Understanding the American healthcare reform debateBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2718 (Published 07 June 2017) Cite this as: BMJ 2017;357:j2718
- Donald M Berwick, president emeritus and senior fellow
- Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
Debates over the US healthcare reform law—the Affordable Care Act (ACA) or “Obamacare”—have raged for almost a decade, with new fury now in the “repeal and replace” initiatives of the Trump administration. The act is complex, the more so because its provisions build on an already tortuous non-system of financing and delivering care to the people of the United States.
Here I present a quick tour of that non-system, an explanation of the basics of the ACA, and an analysis of the present attempts to undo it. Although I have tried to be technically correct, I make no claim to be non-partisan. I was President Obama’s appointee as administrator of the US Centers for Medicare and Medicaid Services between July 2010 and December 2011, which provides insurance at a cost above $820bn (£640bn; €730bn) to over 100 million Americans and which was and is responsible for implementing and managing more than 70% of the provisions of the ACA. I am a fan of the ACA, and I strongly oppose its repeal.
Understanding the ACA and its critics requires an understanding of how the US funds its healthcare. There are seven main routes of funding (box 1).
Box 1: How the US funds healthcare
Employer sponsored insurance for about 160 million people—workers and their families—in which premium costs are shared between employers (usually 60%-80% of the costs) and employees
Medicare—the tax supported federal health insurance scheme established in 1965 for Americans over 65 years of age (about 50 million people) and some others with disabilities
Medicaid—tax supported insurance, also begun in 1965, managed through the states and funded by a sharing of costs between states and the federal government, covering the care of people …