The Healthcare System We Inherited
What decades of reform can teach us after Election Day
Jessica C. Lindley | Founder, Digitique Health Strategy & Innovation | November 4, 2026
The day after Election Day is a useful time to step back from campaign language and look at the healthcare system the next group of elected leaders will inherit. Its history stretches across administrations, political parties, and decades of attempts to make coverage and care work better.
In my work across Medicaid, health plans, technology, and healthcare transformation, I keep returning to the distance between a policy’s promise and what it takes to deliver it. That distance becomes easier to understand when we look at how the system developed.
Today’s healthcare system reflects layers of public programs, private insurance, proposals that never became law, and lessons drawn from other countries. Understanding those layers gives us a better starting point for deciding what comes next.
The Foundations and the Nixon Proposals
Medicare and Medicaid became law in 1965 under President Lyndon B. Johnson. They established enduring public coverage pathways alongside private insurance, with eligibility and benefits expanding over time. [1]
In 1971 and again in 1974, President Richard Nixon proposed broader health insurance reform. His 1974 Comprehensive Health Insurance Plan would have required employers to offer coverage to full-time employees, provided income-related assistance, and established comprehensive benefit standards. Private insurers would have retained a central role. Individual participation would have been voluntary. [2]
Those ideas sound familiar because employer responsibility, financial assistance, and rules for insurance benefits have remained part of the reform debate. But resemblance is not proof that the Affordable Care Act was copied from Nixon’s proposal.
His comprehensive plan did not pass. The HMO Act of 1973 did, providing federal support for the development of health maintenance organizations. That distinction matters: one contributed to the continuing debate over coverage; the other helped shape the growth of managed care. [2, 3]
HIPP and the Connection to Employer Coverage
Another part of this history is the Health Insurance Premium Payment (HIPP) program. The 1990 Omnibus Budget Reconciliation Act added Section 1906 to the Social Security Act, establishing a framework for states to help Medicaid beneficiaries obtain cost-effective group health coverage. This predates both the Clinton reform effort and the ACA. [13]
Through HIPP programs, states can help pay premiums for available employer-sponsored insurance when doing so is cost-effective for Medicaid. Participants remain Medicaid beneficiaries, with Medicaid providing required supplemental benefits and cost-sharing protections. The employer plan generally pays first. Program names and eligibility details vary by state. [14]
HIPP illustrates how public funding and employer coverage can work together. Its value depends on identifying eligible families, evaluating costs, coordinating benefits, and helping members understand how to use both forms of coverage. Those are implementation responsibilities that belong alongside any discussion of coverage expansion.
The Clinton Effort and the Reforms That Followed
In 1993, Hillary Rodham Clinton chaired President Bill Clinton’s Task Force on National Health Care Reform. The resulting Health Security Act proposed universal coverage, employer contributions, comprehensive benefits, and regional health alliances to organize purchasing and competition among health plans. [4, 5]
The proposal did not become law. Still, its central questions remain recognizable: How do people maintain coverage when circumstances change? How can purchasers gain bargaining power? How should insurers compete within rules intended to protect patients?
The Clinton years also produced an enacted expansion: the Children’s Health Insurance Program in 1997, serving children in families whose incomes were too high for Medicaid but who could not afford private coverage. Under President George W. Bush, the 2003 Medicare law created Part D and reshaped Medicare’s private-plan framework under Medicare Advantage. These changes further developed the mix of public financing and private insurance. [1]
Massachusetts and the Affordable Care Act
The closest working template for the ACA’s coverage architecture came from Massachusetts. Its 2006 reform, signed by Governor Mitt Romney, combined an insurance marketplace, financial assistance, and an individual coverage requirement. President Barack Obama explicitly acknowledged the Massachusetts model. [6]
The ACA, enacted in 2010, added subsidized marketplaces, expanded Medicaid eligibility, strengthened insurance protections, and supported changes in how care is delivered and paid for. It preserved the major existing coverage pathways while trying to close gaps between them. [7, 8]
That is why describing the ACA as entirely new—or simply a recycled Nixon plan—misses the history. It drew on an established set of policy ideas, a recent state example, and the practical constraints of changing a system people already relied on.
Where Other Countries Fit In
Looking at other countries broadens the healthcare reform discussion. It shows us different ways to organize coverage, finance care, and set expectations for quality. But those examples do not offer a straightforward blueprint for the United States. Comparing national systems without accounting for the conditions in which they operate can lead us to the wrong conclusions about what would work here.
Comparisons also need to account for the United States’ geographic scale and federal structure. Delivering care across remote communities, rural regions, and major cities presents very different operational challenges. Our states are distinct governments with their own legislatures, budgets, and policy priorities. Within federal requirements, each state administers its Medicaid program and makes consequential decisions about eligibility, benefits, and provider payment. A national comparison can obscure substantial differences within our own country. [15]
Other countries also divide authority across levels of government: Canada, for example, operates provincial and territorial insurance plans under federal standards. The lesson is to examine specific approaches in context, including how they would interact with U.S. state authority and existing coverage arrangements. International experience can inform our choices; applying it here requires attention to the people, institutions, and communities that would make it work. [11]
Switzerland and the Netherlands demonstrate how universal coverage can operate through regulated competing insurers. Their systems combine compulsory coverage, defined basic benefits, affordability assistance, and rules governing insurance markets. Both were examined in U.S. policy discussions before the ACA. They offer useful comparisons for parts of our marketplace approach, but their national systems are not equivalent to ours. [9]
Germany offers another model, with social insurance organized around sickness funds and a separate private-insurance pathway. Canada finances medically necessary hospital and physician services through provincial and territorial public insurance, while coverage for other services varies. England’s National Health Service relies primarily on tax financing and organizes care differently from insurance-market models. [10–12]
These examples make one point particularly clear: universal coverage can be organized in different ways. The practical choices concern financing, participation, benefits, payment, and accountability—not simply whether a system is labeled public or private.
What this History Asks of Us Now
My takeaway is that each new reform inherits the operational consequences of earlier decisions. Adding a coverage pathway can help people while also creating new transitions to navigate, eligibility rules to administer, and systems that must exchange information.
For Medicaid members and people navigating both Medicare and Medicaid, those connections are especially important. A policy can expand eligibility, but implementation determines whether someone completes enrollment, finds an available provider, receives a medication, or gets support at home.
Quality belongs in that conversation from the beginning. We need to examine whether changes improve timely access, preventive care, treatment continuity, and outcomes—and whether the experience becomes easier for members, caregivers, and providers.
AI is becoming part of this next chapter, with opportunities to simplify enrollment, support care navigation, and reduce administrative work. Its value depends on accurate information, responsible oversight, and how well it works for the people using it. As we adopt these tools (or any tool) we should measure whether they improve access, quality, and the experience of getting care.
After Election Day, I hope we make more room for that kind of discussion. The history gives us plenty to learn from. I look forward to seeing how the next chapter builds on those lessons to deliver more affordable, accessible, and higher-quality care.
Sources and Further Reading
Historical proposals are distinguished from enacted laws throughout this article. International examples illustrate comparable approaches and do not imply direct adoption by U.S. policymakers. Sources reviewed November 3, 2026; article prepared for publication November 4, 2026.
