Most comparisons of medical costs abroad set "the US price" against a foreign one, as if the US had a single price. It doesn't. The same hospital service can cost far more in one state than in another, which means a patient in a high-price market has a middle option that's easy to miss: going to a lower-priced US market. This page sets out that spread and shows how to compare local, out-of-state and international care on equal terms.
Key takeaways
- In 2022, employers and private insurers paid hospitals on average about 254% of what Medicare would have paid for the same services (RAND, 2024).
- The state spread is wide. RAND found Arkansas was the only state with an overall relative price below 170% of Medicare, while California, Delaware, Florida, Georgia, New York, South Carolina, West Virginia and Wisconsin were all above 300%.
- Setting matters as much as geography. Common outpatient services at ambulatory surgery centers averaged 171% of Medicare in the same study.
- For a patient in a high-price state, a lower-priced US market can capture part of the saving with less travel, the same legal system and easier follow-up. Going abroad has to beat that option, not just your local price.
What "relative price" means, and why it's the right yardstick
Hospital prices are hard to compare directly, because each one bills a different mix of services. RAND gets around this by measuring what private payers paid against what Medicare would have paid for the same services at the same hospitals. A relative price of 200% means private payers paid twice the Medicare rate.
That approach is useful for you, too. Medicare publishes its rates, so "a multiple of Medicare" is a stable unit you can use to compare a quote from your city, from another state, and, with some care, from abroad. Our Medicare rate benchmark guide shows how to look up the Medicare amount for a procedure.
The state spread in RAND's 2024 study
RAND's Round 5 report used claims from 2020 to 2022. It didn't give exact figures for every state in its summary findings, so we report only what it stated:
| Group | Relative price vs Medicare (2022) | What it suggests for a patient |
|---|---|---|
| National average | ~254% | A commercially insured hospital service costs, on average, about two and a half times the Medicare rate |
| Lowest-priced state (Arkansas) | Below 170% | The only state below that level. Lower-priced markets do exist inside the US |
| Highest-priced states (California, Delaware, Florida, Georgia, New York, South Carolina, West Virginia, Wisconsin) | Above 300% | Patients here have the most to gain from looking outside their local market, whether elsewhere in the US or abroad |
| Ambulatory surgery centers (common outpatient services) | ~171% | Choosing the setting can lower the price as much as moving markets |
Two cautions. These are averages for commercially insured services, not cash prices, and prices vary a great deal between hospitals within a state. A high-price state can still have a reasonably priced facility, and a low-price state can have an expensive one. The state figure tells you where to look, not what you'll pay.
Three options, compared on the same terms
Once you see the spread, the decision has three options rather than two:
Local
No travel, your usual doctors and the simplest follow-up. For self-pay patients in a high-price market, possibly the most expensive option. Ask for the ASC price and a written Good Faith Estimate first.
Another US market
Domestic travel, the same legal and regulatory system, the same language, and your insurance network may extend there. Some hospitals and surgery centers publish bundled cash prices and are used to out-of-area patients.
Abroad
Potentially the lowest procedure price, but with international travel, a longer stay, follow-up at a distance and different recourse if something goes wrong. It has to beat option B, not just option A.
Skipping option B is the most common mistake in medical-travel arithmetic. It makes going abroad look better than it really is for patients who could have saved most of the difference by crossing a state line.
How to build a fair three-way comparison
- Fix the procedure and setting. Use the same procedure code, the same implant class and, where clinically appropriate, the same setting (hospital or ASC) in all three quotes.
- Get written prices. For US self-pay quotes, ask for a Good Faith Estimate. Providers must give one within set timelines when you schedule or ask about cost, and it should list co-providers (CMS, 2021). For hospital-published prices, our guide to pulling a cash price from a price transparency file walks through it step by step.
- If insured, use your out-of-pocket cost. Your local in-network cost may be capped by your out-of-pocket maximum. An out-of-network hospital in another state may cost you more, not less, even if its price is lower.
- Add travel to B and C. Include flights or driving, lodging until you're cleared to go home, a companion if needed, and time off work.
- Add follow-up to B and C. Include the cost and practicality of post-op visits, and who you'd call at 2 a.m.
- Convert each total to a multiple of Medicare for a sense of scale, then compare.
If you're insured, the spread works differently
The state spread matters most to self-pay patients, who pay the facility's price directly. If you have insurance, three things can change the picture:
- Network rules. An out-of-network hospital in a lower-price state may still cost you more, because your plan pays less or nothing for out-of-network care.
- Your out-of-pocket maximum. If a planned surgery will take you to your annual limit wherever it's done, a lower facility price may not lower your cost at all.
- Plan travel programs. Ask your plan or employer whether it has designated facilities for certain procedures, and whether it covers travel to them. If it does, that's an option B someone else is helping to pay for.
So check your own plan documents before you act on state averages. Our guide to the deductible trap explains when your insured cost is effectively a cash price anyway.
An illustrative way to lay it out
The table uses placeholder letters, not prices. Fill it in with your own written quotes.
| Line | A: Local | B: Other US state | C: Abroad |
|---|---|---|---|
| Procedure (facility + surgeon + anesthesia) | PA | PB | PC |
| Implant or device, if separate | DA | DB | DC |
| Travel and lodging | 0 | TB | TC |
| Follow-up visits | FA | FB | FC |
| Time off work, companion | WA | WB | WC |
| Reserve for the unexpected | RA | RB | RC |
| Total | ΣA | ΣB | ΣC |
The reserve line usually grows from A to C, because the further you are from home, the more an unplanned extra day or visit costs. If C beats B only once its reserve is set close to zero, B is probably the better choice.
When going abroad still comes out ahead
An international option tends to keep its advantage when the procedure is expensive in every US market, when you're paying cash and can't use an in-network option, and when recovery fits a single trip. For procedures where it often doesn't, see US cash-pay vs abroad: procedures where flying doesn't pay. Either way, the lesson from the state data stays the same: compare against the best domestic option you could realistically use, not the most expensive one near you.
Frequently asked questions
How much more do private insurers pay than Medicare for hospital care?
RAND's 2024 study found that in 2022 employers and private insurers paid hospitals about 254% of what Medicare would have paid for the same services at the same facilities, on average.
Which states have the highest and lowest hospital prices?
In RAND's 2024 report, Arkansas was the only state with an overall relative price below 170% of Medicare. California, Delaware, Florida, Georgia, New York, South Carolina, West Virginia and Wisconsin were all above 300%.
Is it worth traveling to another US state for surgery?
It can be, especially for self-pay patients in high-price markets. Compare the total, including travel and follow-up, and if you're insured, check whether the out-of-state facility is in your network.
Does an ambulatory surgery center cost less than a hospital?
Often, for procedures suitable for that setting. RAND found common outpatient services at ambulatory surgery centers averaged 171% of Medicare, lower than the overall hospital average.
How should I compare a cheaper US state with going abroad?
Use the same procedure, implant class and setting in each quote, add travel, follow-up, time off and a reserve, and compare the totals. Going abroad should beat the best domestic option you could realistically use.
Next step: turn this range into your number
State-level spreads show where to look. The worksheet helps you compare a local quote, an out-of-state quote and an international one on equal terms. Then request written quotes for the options that survive.
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