What Surprised Me the Most About the U.S. Healthcare System

Recently, on my channel, I spoke with Dr. Igor Kirzhner, an anesthesiologist and healthcare executive who has spent many years working inside the American hospital system. He manages medical teams and helps optimize clinical operations across dozens of hospitals in the United States.

We talked about how healthcare in the U.S. actually works — not the simplified version people often hear in the media, but the real system with all of its complexity, strengths, and contradictions.

Here are several insights from our conversation that surprised me the most and may be especially useful for people who already live in the United States or are planning to move here.

1. In the U.S. healthcare system, you almost never receive just one bill

One of the biggest surprises for immigrants is the number of bills that can arrive after a single medical visit.

Dr. Kirzhner explained that the U.S. system involves many separate participants, and each of them may bill you independently. If you are treated in a hospital, you might receive bills from the hospital itself, the attending physician, the surgeon, the anesthesiologist, the laboratory, and even the radiologist who reviewed your imaging.

In other words, one visit can generate multiple bills, and this is completely normal in the American healthcare system.

There is also another important detail: the amount on the bill is often just the starting point. Insurance companies rarely pay the full amount listed. Instead, the number serves as the initial figure before negotiations and adjustments between the hospital, the insurance provider, and the patient.

2. The emergency room is not the same as an ambulance

Another important difference becomes obvious when you compare the U.S. with many post-Soviet healthcare systems.

In those countries, an ambulance usually arrives with doctors on board. In the United States, things work differently. Ambulance services are typically run by private companies that specialize in transportation and stabilization of patients. The staff are highly trained emergency medical technicians or paramedics, but there is usually no physician inside the ambulance.

Meanwhile, the Emergency Room (ER) is a hospital department where patients can arrive on their own.

U.S. law requires emergency departments to treat patients regardless of their insurance status or ability to pay. Because of this rule, many Americans use the ER as the primary entry point into the healthcare system when they need urgent medical attention.

3. The paradox of American healthcare: it can be easier to be very poor or very wealthy

This point may sound surprising, but it reflects the financial structure of the system.

People with very low incomes may qualify for government programs that cover many healthcare costs, and hospitals sometimes write off debts for patients who truly cannot pay.

At the other extreme, wealthy individuals can afford the best services and specialists.

The group that often faces the greatest burden is the middle class. They typically earn too much to qualify for government assistance but still feel the full impact of healthcare costs and insurance deductibles. This dynamic is one of the reasons the U.S. healthcare system is considered among the most expensive in the world.

4. Preventive care is one of the weaker areas of the system

Another insight that surprises many immigrants is how limited preventive medicine can be in the U.S.

Dr. Kirzhner explained that historically, health insurance has been tied to employers. Since people frequently change jobs, insurance companies have little financial incentive to invest heavily in long-term prevention if the patient might switch insurers in a few years.

As a result, preventive care is often less proactive, routine testing can be harder to obtain, and the system frequently reacts after a health problem has already appeared rather than focusing heavily on early prevention.

5. But when it comes to surgery and complex treatment, the U.S. is world-class

Despite its challenges, the American healthcare system excels in certain areas.

When it comes to surgery, complex procedures, and emergency treatment, the U.S. is often considered among the best in the world. Advanced technology, cutting-edge research institutions, and highly specialized physicians allow hospitals to perform some of the most complex procedures available anywhere.

If a patient requires a major operation or sophisticated medical intervention, it is difficult to find a system with more advanced resources.

6. Hospitals are financially motivated to discharge patients quickly

Another interesting aspect of the system is how hospitals are paid.

In the past, hospitals were reimbursed for each procedure and every day a patient stayed in the hospital. Today, many treatments are reimbursed as a fixed payment per case.

For example, a hospital might receive a set amount for treating appendicitis regardless of how many procedures are performed or how long the patient stays.

If a patient remains in the hospital longer than expected, the hospital may actually lose money. This is why hospitals focus heavily on safely discharging patients as soon as possible.

7. One of the most surprising facts: hospitals can be among the dirtiest environments

This may sound paradoxical given the strict hygiene protocols in healthcare facilities.

However, hospitals are environments where many sick people are treated in close proximity. Because of this, they can contain a high concentration of bacteria, including strains that are resistant to antibiotics.

That is why doctors themselves often say: if you are healthy enough to go home, it is better to leave the hospital sooner rather than later.

8. The United States faces a serious shortage of physicians

Another structural issue in American healthcare is the shortage of doctors.

The number of patients continues to grow, while the number of new physicians entering the system increases slowly. One major reason is the length of medical training.

Becoming a doctor in the United States typically requires about 12 years of education and training: four years of college, four years of medical school, and three to four years of residency.

Because the training pipeline is so long, expanding the physician workforce takes many years.

9. Physician salaries vary dramatically

Doctor salaries in the United States vary widely depending on specialization.

Pediatricians may earn roughly $150,000 to $300,000 per year, while internal medicine physicians often earn between $250,000 and $400,000. Surgeons can earn anywhere from $350,000 to well over $1.5 million annually, particularly in highly specialized fields such as neurosurgery, cardiac surgery, or orthopedic surgery.

Interestingly, salaries are not always tied to the cost of living. In some cases, physicians practicing in smaller states or rural areas may earn more than those working in major cities like New York or San Francisco.

10. The most important principle: personal responsibility for your health

At the end of our conversation, Dr. Kirzhner shared a thought that captures an essential principle of the American healthcare system.

No one knows your body better than you do.

A doctor may see you only a few times a year, but you live with your body every day. That is why it is important to understand your diagnoses, know the medications you take, pay attention to your health, and take an active role in medical decisions rather than relying entirely on doctors.

Final thoughts

After this conversation, one conclusion became clear to me: the U.S. healthcare system is far from perfect. But it is also an incredibly powerful, technologically advanced, and highly complex ecosystem.

It combines cutting-edge medical technology, a complicated financial structure, and a strong expectation that patients take responsibility for their own health.

You may end up managing a minor illness mostly on your own. But if something truly serious happens, you are likely to find yourself inside one of the most advanced medical systems in the world.