Health care in the US

Keeping you safe

SummaryPolitical BackgroundCrime & KidnappingHealth CareCultural Considarations

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Health insurance and health care services in the US are complex issues. The basic point for travelers and expats alike is the same: Get proper and full range health insurance. Foreigners are not covered by the ACA (Obamacare) unless they have a Green Card, and even so the quality of treatment will be better and much more affordable with health insurance.

Given its size risks will vary across the US. Travelers and expatriates should face an overall benign security environment, although crime is a concern as is terrorism to some extent.

Violent and common crime warrants attention. While violent crime is not common, the unwary traveler may stray into hot spots or become a victim of crimes of opportunity. Most major and large cities have areas that are best avoided, so seek local advice from friends and colleagues. Do not wander or drive about in unfamiliar urban areas, particularly after dark.

Terrorism is a concern since the US has clearly been a major target for international terrorist groups for decades and due to home-grown terrorists too. The objective risk of getting caught up in an attack is very small though, and travelers and expats should pay more attention to the mundane risk from crime.

The political system is stable. However, demonstrations may sometimes turn violent and US police forces have a well-deserved reputation for a somewhat heavy-handed behavior. If arrested, demand representation and to contact your embassy.

Political background

The US is a federal, democratic republic. At the federal level executive power rests with the president and the cabinet, which the president appoints. Legislative power rests with the bicameral Congress, which controls the federal funds and must approve candidates for e.g. cabinet posts as proposed by the executive. The Supreme Court is the highest court in the land, and the judicial system is independent of the executive and the legislative branches.

Elections for the presidency take place every four years, while parts of Congress are up for grabs every 2 years, which means the political system is basically ever in electoral mode.

At the state level this structure each state is headed by a governor who, like the president, wields real executive power.

The US has a vibrant civil society and is home to diverse cultures. Political activity rarely turns violent but do avoid demonstrations and protests as police may act heavy handedly. Note that cultural sensitivities may be high in many parts of the country, and avoid taking a stance on sensitive issues such as religion, abortion, gun-laws and similar. People expect their beliefs and sensitivities to be respected here.

Crime & kidnapping

Crime can be an issue for travelers and expatriates in the US. While rates vary and hot spots do exist, the basic problem is that foreign visitors will often lack the local knowledge, or “street smarts” needed to avoid such areas and may stray into them. Note also that crime may happen anywhere at any time, but that overall the  risk is not high.

Ordinary crime such as pick pocketing or car theft aside, the concern is violent crime including robbery, armed robbery, assault, residential crime and, while rarer, express kidnapping and more classical kidnapping.

Travelers and expatriates should seek advice from trusted friends and colleagues as to the local situation in their environment, including any would-be hot spots. While crime used to be a problem most prevalent in the old inner cities, this has changed during the last 10-20 years and crime has become less concentrated and thus less predictable. But rates have also dropped overall.

Expatriates should make sure their residence is properly protected against residential crime. Alarms, locks and dead-bolts go a long way. While many US citizens have firearms for “home protection” this is something you should consider very carefully before acquiring. Firearms can be quite a risk for the untrained, and some 5% of all gunshot fatalities are accidents. If you do decide to procure firearms, make sure you do so legally and that you are proficient in their use and safekeeping.

When out and about use the information you have. Risks always increase after dark. Avoid driving or walking in run down or poor neighborhoods. It is best to travel in a group using the “buddy system”. If you sample the night-life note that drink-drugging can be a problem and keep an eye on your drink at all times.

If you are faced with armed robbers or a snatch-and-run robbery, do not resist. Hand over any and all valuables on demand. Try and keep calm and avoid eye-contact.

While kidnapping is rare high-level managers and their families may wish to retain advice from security professionals to ward of the risk. Extortion is less rare, and it is prudent to keep personal information and family data confidential.

Health care

Health insurance does not come cheap here. The US boasts some of the world’s finest hospitals as well as one of the most expensive healthcare systems. The quality of treatment varies but for those with means, or indeed a good health insurance, high quality is certainly available. The basic point is that you should expect to pay for everything, including emergency services. Medicine is quite expensive too.

If you need an ambulance dial 911.

Health insurance documentation should be presented upon admission to a hospital present the as soon as possible. Contact your health insurance company to inform them of your situation.

Health insurance should also pay for medicine, which is available at pharmacies and in many large stores. If you bring prescription drugs to the US, or carry them around make absolutely sure you have proper documentation as some medicine may resemble narcotics.

Health insurance under ACA
Health insurance is mandatory for US citizens under the Affordable Care Act (ACA or “Obamacare”), but the vast majority of foreigners visiting the US will not be offered the reasonably priced (and mediocre) covers under this law. Note that the ACA is not a universal health insurance and health care system as known in parts of Europe.

Foreign travelers are not offered cover by the ACA and must make sure they have extensive health insurance in place. This should provide ample cover, without significant exemptions and sums covered should be high due to the risk of spiraling costs: Note that price of treatment and medicine can be very high indeed.

Most expatriates will not be offered cover under ACA, but those who are legal immigrants and have a Green Card will. It is normal for employers to offer some sort of health insurance, but you should make absolutely sure that this covers your needs and those of your family if you bring them as well. Note again the very high costs in the system.

Cultural Considerations

Briefly on culture
To people at home within a given culture, there will be a set of norms and values which governs everyday life, often in an almost subconscious manner. Think of how people tend to interact back home: How are relations between age-groups, genders, colleagues, religious groups, employers and employees, citizens and state etc. usually defined? Then consider that these relationships and the norms and even rules which govern then are very familiar to you – indeed you will probably consider them almost natural. This is the effect of culture upon people living within a group.

But the world is a diverse place, and cultures are very different around the globe. To complicate matters further cultures are anything but static; indeed, by their very nature they are always in flux. A country will often be home to different cultures as well, although it may sometimes be possible to identify a preponderant culture within a country.

Cultural differences and travel security
When you travel to a country or an area with a significantly different culture from your own this may affect your safety. This effect may take several different shapes.

The most basic effect is that of simply being different, of sticking out, familiar to any tourist in the world: The local population has little trouble identifying you as a traveler, tourist or expat. This raises your profile and increases your vulnerability, especially to street crime and scams, which may be serious in high-risk countries. While probably difficult to avoid, this basic fact should always be borne in mind. You will be more exposed and have less instinctive understanding of your surroundings that would the case back home.

Examples of specifics: Locals laws and customs
There may be more specific effects as well. Local laws will reflect the local culture, and this can have a very direct effect, e.g. bans on specific products, behavior or rules affecting interaction between people. Classic examples include a ban on consumption of alcohol or drugs, limits on driving, bans on homosexuality or laws governing interaction between unmarried couples. Clearly local laws must be obeyed as they apply to all.

Health care and health insurance may also be affected. This is most often the case when it comes to how much practical support relatives are expected to supply at a hospital or clinic (e.g. food and basic care), or how much access family members can have to a hospitalized dependent.

But specific effects may also be subtle. As a foreigner, it is easy to break local customs unwarily, which may cause offense or resentment. This can be embarrassing of course; however, to transgress deeply held convictions e.g. of a political or religious nature may trigger hostility. Travelers and expats should always refrain from any political debates with locals, and should at least make themselves familiar with local customs and religious beliefs.

When it comes to religion specifically sensitivity may be high. If confronted with locals, it is best to express agreement with their stated convictions in a discussion. Most often it is not a problem to belong to a different major faith or denomination, but it may be. It is almost always a bad idea to confess to atheism if confronted by zealots.

Always remember that, even though you may disagree vehemently with elements of the local culture, you are the visitor. Do not try to convince locals of “the errors of their ways” and never, ever proselyte.