The healthcare reform debate in the United States has been a political issue focusing upon increasing medical coverage, decreasing costs, insurance reform, and the philosophy of its provision, funding, and government involvement.
Details During the presidency of Barack Obama, who campaigned heavily on accomplishing health care reform, the Patient Protection and Affordable Care Act (PPACA) was enacted in March 2010.
In the 2016 administration, President Donald Trump said during the election that the healthcare system should work based on free market principles. He endorsed a seven-point plan for healthcare reform: repeal Obamacare reduce barriers to the interstate sale of health insurance institute a full tax deduction for insurance premium payments for individuals make Health Saving Accounts inheritable require price transparency block-grant Medicaid to the states allow for more overseas drug providers through lowered regulatory barriers
He also suggested that enforcing immigration laws could reduce healthcare costs.
The Trump administration made efforts to repeal the ACA and replace it with a different healthcare policy (known as a "repeal and replace" approach), but it never succeeded in doing so through Congress. Next, the administration joined a lawsuit seeking to overturn the ACA, and the Supreme Court agreed at the beginning of March 2020 that it would hear the case. Under normal scheduling, the case would be heard in the fall of 2020 and decided in the spring of 2021. However, as the Supreme Court subsequently went on hiatus in response to the coronavirus pandemic, it is unclear when the case will be heard.
Cost debate
U.S. healthcare costs were approximately $3.2 trillion or nearly $10,000 per person on average in 2015. Major categories of expense include hospital care (32%), physician and clinical services (20%), and prescription drugs (10%).CDC-National Center for Health Statistics-Retrieved July 2, 2017 U.S. costs in 2016 were substantially higher than other OECD countries, at 17.2% GDP versus 12.4% GDP for the next most expensive country (Switzerland).OECD Health Stats-Health Expenditure and Financing-Retrieved July 2, 2017 For scale, a 5% GDP difference represents about $1 trillion or $3,000 per person. Some of the many reasons cited for the cost differential with other countries include: Higher administrative costs of a private system with multiple payment processes; higher costs for the same products and services; more expensive volume/mix of services with higher usage of more expensive specialists; aggressive treatment of very sick elderly versus palliative care; less use of government intervention in pricing; and higher income levels driving greater demand for healthcare. Healthcare costs are a fundamental driver of health insurance costs, which leads to coverage affordability challenges for millions of families. There is ongoing debate whether the current law (ACA/Obamacare) and the Republican alternatives (AHCA and BCRA) do enough to address the cost challenge.
In 2009, the U.S. had the highest health care costs relative to the size of the economy (GDP) in the world, with an estimated 50.2 million citizens (approximately 16% of the September 2011 estimated population of 312 million) without insurance coverage. Some critics of reform counter that almost four out of ten of these uninsured come from a household with over $50,000 income per year, and thus might be uninsured voluntarily, or opting to pay for health care services on a "pay-as-you-go" basis. Further, an estimated 77 million Baby Boomers are reaching retirement age, which combined with significant annual increases in healthcare costs per person will place enormous budgetary strain on U.S. state and federal governments. Maintaining the long-term fiscal health of the U.S. federal government is significantly dependent on healthcare costs being controlled.
Public opinion on prescription drug prices In the March 2026 KFF Health Tracking Poll, for example, more than half of respondents reported being worried “a great deal” about how they would pay for needed prescription drugs, and most supported allowing the government to negotiate lower prices with drug companies (KFF Health Tracking Poll, Question 8). Consistent attention to this issue over time underscores that it is not simply a one-time political issue. Public opinion can also matter because, at times, elected officials think about issues that matter deeply to voters. When huge numbers of Americans experience the burden of high healthcare costs, they expect elected officials to do something about the problem when they hit it. By continuing to cover the high cost of prescription drugs in the latest round of survey questions on healthcare affordability, NHPC projects Americans’ continued strong concern about this issue, which they perceive to need policy action.KFF. (2019). KFF Health Tracking Poll: February 2019 Prescription Drugs. https://www.kff.org/health-costs/kff-health-tracking-poll-february-2019-prescription-drugs/
Quality of care There is significant debate regarding the quality of the U.S. healthcare system relative to those of other countries. Physicians for a National Health Program, a political advocacy group, has claimed that a free market solution to healthcare provides a lower quality of care, with higher mortality rates, than publicly funded systems.For-Profit Hospitals Cost More and Have Higher Death Rates, Physicians for a National Health Program The quality of health maintenance organizations and managed care have also been criticized by this same group.For-Profit HMOs Provide Worse Quality Care, Physicians for a National Health Program
According to a 2015 report from The Commonwealth Fund, although the United States pays almost twice as much per capita towards healthcare as other wealthy countries with universal healthcare, patient outcomes are poorer. The United States has the lowest life expectancy overall and the infant mortality rate is the highest and in some cases twice as high when compared with other Organisation for Economic Co-operation and Development (OECD) countries. Also highlighted in this report is data that shows that although Americans have one of the lowest percentages of daily smokers, they have the highest mortality rate for heart disease, a significantly higher obesity rate and more amputations due to diabetes. Other health related issues highlighted were that Americans over the age of 65 have a higher percentage of the population with two or more chronic conditions and the lowest percentage of that age group living.
According to a 2000 study of the World Health Organization (WHO), publicly funded systems of industrial nations spend less on healthcare, both as a percentage of their GDP and per capita, and enjoy superior population-based health care outcomes. However, conservative commentator David Gratzer and the Cato Institute, a libertarian think tank, have both criticized the WHO's comparison method for being biased; the WHO study marked down countries for having private or fee-paying health treatment and rated countries by comparison to their expected healthcare performance, rather than objectively comparing quality of care.David Gratzer, Why Is not Government Health Care The Answer? , Free Market Cure, July 16, 2007Glen Whitman, "WHO's Fooling Who? The World Health Organization's Problematic Ranking of Health Care Systems," Cato Institute, February 28, 2008
Some medical researchers say that patient satisfaction surveys are a poor way to evaluate medical care. Researchers at the RAND Corporation and the Department of Veterans Affairs asked 236 elderly patients in two different managed care plans to rate their care, then examined care in medical records, as reported in Annals of Internal Medicine. There was no correlation. "Patient ratings of health care are easy to obtain and report, but do not accurately measure the technical quality of medical care," said John T. Chang, UCLA, lead author.
There are health losses from insufficient health insurance. A 2009 Harvard study published in the American Journal of Public Health found more than 44,800 excess deaths annually in the United States due to Americans lacking health insurance. More broadly, estimates of the total number of people in the United States, whether insured or uninsured, who die because of lack of medical care were estimated in a 1997 analysis to be nearly 100,000 per year.A 1997 study carried out by Professors David Himmelstein and Steffie Woolhandler (New England Journal of Medicine 336, no. 11 1997) "concluded that almost 100,000 people died in the United States each year because of lack of needed care—three times the number of people who died of AIDs." "The Inhuman State of U.S. Health Care", Monthly Review, Vicente Navarro, September 2003. Retrieved September 10, 2009
A 2007 article from The BMJ by Steffie Woolhandler and David Himmelstein strongly argued that the United States' healthcare model delivered inferior care at inflated prices, and further stated: "The poor performance of US health care is directly attributable to reliance on market mechanisms and for-profit firms and should warn other nations from this path."
Cost and efficiency
The United States spends a higher proportion of its GDP on healthcare (19%) than any other country in the world, except for East Timor (Timor-Leste). The number of employers who offer health insurance is declining. Costs for employer-paid health insurance are rising rapidly: since 2001, premiums for family coverage have increased 78%, while wages have risen 19% and prices have risen 17%, according to a 2007 study by the Kaiser Family Foundation.
Private insurance in the US varies greatly in its coverage; one study by the Commonwealth Fund published in Health Affairs estimated that 16 million U.S. adults were underinsured in 2003. The underinsured were significantly more likely than those with adequate insurance to forgo healthcare, report financial stress because of medical bills, and experience coverage gaps for such items as prescription drugs. The study found that underinsurance disproportionately affects those with lower incomes – 73% of the underinsured in the study population had annual incomes below 200% of the federal poverty level.
However, a study published by the Kaiser Family Foundation in 2008 found that the typical large employer Preferred provider organization (PPO) plan in 2007 was more generous than either Medicare or the Federal Employees Health Benefits Program Standard Option.Dale Yamamoto, Tricia Neuman and Michelle Kitchman Strollo, How Does the Benefit Value of Medicare Compare to the Benefit Value of Typical Large Employer Plans? , Kaiser Family Foundation, September 2008 One indicator of the consequences of Americans' inconsistent health care coverage is a study in Health Affairs that concluded that half of personal bankruptcies involved medical bills, although other sources dispute this.Todd Zywicki, "An Economic Analysis of the Consumer Bankruptcy Crisis", 99 NWU L. Rev. 1463 (2005)
Proponents of healthcare reforms involving expansion of government involvement to achieve universal healthcare argue that the need to provide profits to investors in a predominantly free market health system, and the additional administrative spending, tends to drive up costs, leading to more expensive provision.
According to economist and former US Secretary of Labor, Robert Reich, only a "big, national, public option" can force insurance companies to cooperate, share information, and reduce costs. Scattered, localized, "insurance cooperatives" are too small to do that and are "designed to fail" by the moneyed forces opposing Democratic health care reform.
Impact on U.S. economic productivity