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USA: Healthcare system

The USA has no single national health system: people get care through different kinds of insurance (employer, individual, Medicare and Medicaid).

Last updated: ~1 min read
A mosaic of plans
Figure 1.A mosaic of plans — USA: Healthcare system

01Short answer

Many people get insurance through their employer. Individual plans are bought through HealthCare.gov or state marketplaces. Medicare is a government programme mainly for people aged 65 and over and some people with disabilities; Medicaid is for people on low incomes (rules vary by state). Each plan has a “network”: in-network doctors and hospitals cost less. Some plans require a referral to see a specialist or prior authorization.

02Simple explanation

Several kinds of insurance: employer, individual, Medicare, Medicaid.

Network: in-network costs less.

Authorization: needed in advance for some services.

03Scientific explanation

Law: the Affordable Care Act (ACA) bans refusing coverage because of a pre-existing condition.

Cancer centres: NCI provides a guide to finding health care services.

04What happens in the body?

Kinds of insurance

Find your plan type and what it covers from your card and plan documents.

Network

Check in advance that your haematologist and hospital are in-network.

On a dark navy background, hospital points.
Figure 2.Network map — USA: Healthcare system

Referral

Some plans need a referral from your primary care doctor or approval from the plan.

On a dark navy background, a path from a clinic to a centre.
Figure 3.Referral path — USA: Healthcare system

05Finding your way

Four steps.

Coverage — Read your plan.1CoverageRead your plan.
Network — Check the doctor.2NetworkCheck the doctor.
Authorization — Referral or approval.3AuthorizationReferral or approval.
Urgent — ER or urgent care.4UrgentER or urgent care.
AccessThe route to a doctor is clear.
CostsFewer surprises.

06Key points at a glance

TopicIn brief
Kinds of insuranceFind your plan type and what it covers from your card and plan documents.
NetworkCheck in advance that your haematologist and hospital are in-network.
ReferralSome plans need a referral from your primary care doctor or approval from the plan.

07Key terms

Network
Doctors and hospitals included in the plan.
Prior authorization
Approval in advance.
Medicare
Programme for people 65+ and some with disabilities.
Medicaid
Programme for people on low incomes.

08Key points

  • Keep your insurance card.
  • Check the network.
  • Ask about authorization rules.
  • Emergency number: 911.
  • Talk to a financial counsellor.

09Frequently asked questions

Can I be treated without insurance?

Emergency departments must assess you, but costs can be very high; ask about financial assistance.

Can I go straight to a specialist?

It depends on the plan; some require a referral.

What should I compare when choosing a plan?

Network, deductible, out-of-pocket maximum and drug list.

10Questions for your doctor

Take these questions to your appointment. The ones you save are collected on the “My questions” page and stay on this device only.

  1. Can I be treated without insurance?

  2. Can I go straight to a specialist?

  3. What should I compare when choosing a plan?

My questions

12Sources

  1. HealthCare.gov (U.S. Government). Official website
  2. Medicare.gov (U.S. Government). Official website
  3. HealthCare.gov. Coverage for pre-existing conditions
  4. National Cancer Institute (NCI). Finding Health Care Services
  5. American Cancer Society. Where to Find Cancer Care
  6. Charité – Universitätsmedizin Berlin. Allogeneic stem cell transplantation, Campus Virchow-Klinikum (in German)
  7. Charité – Universitätsmedizin Berlin. For international patients
  8. Heidelberg University Hospital. Stem cell transplantation
  9. Heidelberg University Hospital. Treatment inquiry and appointment for international patients
  10. Clínica Universidad de Navarra. Hematopoietic stem cell transplantation (in Spanish)
Medical disclaimerThis information is for educational purposes only and does not replace medical advice.
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