# What a State: Why the U.S. is Still Bad for Your Health (Policy)

## TL;DR

The paper examines how U.S. political structures hinder progressive healthcare reform, using Trump's new legislation as an example.

## Contribution

It argues that institutional factors, not just ideology, drive conservative bias in U.S. health policy.

## Key findings

- The U.S. state's political structure significantly biases health policy toward conservative outcomes.
- Trump's Big Beautiful Bill is expected to weaken Medicaid and Obamacare further.
- Institutions are as important as ideology in explaining American exceptionalism in healthcare.

## Abstract

The second Trump administration's centrepiece legislation, the modestly‐named Big Beautiful Bill, passed by the House of Representatives and going through the Senate at time of writing, offers an opportunity to reflect upon how the U.S. state affects health policy and the prospects for equitable access to affordable healthcare. Is the U.S. still an outlier (by comparison with Europe and much of the world), in that its many of its citizens are either uncovered, poorly covered or tenuously and only temporarily covered by health insurance? The answer is yes. And the chipping away at Obamacare and Medicaid by Trump 2.0 (learning from his failure to repeal Obamacare in 2017) as part of the Big Beautiful Bill, shows us that it is easier for the Right to dismantle progressive social legislation than it is for the Liberal‐Left to assemble it. To understand why, and to revisit why the U.S. polity struggles to enact progressive healthcare reform, we have to understand the effect of the U.S. state (i.e. political structure) upon public policy. This article revisits the nature of that state, to depict the underlying causes of ‘American exceptionalism’ which are partly ideological but also more significantly institutional than often realised.

Shows how the U.S. state biases health policy in a conservative direction.Trump's Big Beautiful Bill will further weaken ‘Obamacare’ (the Affordable Care Act) by weakening Medicaid significantly.Institutions are as much as a cause of American exceptionalism as ideology; the U.S. state's effect upon health policy is perhaps the key example.The main international lesson is that political structure can facilitate or retard effective health policy, and facilitate or retard conservative attempts to weaken equitable national healthcare systems. The U.S. state is quite exceptional by comparison with Europe but, for countries forging new constitutions or changing their structures, the problems encountered in the U.S. should offer a warning.

Shows how the U.S. state biases health policy in a conservative direction.

Trump's Big Beautiful Bill will further weaken ‘Obamacare’ (the Affordable Care Act) by weakening Medicaid significantly.

Institutions are as much as a cause of American exceptionalism as ideology; the U.S. state's effect upon health policy is perhaps the key example.

The main international lesson is that political structure can facilitate or retard effective health policy, and facilitate or retard conservative attempts to weaken equitable national healthcare systems. The U.S. state is quite exceptional by comparison with Europe but, for countries forging new constitutions or changing their structures, the problems encountered in the U.S. should offer a warning.