Understanding the American healthcare reform debate

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).