THE AMERICAN DREAM SCORECARD
Healthcare: D
Americans pay more for healthcare than any other country on Earth and live shorter lives than most of the developed world. Maternal mortality is the highest in the developed world and rising. 25 million Americans have no health insurance. The system that employs millions is being dismantled by federal funding cuts in real time.
Part of Ida's America 250 series. Full scorecard at readida.com/american-dream-scorecard
THE GRADE: D
250-year arc: C. America went from a country with virtually no formal medical care, a life expectancy of 35, and no understanding of germ theory to one of the most medically advanced nations in human history. Polio is eliminated. Smallpox is eradicated. Infant mortality has dropped by 95 percent since 1900. That progress is real and documented.
Last 50 years: D. The cost of healthcare has risen faster than inflation every decade since the 1970s. The U.S. now spends nearly twice what comparable developed nations spend per person and achieves worse outcomes on nearly every major health metric. The managed care and pharmaceutical industries grew into dominant economic forces whose financial interests have not consistently aligned with patient outcomes.
Last 25 years: D. The Affordable Care Act of 2010 expanded coverage to 20 million Americans and eliminated lifetime coverage caps. Life expectancy peaked at 78.9 years in 2019. The opioid crisis killed more than 500,000 Americans. Maternal mortality rose rather than fell. Healthcare costs continued to outpace wages.
Last 10 years: D. Life expectancy fell during the pandemic and has not fully recovered. Maternal mortality reached a 60-year high in 2021 at 32.9 deaths per 100,000 live births, the highest rate in the developed world. The Medicaid expansion under the ACA reduced the uninsured rate to historic lows — then federal policy reversals began pushing it back up.
Last 5 years: D. The One Big Beautiful Bill Act, signed July 4, 2025, cut Medicaid in ways the Congressional Budget Office projected will cause 4.8 million Americans to lose coverage. Work requirements taking effect this fall require Medicaid recipients to prove they are too sick to work or lose benefits. The administrative burden falls on patients and caregivers. States are implementing cuts ahead of the federal timeline.
THE 250-YEAR STORY
In 1776 the average American life expectancy was approximately 35 years. There were no antibiotics, no vaccines, no understanding of how disease spread. Childbirth was the leading cause of death for women of reproductive age. Surgery without anesthesia or sterile technique killed more patients than it saved.
The transformation of American medicine over 250 years is one of the genuine achievements of the American experiment. Vaccines eliminated diseases that killed millions annually. Antibiotics transformed fatal infections into treatable conditions. Surgical advances, diagnostic technology, and cancer treatments extended and improved lives at a scale previous generations could not have imagined.
The problem is not that American medicine is bad. American medicine at its best is extraordinary. The problem is access, cost, and the structural decisions that have made the world's most expensive healthcare system deliver worse average outcomes than almost every other wealthy nation.
THE ADMINISTRATIONS AND LEGISLATION THAT SHAPED THIS CATEGORY
The Social Security Act was signed by President Franklin Roosevelt in 1935, establishing federal involvement in health and welfare for the first time.
Medicare and Medicaid were signed into law by President Lyndon Johnson in 1965 as part of the Great Society legislation, establishing federal health insurance for Americans over 65 and for low-income Americans respectively. Before Medicare, more than half of Americans over 65 had no health insurance. Medicare remains the foundation of healthcare coverage for every American who reaches retirement age.
The Health Maintenance Organization Act was signed by President Nixon in 1973, establishing the framework for managed care that transformed how most Americans receive healthcare. The managed care model prioritized cost control and fundamentally changed the physician-patient relationship.
The Emergency Medical Treatment and Labor Act was signed by President Reagan in 1986, requiring hospitals that accept Medicare funding to provide emergency care regardless of ability to pay. It is the closest thing to a universal healthcare guarantee in American law and it applies only to emergency situations.
The State Children's Health Insurance Program was established under President Clinton in 1997, extending coverage to children in families that earned too much to qualify for Medicaid but could not afford private insurance.
The Affordable Care Act was signed by President Obama in 2010, expanding Medicaid eligibility, creating insurance marketplaces with subsidies, eliminating lifetime coverage caps, requiring coverage of preexisting conditions, and allowing children to stay on parents' insurance until age 26. The ACA reduced the uninsured rate from 16 percent to under 9 percent. The Supreme Court's 2012 ruling in NFIB v. Sebelius made the Medicaid expansion optional for states, resulting in 12 states initially refusing to expand and millions of low-income adults falling into a coverage gap.
The Tax Cuts and Jobs Act signed by President Trump in 2017 eliminated the individual mandate penalty, accelerating coverage losses among younger and healthier Americans.
The American Rescue Plan Act signed by President Biden in 2021 temporarily enhanced ACA subsidies, reducing premiums for millions of Americans buying insurance on their own. The Inflation Reduction Act of 2022 extended those enhancements through 2025.
The One Big Beautiful Bill Act signed by President Trump on July 4, 2025 cut Medicaid through work requirements, reduced federal matching funds to states, and allowed enhanced ACA subsidies to expire. The Congressional Budget Office projected 4.8 million Americans will lose Medicaid coverage and millions more will lose ACA marketplace coverage as a result. This loss of coverage has forced some hospitals and clinics to close with the anticipation of the lost revenue they will experience when patients lose coverage and the hospitals won’t be paid for care they provide. This may also lead to job loss for healthcare professionals as hospitals that do stay open, have to make budget cuts.
WHERE AMERICAN HEALTHCARE STANDS RIGHT NOW
The United States spends approximately $13,000 per person per year on healthcare — nearly twice the average of comparable wealthy nations. Despite that spending, American life expectancy at 76.4 years ranks below 40 other countries. American maternal mortality at 23.8 deaths per 100,000 live births is the highest in the developed world and more than three times higher than Canada, Australia, and most of Western Europe. For Black women the maternal mortality rate is 69.9 per 100,000 — nearly three times the rate for white women.
25 million Americans have no health insurance. Another 40 million are underinsured, meaning their coverage is inadequate to protect them from catastrophic medical costs. Medical debt is the leading cause of personal bankruptcy in the United States. It is the only developed nation where that is true.
4.8 million Americans are projected to lose Medicaid coverage under the One Big Beautiful Bill Act, confirmed CBO. Work requirement documentation burdens are projected to cause millions of eligible people to lose coverage not because they stop qualifying but because the administrative process is too complex to navigate. The experience in Arkansas in 2018, the only state to fully implement a Medicaid work requirement before a federal court blocked it, confirmed this: 18,000 people lost coverage, almost all of them eligible, almost all of them unable to navigate the documentation requirement.
THE DIABETES CONFERENCE INCIDENT — WHAT IT SIGNALS
On June 5, 2026, five scientists including the editor-in-chief of Diabetes Care, the American Diabetes Association's flagship peer-reviewed journal, were removed by police from the ADA's annual scientific conference in New Orleans for handing out copies of a peer-reviewed editorial criticizing federal cuts to biomedical research. The editorial criticized a requested $5 billion cut to NIH funding for 2027 and documented $66 million already cut from diabetes-specific research. Dr. Jay Bhattacharya, the NIH director, cancelled his keynote appearance at the last moment. Video confirmed a researcher was chest-bumped by a police officer. Copies of the editorial were confiscated.
The ADA stated those removed violated the conference code of conduct. Louisiana State Police confirmed event organizers requested their removal.
What this incident documents is the environment in which American medical research is currently operating. Scientists distributing peer-reviewed research at a scientific conference were removed by police. The research they were distributing documented the confirmed financial impact of federal cuts to diabetes research. 38 million Americans have diabetes. The research pipeline that develops treatments and potential cures for that population is being cut.
That is not a partisan characterization. That is the confirmed sequence of events.
WHAT WOULD CHANGE THE GRADE
The Healthcare grade improves when the uninsured rate falls rather than rises. It improves when maternal mortality, the most preventable category of healthcare failure, declines toward the rates achieved by comparable wealthy nations. It improves when medical debt stops being the leading cause of personal bankruptcy and when the cost of healthcare grows at a rate that does not consistently outpace wages. It improves when the research pipeline that produces the treatments Americans rely on is funded at levels that reflect the disease burden of the population.
All of these are measurable. All of them have confirmed policy levers. None of them are beyond the capacity of the wealthiest country in human history to address.
Sources: CDC confirmed U.S. maternal mortality rate 23.8 per 100,000 and Black women rate 69.9 · OECD confirmed U.S. healthcare spending $13,000 per person · Commonwealth Fund 2023 confirmed U.S. ranks last among wealthy nations on healthcare outcomes · CDC confirmed life expectancy 76.4 years and 2019 peak 78.9 · KFF Health News confirmed 25 million uninsured and 40 million underinsured · Congressional Budget Office confirmed 4.8 million losing Medicaid coverage under OBBBA · Washington Post June 3, 2026 confirmed diabetes conference ejections · Times-Picayune confirmed Louisiana State Police involvement · IBTimes confirmed chest-bump video and editorial contents · ADA confirmed code of conduct statement · Congressional Record confirmed all legislative history · NFIB v. Sebelius 2012 confirmed Medicaid expansion optional ruling · Arkansas work requirement outcomes confirmed via KFF analysis and federal court records
Now you know. Full American Dream Scorecard at readida.com/american-dream-scorecard