Intended for healthcare professionals

Feature US health care

America’s health choices

BMJ 2008; 337 doi: (Published 23 September 2008) Cite this as: BMJ 2008;337:a1563
  1. Vidhya Alakeson, policy adviser
  1. 1US Department for Health and Human Services, Washington DC, USA
  1. alakesonvidhya{at}

    Getting American voters to back much needed healthcare reforms will be a challenge for both contenders for the White House. Vidhya Alakeson explains the difficulties

    US presidential candidate Barack Obama was not even born when national health insurance was first proposed under the Truman presidency in the 1940s. Twenty years later, Congress voted in Medicare, a publicly funded, national insurance programme for everyone over 65. At the time, Medicare seemed to be the first step towards universal coverage. But further steps were never taken. Failed health reforms in the 1970s and 1990s have left the United States as the only developed country not to provide all its citizens with access to health care.

    America’s inability to fix something that all other developed nations take for granted may seem baffling. But two facts begin to explain the puzzle: 94% of Americans who vote have health insurance,1 and nearly three quarters of people who have insurance think that what they have is either good or excellent.2 While most voters agree that everyone has a right to high quality, affordable health care, no one wants to give up too much of what they already have to fix the problem. Mindful of this, proposals by Mr Obama and presidential rival, John McCain, steer clear of grand reform. The question is whether either candidate’s proposals will be enough to make a real difference to health care but not too much to put off voters.

    Health challenges

    The World Health Organization’s final report on the social determinants of health, published in August this year, called on national governments to develop healthcare services on the principle of universal coverage, focusing on primary care. The report is relevant to the US, which not only does not provide health coverage for all but is the most expensive system in …

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