How US Healthcare Works
There is no single US healthcare system. It is a patchwork of employer-sponsored insurance, government programs (Medicare for 65+, Medicaid for low-income, VA for veterans), and individual private plans. The government does not provide universal healthcare.
For most working-age expats, health coverage comes from:
- Your US employer — if sponsored on a work visa
- ACA Marketplace — individual plans via healthcare.gov
- Private plans — direct from insurers
- International insurance — Cigna Global, Allianz, GeoBlue
Insurance Types
- HMO (Health Maintenance Organization) — cheapest; limited network; need referrals
- PPO (Preferred Provider Organization) — more flexible; higher cost
- EPO (Exclusive Provider Organization) — middle ground
- HDHP (High Deductible Health Plan) — lowest monthly cost, high out-of-pocket before coverage kicks in. Paired with HSA (tax-advantaged savings account).
Marketplace Plans
Any legal US resident (visa holder, green card, citizen) can buy Marketplace plans. Open enrollment is Nov 1 to Jan 15; outside of this you need a Special Enrollment Period (new arrival qualifies). Plans are tiered:
- Bronze: Cheapest monthly, 40% out-of-pocket. Best for healthy people.
- Silver: Mid-range. Subsidized for low-income earners.
- Gold: Higher monthly, 20% out-of-pocket.
- Platinum: Highest monthly, 10% out-of-pocket. Best for frequent users.
Employer Insurance
If you work for a US employer, they usually provide health insurance. Typical employee contribution: $100-300/month for individual, $400-1,000 for family. Employers often pay 70-80% of the premium. You enroll within 30 days of starting.
Costs
| Type | Monthly (single) | Monthly (family) |
|---|---|---|
| Marketplace Bronze | $300-450 | $900-1,400 |
| Marketplace Silver | $450-650 | $1,300-2,000 |
| Marketplace Gold | $600-850 | $1,800-2,700 |
| Employer individual (employee pays) | $100-250 | $400-900 |
| High-deductible HSA | $250-400 | $700-1,200 |
Additionally: deductibles ($500-7,500/year), copays ($25-75 per visit), coinsurance (10-40% of service), out-of-pocket maximums ($7,000-16,000).
ER vs Urgent Care
See our health guide for the full breakdown. Summary: urgent care for minor issues ($150-400), ER only for true emergencies ($2,000+).
Medications
Prescription drugs in the US are the most expensive in the world. Tips:
- GoodRx app — discounts of 30-90% on most prescriptions
- Mail-order pharmacy — 90-day supplies through insurance
- Generic alternatives — always ask
- Cross-border pharmacy — Canada and Mexico are sometimes used (with caveats)
Tips for Expats
- Get insurance on day 1 — do not go bare, even briefly
- SafetyWing or similar travel insurance as a bridge if needed
- Learn your plan — deductibles, copays, network
- Find an in-network PCP early
- HSA is your friend — tax-advantaged medical savings
- Preventive care is often free — annual check-ups, screenings