where the sky’s supposedly the limit (the US of A) lags behind in the gender equity department. Speaking of third world, Chinchilla recently asked, “Who gets to decide if a country is deemed “developing” or “developed?” Interesting question. Chinchilla thinks Costa Rica qualifies as the latter.

Click here for election photos and here for a truly bizarre campaign video from one of Chinchilla’s competitors in the Presidential race. A middle-aged man naked except for a diaper cavorts among pregnant women singing a takeoff on the 60s classic, “I will follow him.”

One of the pleasures of living abroad is starting to see world history and events from another–often radically different–angle.

You can start to make that shift pretty much anywhere–reading the local newspaper at your favorite expat cafe, exploring a crumbling castle, or talking politics with the guy who repairs your car with tin foil and fishing wire. But some places are particularly well-suited for contemplating history from a decidedly local perspective.

Covert ops hottie visits El Avion bar? Lovers of freedom should be so lucky.

An old plane sits grounded atop a lush hillside on Costa Rica’s Pacific coast. The battered Fairchild C-123, built in 1954 and now part of a popular open-air bar, is the perfect place to nurse a cold cerveza, watch the sunset, and remember a bizarre chapter in history: the Iran-Contra affair, which from this Central American vantage point would more accurately be called the Contra/Iran affair, with the illegal arms sale to Iran a minor chapter in the 80s-era U.S. covert funding of armed guerillas (the Contras) bent on bringing down Nicaragua’s Sandinista government.

Part of the Costa Verde hotel, the Avion Bar is the perfect place for ruminating on that 1980s arms-for-hostages-and-while-we’re-at-it-let’s-fund-some-paramilitaries scandal because the plane itself played a starring role in the fiasco.

The plane was dubbed “Ollie’s Folly” for its connection to Oliver North, chief architect of a covert operation—lodged firmly in the heart of the Reagan administration—that funded and provided military assistance to the Contras.

Though the U.S. government supported the Contras in the early 1980s, Congress cut off all funding in late 1984, afraid that Nicaragua would become the next Vietnam, and alarmed by reports that the C.I.A. had secretly mined Nicaraguan harbors.

Who needs Congress when you’ve got Ollie North?

Despite signing into law the bill cutting off all funds to the Contra’s paramilitary operations, Reagan ordered his staff to find a way to help the Contras keep ‘body and soul together,’ in his words. Reagan and his staff—especially those in the National Security Council (NSC), secretly raised $34 million for the Contras from other countries, with an additional $2.7 million from private contributors, and later, with funds from the illegal arms sale to Iran. This money was funneled into a private company called ‘the Enterprise,’ and put under the direction of Lieutenant Colonel Oliver North.

The Enterprise had its own operatives, Swiss bank accounts, airfields, and airplanes, including two Fairchild C-123s, one of which now holds up the roof of the Avion bar.

For 16 months in the mid-1980s, the Enterprise provided covert aid to the Contras—aid that the U.S. Congress had specifically prohibited. When U.S. and world press caught wind of the operation and reported on it, Reagan, National Security Adviser Robert McFarlane and other administration officials repeatedly assured the public (and Congress) that nothing illegal or untoward was going on.

The game is up.
But on October 5, 1986, evidence to the contrary fell to earth over southern Nicaragua. A plane carrying supplies to the Contras was shot down; the two pilots were killed, but Eugene Hasenfus, a former Marine from Wisconsin who’d been hired by the C.I.A., parachuted to safety, only to be captured by Nicaraguan government forces. Hasenfus’ capture was instrumental in uncovering the U.S. covert operation providing money and military help to the Contras. The plane shot down that October day was the sister plane to the one now reincarnated as a hilltop bar in Costa Rica.

Allan Templeton, owner of the Costa Verde hotel, was intrigued by the plane’s history and bought it in 2000 for $3000. Templeton had the plane moved, at great expense and trouble, to its current perch close to Manual Antonio,

'Fusilage suite' at Costa Verde hotel

Costa Rica’s most popular national park. The Costa Verde has a taste for giving old modes of transport new life—recently, they transformed a 1965 Boeing 727 into a high-end ocean-view suite. And they just opened what must be one of the few places in Costa Rica where you can get a Hebrew National kosher hot dog. It’s called The Wagon, and it’s housed in an old train car.

But let’s return to the 1980s for a minute. What happened in Nicaragua back then didn’t stay in Nicaragua. In fact, Ollie North had a secret airstrip built in Costa Rica to support his covert ops in Nicaragua, then got himself barred from Costa Rica for life for that and for his alleged part in drug smuggling to fund the Contra effort.

More information on traveling and living in Costa Rica.

For more information in the Iran/Contra Affair: U.S. Congress Iran Contra Committee: Key Findings in 1987

Photos: Costa Verde Hotel.

Sandra Shaw Homer, who has lived in Costa Rica for over 20 years, did something a little over a year ago that all writers will applaud and probably envy. She pared away from her life all but the essential, so that she might, for a year, concentrate on writing the book she knew she was meant to write.

She’d been very active in a few local nonprofits, and she scaled back her commitments, quitting boards and letting people know that she’d be putting her energies elsewhere for a time.

And dammit of she didn’t write that book! In a year. I’m beyond envious—I’m positively inspired. I keep looking at little huts on the side of the road or up on top of mountains, thinking, Now there’s a good place to hole up and write.

The book is Evelio’s Garden: A Memoir of Costa Rica. It centers around a garden on her land on the shores of Lake Arenal, an organic garden a longtime friend, Evelio, tries to create out of nothing. Evelio is a local, born and bred in the Arenal area, and he has a natural talent for planting and tending. But trying to garden organically, and on a plot ravaged by the winds off the lake, turns out to be more than he–and Sandy, as his enabler/landlord/cheerleader–bargained for.

Sandy describes the ups and downs of the gardening project, but more than that, she details how the achingly beautiful land around the lake is at risk of devastation. Not incidentally, a portrait of expat life emerges, as we learn of Sandy’s neighbors from Europe and North America and Costa Rica and see how they all coexist, sometimes peaceably, sometimes contentiously.

It’s a book about how we live on the land, how it nourishes us and how we should nourish it. It’s beautifully written and has a strong sense of place. I’m honored that Sandy let me read it and that she’s allowing me to publish an excerpt here.

Excerpt from Evelio’s Garden: A Memoir of Costa Rica, by Sandra Shaw Homer

All land has a history, and the history around here goes back a long way.  Satellite images have picked up old roads all over this canton, long grown over, made by the indigenous peoples of pre-Columbian times.  One of these roads runs along the south shore of the lake, uphill from the current road and downhill from the ridge that links Tilarán with the tiny villages of Silencio and Río Chiquito.  I have ridden my mare along one stretch of this old road that runs behind San Luís and Tronadora, much washed out and crowded with second-growth forest, and it took a man on horseback with a machete to cut open a way for us to pass.  Artifacts of the native people show up everywhere.  When the lake is low, you can go out in a kayak or canoe and explore along the naked shoreline for pottery shards.  In town, there’s hardly a house that doesn’t sport a metate, or corn-grinding stone, that turned up when the foundation was being dug.  It usually has a potted plant sitting on it.

Modern local history dates from the late nineteenth century, when there were gold mines south of here in Las Juntas and Líbano.  It was rough country then, virgin forest, and the only way in was by horse or mule.  The gold was shipped out in ox-carts.  (More recently it was taken out in helicopters!)  Gradually settlement drifted north, and people carved farms out of the ancient forests, establishing a fiercely independent, frontier life-style.  Even in the 1930s, it could take the better part of a week to get to San José – from Tilarán on horseback (oxcart took longer) to Cañas, where you waited days for a small boat to take you down the Bebedero to the Río Tempisque and the port of Puntarenas, then by all-day train up to the Central Valley.  The Inter-American highway wasn’t completed along its northern reaches until the sixties.  There was no paved road around the lake until the eighties.  (It’s still not finished.)  I have met retired school teachers in Tilarán who remember four-hour treks on horseback to get to their one-room school houses on the lake, sometimes in mud up to the horses’ knees.  The niece of one of these teachers told me that her grandparents owned our farm in those days, and that it was a much bigger property.  A lot of the farms around here were broken up when ICE acquired the land for the reservoir.  Since then, the process of development has been inexorable.  As long as there’s someone to buy, sooner or later a farmer will face the economic conditions that force him to sell, frequently just a small piece at a time, enough to give him ready cash to get along until beef prices go up, or the weather improves enough to let him get a good crop in.  There are still some fair-sized farms around the lake, but since the early nineties development has speeded up and been gringo-ized. (At least in Tilarán, the word gringo can refer to Europeans as well as to non-native-Spanish-speakers from north of the Río Grande. Our nearest neighbors are Germans.)

Earlier this year an 18-wheeler parked its trailer by the side of the road just uphill from Cinco Esquinas, smack in your face where the first grand view of the lake should be.  It was a mobile office with the name of an international real-estate company painted in large letters on its side.  This was beyond ugly, but it never opened.  Instead the world-wide recession brought local real estate sales almost to a halt.  Still the trailer sat there, month after month, until finally some locals couldn’t resist jacking the thing up to steal a pair of off-side tires, leaving it listing crazily on a slender pile of cement blocks.  Just the other day it finally disappeared.  How it was moved, nobody seems to know.  But nobody was sorry to see it go.  This little story – especially the part about getting that trailer out of there – is no doubt already brewing up into a local legend.

We’ve been here long enough to see people come and go.  Some can brave the remoteness, the vagaries of the weather and the strangeness of the culture, and some can’t.  Some people get attached to the land, and some don’t.

When I was growing up, my family never lived long enough in one place for me to become bound to the land.  We lived in some beautiful – and not so beautiful – places, both rural and suburban.  From my early twenties until I came to Costa Rica, I moved almost as frequently, living exclusively in cities.   It was a little shock to realize, when we started building this house five years ago, that I’ve lived on Lake Arenal, and on this particular plot of ground, longer than I’ve lived any place else in my entire life.

You can’t get attached to the earth in Philadelphia or New York.  How many millions of people never do?  It’s this attachment that fires my desire to protect it – but not just my attachment to this particular plot of ground, but to the whole thing, the planet.  It’s not such a giant leap of the imagination from the sight of a growing young forest to the image of a tiny blue speck in the vastness of the universe.  So, finally, it is the sense of place that has captured me and pinned me to the planet.

It is gratifying to be part of the history of the land, to be growing a farm instead of shrinking it, to be building a forest instead of cutting it down.  Here, in one tiny corner of the planet, the question becomes obvious:  do we add something by our tenancy of the earth, or do we take it away?

Alex Leff recently reported in the Global Post that Americans are coming to Costa Rica for stem cell treatments, which in the U.S. are often prohibitively expensive, if they are available at all. Treatments not yet approved in the U.S. can often be had at hospitals and clinics abroad, from China to Costa Rica.

Some stem cell scientists in the U.S. say these treatments offer false hope to patients desperate enough to take a chance on techniques that have not been scientifically proven.

Costa Rican doctors like Dr. Fabio Solano, who directs the stem cell institute at San Jose’s CIMA Hospital, disagree. Solano says they’re providing medical tourists with groundbreaking (and affordable) treatments. Dr. Solano estimates that his team has treated as many as 400 patients with procedures that involve stem cells.

Costa Rica is known for its high-quality medical care.  More and more medical tourists come here for surgery and other treatments that they can’t afford back home.

And despite the naysayers, success stories about stem cell treatments in Costa Rica abound, from 8-year-old Kenneth Kelley receiving stem cell treatment for autism to Trish Stressman seeking treatment for her chest-down paralysis, to Jennifer Blankenship, who received treatment for her multiple sclerosis (MS).

But many doctors urge caution. Dr. Jack Kessler, an expert in stem cell research at Northwestern University’s Feinberg School of Medicine in Chicago, warns, “The lay press is unfortunately replete with many overstatements and misconceptions about what can be accomplished in the short term by stem cell biology,”

FDA says don’t go abroad for treatment, but are they tarring all non-U.S. facilities with the same brush?

CNN reports that the International Society of Stem Cell Researchers and the FDA discourage Americans from traveling overseas for stem cell therapy. Clinics are operating worldwide–in China, Russia, Mexico, and Costa Rica, among other places.

I fear ISSCR and the FDA may be tarring too many countries, hospitals, and procedures with the same brush. I have personal experience of Costa Rican (private) hospitals and can attest to their quality. As for providing treatments not allowed in the U.S., I’m not an expert, but have read a bit about the lengthy (and sometimes arbitrary) review process that new drugs and procedures must go through in the U.S.

There’s also the issue of stem cell research and treatment being a political hot potato in the U.S., which has probably set medical advances back years, if not decades. It wasn’t until March of this year that President Obama issued an executive order that lifted Bush-era restrictions on federal funding for stem cell research.

Stem cell research is also a political issue in Catholic Costa Rica, where researchers are not allowed to work with human embryos (even in vitro fertilization is against the law). Doctors and researchers in Costa Rica have supposedly done an end run around that prohibition by working with “adult” stem cells (derived from tissue including body fat and umbilical blood or tissue).

About stem cell treatment

Wikipedia defines stem cell treatments as “a type of cell therapy that introduce new cells into damaged tissue in order to treat a disease or injury. Many medical researchers believe that stem cell treatments have the potential to change the face of human disease and alleviate suffering. The ability of stem cells to self-renew and give rise to subsequent generations that can differentiate offers a large potential to culture tissues that can replace diseased and damaged tissues in the body, without the risk of rejection and side effects.”

This year’s Medical Tourism Congress (Oct. 26 – 28 in Los Angeles) features Costa Rica in its portrait of the growing trend of going overseas for affordable care.

The focus on Costa Rica’s medical system doesn’t surprise me. I lived there, and ended up having major surgery in the capital city of San Jose. No hospital stay is fun, but I received very competent care, and the bill didn’t push me to the brink of bankruptcy (the biggest cause of bankruptcy in the U.S. is said to be unpaid medical bills.)

In the Medical Tourism Conference video, we see Bob (his last name is not provided) from Orlando, Florida, as he flies to San Jose, Costa Rica, to have a double knee replacement at Clinica Biblica, one of the top rated facilities in a country. Bob consults with English-speaking doctors, jokes that this is the first time the doctor was waiting for him, and sings the praises of Costa Rican medical care. He even fits in a visit to the rainforest aerial tram at Braulio Carillo National Park.

The video says Bob’s double knee surgery would have cost $100,000 in the U.S., and that it cost him about $20,000 in Costa Rica.

The video has that marketing vibe, where you wonder if they’re telling you the full story. But it happens to be true that Costa Rica’s not a bad place to go for medical care. No system is perfect, but I’ve had surgery (lucky me!) in both the U.S. and Costa Rica, and felt I received good care in both cases. And the cost difference is staggering.

This year’s medical tourism gathering hopes to draw as many as 2,000 participants.  Last year’s congress (the first of its kind) drew around 850 attendees from 45 countries. Insurance companies and insurance providers came, along with representatives from hospitals, clinics, and governments around the world. Everyone wants in on this new industry, which, according to Deloitte, will have up to 23 million Americans traveling internationally for medical care by 2017, spending up to $79.5 billion dollars each year.

For more on health care in Costa Rica

Photo credit: zipline from Skytrek, Monteverde

Here’s what we know for sure: the number of U.S. citizens moving abroad has exploded in the last 50 years. Seems that people want to bust out of provinciality in the same way prisoners want to bust out of jail.

• Between 1966 – 1996 the number of Americans living abroad quadrupled, from 70,000 in 1966 to between 3 and 4 million in 1996 (Source: U.S. State Dept.).
• Ten years later, in 2006, estimates were closer to 6 million.

But the word estimate is key here.

When I wrote Living Abroad on Costa Rica, I had the devil of time finding a reliable number for how many Americans made that very livable Central American country their home.

Estimates ranged from 200,000 to almost four times that, but there didn’t seem to be any credible sources with accurate numbers.

It’s just as hard, if not more so, to nail down the number of Americans living abroad in general.

God knows the U.S. government has tried. In 2004 the Census Department did what they called an Overseas Enumeration Test, attempting to count the number of Americans living in Kuwait, Mexico, and France. The program was a dismal failure. In Mexico, for example—where the estimates of American expats ranges from 300,000 (according the the US State Dept.) to over a million (according to groups representing Americans overseas) — only 250 people completed a census form! The response was also weak in France, where 2,600 people filled out a form of an estimated American population of 112,000.

Census official Louis Kincannon admitted that issues of confidentiality and taxation might be at play here. “There are people who have a disinclination to be identified to any government,” Kincannon said.

In other words: Those who want to lose themselves often don’t want to be found.

Individuals saving thousands of dollars by having elective surgery abroad is just part of the story. More and more U.S. insurance companies are providing a medical tourism option for their clients. A recent USA Today article reports that “The four largest commercial U.S. health insurers — with enrollments totaling nearly 100 million people — have either launched pilot programs offering overseas travel or explored it. Several smaller insurers and brokers also have introduced travel options for hundreds of employers around the country.”

In addition, the very fact that the medical tourism option exists fosters healthy competition, allowing U.S. insurance companies (or whoever ends up being our ‘provider’) to negotiate better rates on procedures right here in the United States.

USA Today reports that “Shortly after Hartford, Conn.-based Aetna Inc. and the Maine-based grocery chain Hannaford Bros. Co. launched a program to send patients to Singapore for hip and knee replacements, some New England hospitals countered with their own deals. So far, three patients have benefited from the competitive pricing; Hannaford has sent no one overseas, even though the program pays travel and lodging costs.”

Everywhere you look, newspapers and magazines are reporting on Americans going abroad for elective procedures and saving thousands, or even tens of thousands of dollars. For example,

Elizabeth Kunz of South Carolina needed eight crowns, a filling and a root canal. Though she had insurance, the procedures would have cost around $10,000 in the U.S. Her insurance company, BlueCross BlueShield, said they’d pay for her to see a dentist in Costa Rica. She booked a trip. The work cost her $2,800.

Ben Schreiner, 63, also of South Carolina, was going to wait until he turned 65 (and qualified for Medicare) to have his hernia surgery. Without Medicare, but with his current medical insurance, he would have had to pay a $10,000 deductible. After hearing about medical tourism, he did some research, and then flew to Costa Rica for the surgery. He ended up spending $4,400, including travel expenses.

Some say that medical tourism is not yet common enough to play a role in health care reform. Paul Keckley, executive director of the Deloitte Center for Health Solutions, estimates that medical tourism spending accounted for no more 1% of the $2.36 trillion spent on health care in the United States in 2007.
But the practice is on the rise. And knowing that many Americans must go abroad to afford the medical care they need gives the push for health care reform even more urgency.

Photo by Erin Van Rheenen: Children’s examination room, at Hospital CIMA in Escazú, Costa Rica.

More information on healthcare in Costa Rica.

Recently, the Costa Rican Congress unanimously approved a law overhauling the country’s immigration policy. The new law is expected to take effect in early 2010.

Costa Rica is by far the most popular Central American country for Americans to buy a second home or to make the move and live there full time. Many in the latter group chose to become permanent legal residents of the country. The process for doing so is fairly simple (though often rife with bureaucratic delays).

The new law, however, increases the monthly income aspiring residents must prove to be given residency status.

For the pensionado (pensioner/retiree) category, you used to have to prove just $600 a month in pension income, from either the U.S. government or a private source (like the brokerage house that administers your IRA account). When the new law goes into effect, you’ll need to prove $1000/month in retirement income.

For the rentista (small investor) category, it was necessary to prove a monthly income of $1000 (usually a CD or annuity), guaranteed by a banking institution. When the new law goes into effect next year, you’ll need to prove a monthly income of $2,500.

For more information, see How do I get residency in Costa Rica?