“Nobody knew that healthcare could be so complicated”

“Nobody knew that healthcare could be so complicated”

Nobody knew that healthcare could be so complicated.” So said President Donald Trump on February 27, 2017, in an address to the National Governors Association meeting at the White House in Washington DC.

The next day, President Trump tweeted, “I am calling on Congress to REPEAL & REPLACE OBAMACARE with reforms that expand choice, increase access, lower costs & provide better care.

The President through both these statements made another connection with the disaffected Americans who voted for him. He continues to seek to align with the general public in the United States, who often know very little about the complexity of healthcare – apart from what it costs them as individuals.  It is no wonder that the Republicans’ proposed replacement for the Affordable Care Act, known as Obamacare, attracted so much attention.  Soon after the release of the Republican plan, many media outlets took to calling the new plan Trumpcare, and within 48 hours there were over 1,000,000 results for Trumpcare on Google.

For family doctors, dealing with disruption in the lives of our patients is part of our everyday experience. It is clear that President Trump is someone who understands the nature of disruption and the powerful embrace of the millennial short attention span. In the words of one of our colleagues, he “challenges the status quo, dislikes bureaucracy, insists on practical and effective solutions, and is prepared to think outside the box”. He also embraces new technology and the power of digital communication.

As aliens to the USA, we have been surprised to learn about the patchiness of the rollout of the Obamacare reforms over the past seven years. The opportunity to innovate to provide greater health care coverage to vulnerable and marginalised people, and especially to poorly paid workers and their families, has been embraced far more by some States than by others. There is evidence that some of these innovations are already starting to show financial benefits with improvements in access and quality of health care delivery without increasing costs.

This must be an unsettling time for the 20 million Americans who have benefited from Obamacare reforms, and for the many clinicians who have been seeking new ways to engage clinically in an insurance-driven model of health service delivery.  The unequal rollout means that the people who have benefited in some States will feel they have much more to lose than people still without adequate coverage in others. And of course there will be the further great, usually unmeasured, cost that accompanies any large scale disruptive change.

Just like Obamacare, the rhetoric will long precede much real change. Congress is deeply divided and any of the Republican’s proposed changes will take time to action, in some cases several years, and will again differ in their implementation from State to State. It also appears that the proposed replacement of Obamacare will actually retain many of the benefits for some, but not all, people who have gained affordable health insurance coverage over the past seven years.  This may be seen as a paradoxical success of President Obama’s vision as many of the principles of Obamacare appear to have been retained in the new legislation developed by the Republicans, after years of what seemed to have been implacable opposition. In the hiatus, there is an opportunity for American family doctors, and other health providers, to work together in each of their States shaping how the new changes will work best for the people who trust them for their health care and advice.

President Trump is also having an impact on health care developments outside the USA. The cancellation of the proposed Trans Pacific Partnership represents the closure of a health border. The loss of opportunities for trading partners in nations of the Pacific Rim, including the movement of pharmaceuticals and other therapeutic goods, as well as the movement of health professionals and researchers between participating countries, will have immediate ramifications in the short term for trading partners in the region, and potential longer term implications as China fills a void to strengthen its own local partnerships.

The immediate worry is the legitimacy afforded by attitudes broadcast by the global media about who does, and who does not, deserve access to subsidised health care services in America. There is a risk that this dialogue will embolden politicians elsewhere in the world to reduce their commitment to universal health coverage, health for all people, and to reduce the provision of access to health care by marginalised people, at a time when gains are being made in many parts of the world.  The same risk applies to the potential global impact of changes to sexual and reproductive health policy in the United States.

On the bright side, there are the potential opportunities for other countries to benefit from disenfranchised American scientists and clinicians.  Will we see a brain drain from the USA, and the establishment of new centres of health and medical innovation offshore, rather than in America, especially in the rapidly expanding economies of countries such as China and India?

Clever health policy makers in other countries will also be exploring the outcomes of many of the innovations of Obamacare, and its replacement, to see what findings can be adapted by their own health systems to “expand choice, increase access, lower costs and provide better care”.

Global lessons about the benefits of strengthening primary care and family medicine must not be lost on President Trump. Worldwide we have seen how primary care can deliver on the Presidential challenge to the status quo and deliver substantial improvements.

The opportunity to keep more people fit and well and out of expensive hospitals, and working and contributing to America’s economic recovery, will be appealing to President Trump.  This will only be achieved through improved access to strong primary care services, through every American having access to well trained family doctors and the members of family health teams based in local medical homes, and through the delivery of high quality, comprehensive, cost-effective health care to all.


Professor Michael Kidd is the immediate past president of the World Organization of Family Doctors (WONCA), Professor and Chair of Family and Community Medicine at the University of Toronto in Canada, and Honorary Professor of Global Primary Care at Flinders University in Australia.  In 2018, he was a visiting scholar at the Robert Graham Center of the American Academy of Family Physicians, based in Washington DC.

Professor Deborah Saltman is Chairman of ISAC, Medicines Health and regulatory Products Agency, and an Honorary Professor at Imperial College, London. She runs workshops for Harvard University and Imperial College on leadership for women health professionals.