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We got the cancellation insurance.  Do we really need travel insurance, since it's all in the US?  

 

We visited the infirmary on the Rotterdam in Boston, and had to submit it to Medicare.  Medicare paid!

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No real medical facilities on the ship. If you have a serious issue, you would go to a hospital or clinic on land which would be covered by Medicare (in the USA). Not sure how Medicare would address transportation back to your home.

 

If you don't buy travel insurance you will have no coverage for lost luggage. If you were to get sick on day 1 of the cruise and were unable to continue the cruise, the ACL cancellation policy would pay you ZERO.

 

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