Writing from the US amid a government shutdown, Lucinda Hiam asks why the world’s most expensive health system still fails to deliver fair and universal access to care
The Trump administration’s unprecedented assaults on science, democracy, and human rights have shaken institutions to a degree not seen before. Yet, while politics may feel newly volatile, problems with the US health system feel stubbornly old.
As an outsider I’ve long found US healthcare baffling: a patchwork of public and private programmes, insurers, and employers that spend more money per capita on healthcare than any country in the world1 but consistently deliver some of the worst health outcomes among high income countries.2 The Commonwealth Fund’s Mirror, Mirror report from 2024 ranks the US last among comparable nations on overall health system performance, using measures including access, equity, and outcomes.2 These statistics are familiar, but after interacting with the health system myself I find it even more fragmented and confusing than I’d imagined.
I’m fortunate enough to have comprehensive health insurance while I’m in the US. Using it, however, is a bewildering maze of bureaucracy and barriers, with an incoherent rule book. Take emergencies, for example: you should call an ambulance, and if your case is later deemed life threatening or serious, the cost will be covered by the insurance. But there’s a catch: it will be covered only if the ambulance that comes is “in network”—meaning that it’s covered by your specific health insurance plan. But when you call 911 you can’t choose the ambulance provider.
The incoherence of the health system isn’t a problem just for those of us who are new to it. As a US health expert I spoke to recently explained, “I’m a nurse with a PhD in health policy, and I can’t navigate my own healthcare.”
History of failed reform
Healthcare reform in the US has been repeatedly attempted by Republicans and Democrats but usually ends in failure.3 The Affordable Care Act (ACA), passed in 2010, was a rare exception.4 It cut the proportion of Americans without health insurance from around 16% to under 9%, largely by expanding Medicaid and creating insurance marketplaces.5 The ACA was no panacea, but it represented the most substantial progress in half a century.
That progress was fragile. During President Trump’s first term, Republicans in Congress voted dozens of times to repeal the ACA. There was no credible replacement plan, and the effort finally collapsed with Senator John McCain’s dramatic “thumbs down” on the Senate floor.6 The law survived, but the symbolism was clear: health reform was a partisan identity test rather than a debate over policy.
Trump is again promising in the 2025 Federal Budget Reconciliation Bill (better known as the “One Big Beautiful Bill Act”) a proposal that would result in millions of Americans losing health coverage without any serious alternative being offered—a major factor in the current US government shutdown.7 Data suggest that Trump’s voters are among those with the most to lose: more than three quarters (77%) of ACA marketplace enrolees live in states won by Trump in 2024, and 57% live in Republican held congressional districts.89
Even some conservative lawmakers have grown uneasy. Representative Marjorie Taylor Greene, a Georgia congresswoman and Trump supporter, warned that the bill could cause ACA subsidies to lapse, leaving tens of thousands of her own constituents at risk of losing coverage, including her “own adult children.”10 The data and Greene’s warning both highlight the paradox at the heart of US health politics: policies championed by Republicans often threaten the very constituents they represent, highlighting the people harmed by polarised policy shifts.
Healthcare in any country is more than a policy debate—it’s a test of national values. The US is capable of extraordinary care: world leading cancer outcomes, cutting edge research, and some of the best hospitals in the world. But access, not quality, remains the dividing line. As the influential Princeton economist Uwe Reinhardt asked nearly 30 years ago, “Should the child of a poor American family have the same chance of avoiding preventable illness, or of being cured from a given illness, as does the child of a rich American family?”11 In most other wealthy nations, the answer has long been yes. In the US, the debate continues.
Acknowledgments
I thank my UK and US mentors (Stefanie Friedhoff, Philip Landrigan, and Martin McKee) for their comments and feedback in preparing this piece.
Footnotes
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LH is a 2025-26 Harkness fellow based at Boston College and the Information Futures Laboratory at Brown University, supported by the Commonwealth Fund. The views presented here are those of the author and should not be attributed to the Commonwealth Fund or its directors, officers, or staff.
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Competing interests: None declared.
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AI use: ChatGPT was used to improve readability. The research, analysis, and arguments were developed independently by the author.
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Provenance: Not commissioned; not externally peer reviewed.
