The US ranked only 47th out of 64 countries as the best place to live in the world for the second consecutive year.

That’s according to the major benchmark Expat Insider 2019 report which surveyed 20,259 expats, representing 182 nationalities and living in 187 countries or territories.

An expat is defined as an employee sent abroad on a corporate assignment or classed as a new international hire. The survey ran from 7 to 28 March. Respondents were asked to score 48 different factors — which fall into 17 subcategories — related to living abroad. Those 17 subcategories are then put into five pillars —Quality of Life, Ease of Settling In, Working Abroad, Family Life, and Personal Finance.

For a place to be ranked, there needs to be a sample size of at least 75 survey participants per destination. The only exception to this rule is the Family Life Index, where a sample size of at least 40 respondents raising children abroad is necessary.

For the 2019, 64 destinations, respectively, met these requirements, although many countries or territories the sample size exceeded by 75 or even 100 participants.

While 57% of respondents rate the quality of medical care positively versus the global average of 65%, 71% think it isn’t affordable — 45 percentage points above 26% globally.

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One Australian expat said in the report: “I fear something major could happen, like a hospital stay, and I would need a loan to pay the bill.”

Making money go further is something expats are not happy about either.

While one in three working expats think their current income is a lot higher in the US than it would be in a similar position back home, covering daily expenses with their disposable household income is an issue for 29% versus the global average of 23%. Some 45% rate the local cost of living negatively as well.

The cost of education and childcare also prevent the US from being higher in the table.

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While 64% of expat parents rate the quality of education positively, 55% are unhappy with the costs. Nearly three quarters of expat parents think childcare isn’t affordable in the US, compared with a global average of 40%. One French expat said: “If you have kids, their education will cost a fortune.”

Finally, “safety and security seem to be another issue for expats in the US,” says InterNations. While 69% feel safe in the US, this is much lower than the global average of 81%. Meanwhile, less than half rate the country’s political stability positively.

Where the US did score highly was across the Digital Life category — it was placed 7th out of 64 countries. Having a fast internet connection is not an issue, with 90% of expats saying they have easy access to high-speed internet at home versus 75% globally. Moreover, 70% are happy with the availability of administrative and government services online versus 55% worldwide.