Comment: What Makes the US Healthcare System so Difficult to Improve?

Sam Grossman


The US healthcare system depends on a shared responsibility between private and public organizations to ensure that its citizens are properly cared for. This system has been historically inequitable, even after the institution of progressive legislation, including most notably, the enactment of Medicare and Medicaid in 1965 and the Affordable Care Act in 2010. As of 2016, 27.3 million Americans and two thirds of undocumented immigrants remain uninsured (Mossialos, Djordjevic, Osborn, & Sarnek, 2017). At the same time, the country’s per capita healthcare spending is the highest in the world at $9,364 US dollars as of 2014, while life expectancy (31), infant mortality (36), and male and female healthy life expectancy (28 and 29, respectively) rank lower than other developed nations (Berwick, Nolan, & Whittington, 2008; Mossialos et al., 2017). Despite these troublesome statistics, America is still the only industrialized nation without universal health insurance. It may seem that the problems involved in this inequitable and costly healthcare system can be fixed easily with increased access to public health coverage. Unfortunately, the political atmosphere surrounding entitlements spending is one of the most difficult barriers to finding compromise in healthcare reform.

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Roundtable Journal on Health Policy  |  Volume 2  |  Issue 1


The current divisive political atmosphere surrounding healthcare in the United States is not new. There have been democratic pushes for universal healthcare since the the 1930s. Public healthcare in different forms was continually defeated by republicans and conservative democrat’s opposition until the Medicare bill was passed in 1965. Although Medicare and Medicaid have become an essential part of our healthcare system, their conception was not the result of pure altruism. Medicaid was strategically added to the Medicare bill by Senator Wilbur Mills, who opposed national health insurance. By providing health care for low-income Americans through Medicaid, Mills stripped proponents of universal healthcare of their most compelling argument: the need for coverage for the poorest Americans (Blumenthal, Davis, & Guterman, 2008). This political discourse has continued with the 2009 passing of the Affordable Care Act by democrats along party lines and subsequent efforts to repeal the law by republicans in 2017.

Ultimately, efforts to reform the American healthcare system are crippled by a divisive political atmosphere. While there is no doubt that opposition to improved healthcare services is motivated by financial and political factors, there are also significant moral and ethical disagreements the play a role in the political impasse. The most basic argument is whether healthcare should be considered a human right or a privilege. This argument is inextricably entwined with beliefs about the American poor and whether poverty exists as the result of systemic biases or personal choice. As Dr. Atul Gawande explains, “Finding the balance is not a matter of achieving policy perfection; whatever program we devise, some people will put in more and some will take out more. Progress ultimately depends on whether we can build and sustain the belief that collective action genuinely results in collective benefit. No policy will be possible otherwise” (Gawande, 2017). One solution to move the sticky wheel of policy reform is through widespread education about healthcare costs, the benefits of preventative care, and the long-term damage that restricted access to healthcare services does to our economy and our communities. A more important challenge will be to bridge the divide between those who believe in healthcare as a right and those who do not in order to apply the necessary pressure to motivate reluctant politicians to build a better system.


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Berwick, D.M., Nolan, T.W., & Whittington, J. (2008). The Triple Aim: Care, health, and cost. Health Affairs, 27(3), 759-769.

Blumenthal, D., Davis K., & Guterman, S. (2015). Medicare at 50: Origins and Evolution. The New England Journal of Medicine, 372(5), 479-486.

Gawande, A. (2017). Is Health Care a Right? New Yorker. Retrieved from <;.

Mossialos, E., Djordjevic, A., Osborn, R., & Sarnek, D. (2017). International Profiles of Health Care Systems. The Commonwealth Fund. Retrieved from <;.


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