Healthcare in the United States

Written by Lais Cattassini Moderated by Oleksandra Dosii

Lais Cattassini

Lais is a Brazilian journalist and copywriter with over 17 years of experience, writing about things she knows really well (travelling, cinema, social media trends) and things she loves learning about.

Oleksandra Dosii

Oleksandra is a dedicated marketer with a passion for growing HR-tech products. She believes content marketing is about delivering high-quality content that provides value—not just generating leads. Since 2016, Oleksandra has been involved in tech talent relocation.

Last update: September 13, 2024

Next update: Scheduled for February 1, 2025

Interesting facts:

• The US spends more on healthcare than any other country, both per capita and as a percentage of GDP (18%).
• Together, Medicare and Medicaid, the federal health insurance programmes, cover 120 million people, while the population of the United States exceeds 330 million.
• Prescription drug prices in the US are among the highest in the world. The lack of government regulation on pricing and the significant role of pharmaceutical companies in the market contributes to this.

Overview of the healthcare system in the United States

The healthcare system in the United States is complex, even for citizens. Today, it consists of a mixture of public and private providers, insurers, and regulators.

Most Americans receive healthcare coverage through private insurance, often provided by employers. There are many companies offering a range of health plans, including fee-for-service plans, Health Maintenance Organizations (HMOs), and Preferred Provider Organizations (PPOs).

The government provides healthcare for specific groups through programs like Medicare, Medicaid, and CHIP, each with its particularities and specific audiences.

The healthcare delivery system includes a mix of private, non-profit, and public hospitals, clinics, and other healthcare facilities. Doctors, nurses, and other healthcare professionals operate in both private practices and hospital settings.

The cost of healthcare in the United States, for both patients and the government, is the highest in the world. For this reason, out-of-pocket costs can be high, particularly for those without insurance or with high-deductible plans. Prescription drugs also tend to be more expensive than in many other countries, largely due to limited regulation on drug pricing.

Healthcare is regulated at both federal and state levels. The Affordable Care Act (ACA), implemented in 2010, expanded access to healthcare by creating insurance marketplaces, expanding Medicaid eligibility, and preventing insurers from denying coverage based on pre-existing conditions.

How to access the healthcare system in the United States as an expat

Accessing healthcare in the United States involves navigating various private and public insurance options, healthcare providers, and regulatory systems.

Determine Healthcare Coverage

The first step to accessing healthcare is determining how you will pay for medical services. In the US, healthcare is not universally free, and individuals typically need some form of insurance to manage costs.

Many Americans receive health coverage through their employers. If you're employed, check with your HR department to understand your coverage options and whether your employer offers a plan.

If you don't have employer-sponsored insurance, you can purchase coverage through the Health Insurance Marketplace set up under the Affordable Care Act (ACA). The marketplace offers various health plans based on income, and individuals may qualify for subsidies to make coverage more affordable.

Visit Healthcare.gov to shop for plans, compare costs, and enrol during the open enrollment period, which runs from November to January. Special enrollment periods may apply for qualifying life events like job loss or marriage.

You can also purchase health insurance directly from private companies like Blue Cross Blue Shield, Aetna, or Cigna. This option may be more expensive, especially without subsidies.

If you're over 65 or have certain disabilities, you may qualify for Medicare, the federal health insurance program. Low-income individuals and families may qualify for Medicaid, a joint federal and state program. Eligibility requirements vary by state, and you can apply through your state's Medicaid office or online at Healthcare.gov.

If you have children and earn too much to qualify for Medicaid but cannot afford private insurance, your children may qualify for the Children's Health Insurance Program (CHIP).

If you're uninsured, you can still access healthcare, but costs may be high. Many hospitals offer financial assistance programs or sliding-scale payments based on income. Community health centres and free clinics provide care to those without insurance, often at reduced or no cost. These clinics usually offer preventive services, basic care, and referrals to specialists.

Choosing a Healthcare Provider

Once you have insurance or a plan to cover costs, the next step is finding a healthcare provider. Providers include doctors, hospitals, and clinics, but your choice may be influenced by the type of insurance you have.

If you have private insurance, it's important to use in-network providers, as they have agreements with your insurer to provide services at reduced rates. Using out-of-network providers can lead to much higher costs. Most insurers provide online directories where you can search for in-network doctors, specialists, and hospitals.

Your primary care physician (PCP) is typically your first point of contact for most health concerns. They handle routine check-ups, preventive care, and referrals to specialists. For those with insurance, it's important to establish a relationship with a PCP early on. If you don't have insurance, many community clinics offer primary care services at reduced rates.

If you need specialised care, you may need a referral from your PCP, depending on your insurance plan. Some plans, like HMOs (Health Maintenance Organizations), require referrals for specialist visits, while others, like PPOs (Preferred Provider Organisations), allow direct access without a referral.

For emergency medical situations, hospitals and emergency rooms (ERs) must provide treatment regardless of your ability to pay under the Emergency Medical Treatment and Labor Act (EMTALA). However, emergency room care can be very expensive, so it's usually best to seek care in less urgent settings if possible.

Types of health insurance in the United States

Employer-Sponsored Health Insurance

Employer-sponsored health insurance, also known as group health insurance, is typically provided to employees (and sometimes their dependents) as part of a benefits package. Premiums are deducted from the employee's paycheck before taxes.

Many employers offer different plan options, such as Health Maintenance Organizations (HMOs), Preferred Provider Organisations (PPOs), or High-Deductible Health Plans (HDHPs) paired with Health Savings Accounts (HSAs).

Private Health Insurance

These plans are purchased directly from insurance companies by individuals or families not covered by employer-sponsored insurance.

Under the Affordable Care Act (ACA), individuals can buy health insurance through federal or state-run marketplaces like Healthcare.gov. These plans are standardised into tiers (Bronze, Silver, Gold, and Platinum), offering varying levels of coverage and cost-sharing.

Based on your income, you may be eligible for federal subsidies to reduce premium costs or qualify for Cost-Sharing Reductions (CSRs) that lower out-of-pocket expenses.

You can also purchase health insurance directly from private insurers outside the ACA marketplace. These plans are similar to marketplace plans but do not offer federal subsidies.

Some of the top private health insurance companies in the US include UnitedHealth Group, Elevance Health, Centene, Humana, and CVS Health.

Public Health Insurance Programs

Some government-sponsored programs are designed to provide healthcare coverage to specific groups, such as low-income individuals, seniors, or those with disabilities.

Medicare

Medicare is a federal program primarily for people aged 65 or older and for certain younger individuals with disabilities.

It covers hospital stays, skilled nursing facilities, and home health care, outpatient care, doctor services, preventive services, and medical supplies.

Medicaid

Medicaid is a joint federal and state program providing free or low-cost health coverage to low-income individuals and families. Each state has its own eligibility criteria and coverage options, though many states expanded Medicaid eligibility under the ACA.

It covers doctor visits, hospital stays, long-term care, preventive care, and some prescription drugs.

Children's Health Insurance Program (CHIP)

CHIP provides low-cost health coverage for children in families that earn too much to qualify for Medicaid but can't afford private insurance. It includes doctor visits, immunisations, hospital care, and preventive care.

High-Deductible Health Plans (HDHPs) and Health Savings Accounts (HSAs)

HDHP is a health insurance plan with a high deductible and lower premiums. You pay for most routine services out of pocket until you meet the deductible, after which the insurance starts covering a portion of the costs.

A HDHP might be a good option for healthy individuals, who do not need complicated medical procedures, and have the financial means to cover high deductibles.

Health Savings Accounts (HSA) is a tax-advantaged savings account where you can set aside pre-tax dollars to pay for qualified medical expenses.

Catastrophic Health Insurance

Catastrophic Health Plans are available to individuals under 30 or those who qualify for a "hardship exemption" (e.g., financial or life circumstances that make other coverage unaffordable).

It is designed to cover emergency services and major medical events. The premiums are low, but the deductibles are very high.

Short-Term Health Insurance

Short-term health plans are available to cover individuals for a temporary period, usually up to 12 months, but can be renewed up to 36 months in some states.

These plans typically cover emergency services and some basic healthcare needs but do not offer comprehensive coverage (e.g., they may not cover pre-existing conditions, maternity care, or preventive services).

Medigap (Medicare Supplement Insurance)

Private companies sell Medigap policies to supplement Original Medicare. These plans help cover out-of-pocket costs like copayments, coinsurance, and deductibles. It helps fill the "gaps" in Medicare coverage.

Health Maintenance Organizations (HMOs)

HMOs offer healthcare services through a network of providers. You are required to select a Primary Care Physician (PCP) and obtain referrals to see specialists.

Coverage is usually limited to in-network providers except in emergencies.

Preferred Provider Organizations (PPOs)

PPOs offer more flexibility in choosing healthcare providers and do not require referrals to see specialists.

You can see both in-network and out-of-network providers, though you'll pay more for out-of-network care.

Exclusive Provider Organizations (EPOs)

EPOs are similar to PPOs but more restrictive. You must use in-network providers for coverage, except in emergencies.

Point of Service (POS) Plans

It is a mix between HMO and PPO plans. With POS plans, you are required to choose a Primary Care Physician (PCP) and get referrals for specialists, but you can see out-of-network providers at a higher cost.

How much does health insurance in the United States cost?

Costs for health insurance in the US differ between employer-sponsored, individual market plans and government programs like Medicaid and Medicare.

In 2024, the average annual premium for employer-sponsored family coverage was around $22,000 per year, with employees paying about $6,000 of that out-of-pocket.

For plans purchased on the Health Insurance Marketplace (ACA), the average premium in 2024 for a benchmark Silver plan was about $450-$500 per month for individuals, without subsidies.

Premiums are generally higher for older individuals and vary by state due to local healthcare costs and regulations. Plans with more extensive coverage or lower deductibles tend to have higher premiums. Bronze, Silver, Gold, and Platinum plans offer varying cost-sharing levels.

Expat health insurance in the United States

Since 2019, the US has no longer enforced a federal individual mandate that penalises individuals for not having health insurance, so there is no federal penalty for expats without coverage. However, some states, like California, Massachusetts, New Jersey, Rhode Island, and Washington, DC, still have their own individual mandates that require residents, including expats, to have health insurance or pay a penalty. It's important to check state-specific regulations.

Certain visas may have health coverage requirements. For example, J-1 Visa holders are required to have health insurance.

The US healthcare system is expensive, and many expats opt to get health insurance to avoid high medical bills. Expats typically have three options: U.S.-based health insurance through an employer or the individual market, expatriate health insurance tailored to foreign nationals living in the US, or international health insurance, which can cover them in both the US and other countries.

Expatriate health insurance is designed for foreign nationals living temporarily or permanently in the US. It provides coverage for medical expenses, hospital visits, emergencies, and sometimes additional benefits tailored to the needs of expats. Plans are typically customisable to suit individual needs.

Since healthcare costs in the US are higher than in many other countries, expat health insurance plans usually offer high coverage limits to protect policyholders from significant medical expenses.

What to do in an emergency?

If you are in a medical emergency, call 911 for immediate help. Emergency medical services (EMS) will dispatch an ambulance to the location.

To avoid the high costs of medical assistance in the United States, it is important to understand your health insurance coverage in case of emergencies. If you have expatriate or international health insurance, inform the healthcare provider about your insurance plan. If you are covered under a U.S.-based insurance policy, such as an employer-sponsored plan, ensure you have your insurance card ready to present at the hospital or clinic.

If you don't have health insurance in the US, emergency medical services are still legally required to treat you. However, you may face significant out-of-pocket expenses.

After receiving emergency care, contact your insurance provider to understand what is covered and how to process claims. Many expatriate health plans require you to pay out of pocket initially and then submit a claim for reimbursement. If you are uninsured or have significant out-of-pocket expenses, many hospitals allow you to negotiate bills or set up payment plans.

For all of these reasons, it is important that you always have a copy of your health insurance card with you. It's also a good idea to have a digital copy stored on your phone or in the cloud.