Explaining our Health Care Dilemma to the World

I co-wrote the article below for the British Medical Journal with John Park, a Kennedy Scholar at the Harvard TH Chan School of Public Health:

America’s HealthCare Dilemma

The insurance of at least 22 million Americans hangs in the balance

The election of Donald Trump as 45th president of the United States has triggered concerns in many globally important areas of public policy, including climate change. But for Americans, one of the most unsettling challenges is the future of domestic healthcare policy and the fate of the 2010 health reform law, the Affordable Care Act (ACA).

For 45 years, the US healthcare system has been accurately characterized as the most expensive among nations in the Organization for Economic Cooperation and Development (OECD), as mediocre regarding quality and effectiveness, as inadequate in that it left nearly 50 million Americans uninsured, and as substandard in core outcomes such as infant mortality and life expectancy. In short, the only category at which Americans seemed to excel was in spending the most money.1

Between 2005 and 2008, many sectors in American society became vocal in calling for comprehensive healthcare reform to address failings in access, quality, cost, and outcomes. Between January 2009 and March 2010, new President Barack Obama worked with hefty Democratic majorities in the US Senate and House of Representatives to fashion comprehensive reform to tackle these deficiencies, signing the ACA on 23 March 2010. Though some Republican members of Congress initially expressed support for reform, objections to the Democratic approach and political resistance from their grassroots left zero Republican supporters by the time that the ACA was signed.

Over six and a half years, the Obama administration has worked to implement the law with persistent resistance from all levels of the Republican firmament. Implementation has faced numerous obstacles, including the self inflicted and catastrophic initial launch in 2013 of a federal website called Health Insurance Marketplace, two anti-ACA lawsuits that reached the Supreme Court, more than 60 attempts by Congressional Republicans between 2011 and 2016 to repeal or weaken the law, plus normal challenges that accompany the launch of any new complex public program.

By fall 2016, more than 20 million formerly uninsured Americans had obtained affordable coverage, and many millions more had won protections from now prohibited insurance practices such as rating consumers based on medical history; the percentage of uninsured Americans is now estimated at below 9%, the lowest ever.2 The past six years have seen the lowest rates of healthcare inflation in public and private spending since the 1960s.3 The medical care delivery system is embracing a fundamental shift away from fee-for-service towards value based financing models that reward quality and efficiency over quantity.

The 2016 presidential election campaign offered American voters a sharp contrast. Democrat Hillary Clinton promised to fix and strengthen the ACA to have it cover more Americans and provide greater affordability. Republican Donald Trump promised to repeal the act and replace it with alternative reforms such as permitting insurance companies to sell policies across state lines and expanding use of health insurance policies with high deductibles, called “health savings accounts.”4 Since 2010, Americans have sharply disagreed about the ACA, with unfavorable views usually surpassing favorable, neither exceeding the 40% range.5

What can we expect from the impending Trump administration and newly empowered Republican majorities in the US Senate and House starting in January 2017?

Since the election Republican leaders, including Trump, have emphasized their determination to “repeal and replace” the ACA as rapidly as possible.6 7 While it seems that Republicans can inflict substantial and even fatal damage to the act, their path is not simple. The fundamental obstacle is the US Senate, which permits senators to “filibuster” almost any measure they oppose, requiring 60 out of 100 votes to unblock controversial legislation. In January, the Republican caucus will hold 52 seats and the Democrats 48. Nearly all of the Democrats are staunch ACA supporters. Any legislation to replace the ACA would be thwarted if at least 41 Democrats object, a likely prospect.

The Congress and president will probably use a special legislative process known as “budget reconciliation” that enables a bill to avoid filibusters and pass with only 51 votes, though only for federal budget related matters. In January 2016, Senate and House Republicans passed a reconciliation bill that, while not repealing the ACA, would have decimated the financing of its coverage provisions, effectively repealing that fundamental reform part; President Obama vetoed that bill, but it would have been signed by President Trump. Republicans are likely to move legislation modeled on the 2016 bill, as this successfully used the reconciliation process. Unclear, though, is whether moderate Republicans who voted for that 2016 bill because they knew it would not become law, would vote for a bill that would eliminate insurance for as many as 22 million Americans on low and moderate incomes.

The key difficulty is that while Republicans appear to have a vehicle to repeal insurance for 22 million formerly uninsured citizens, they lack a path to pass replacement legislation without using reconciliation rules. Their replacement ideas, thus far, are generic and would leave many millions of currently insured Americans without financial protection from the costs of illness and injury. Last week, Trump seemed to soften his resolve to repeal several popular elements of the ACA, perhaps signaling some willingness to negotiate with Democrats.8

At the core of this conflict is a fundamental difference in values. Democrats see healthcare as a human right and seek to actualize that right in law. Republicans do not see healthcare as a right and prefer the free market approaches to reign. This is not a controversy over technical details but a divide over the appropriate nature of the US social contract. Resolution will be difficult.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare that JEMcD worked in the US Senate between 2008 and 2010 on the writing and passage of the Affordable Care Act.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


Author: John McDonough

I offer insights and opinions on how to improve health care systems for everyone

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