Praava Health and the Digital Transformation of Primary Care in Bangladesh: A Hub-and-Spoke Model for Scalable Equity

Michael Baler, April 2025

Abstract

This paper explores how Praava Health is reshaping primary care delivery in Bangladesh through a digitally integrated, patient-centered hub-and-spoke model. In a healthcare environment constrained by limited public infrastructure, high out-of-pocket spending, and geographic inequities, Praava’s strategy offers a scalable response to systemic challenges. Grounded in international standards and supported by an advanced Health Information System (HIS), the model aims to improve access, efficiency, and clinical outcomes across urban and peri-urban populations. The analysis draws on the Institute of Medicine’s six domains of healthcare quality—effectiveness, efficiency, equity, safety, timeliness, and patient-centeredness—as a framework to assess Praava’s approach. Additionally, Rogers’ Innovation Adoption Model is applied to evaluate the organization’s trajectory from early adopters to broader market penetration. The discussion contextualizes Praava’s model within Bangladesh’s ongoing digital and economic transformation and examines the operational, cultural, and financial factors that will shape its long-term sustainability.

Praava Health: Expanding Access to Quality Healthcare

Bangladesh has historically relied on private healthcare services to support its population. As of 2019, only 255 public hospitals were funded by the public sector, augmented by 5,054 private hospitals and clinics (Bangladesh Investment Development Authority, n.d.). This equates to only 8.8 hospital beds per 10,000 population. Compared to nearby India, which has 16.3 beds per 10,000, it is clear that as Bangladesh continues to develop its economy, it needs to address the gap in providing adequate patient support (World Health Organization, n.d.).

Bangladesh’s healthcare challenges are further impacted by its rate of population growth, 257.1% since 1960 compared to 165.9% globally (Worlddata.info, n.d.), and limited government investment of 2.48% of GDP on health care, well below the global average of 10% (Islam et al., 2023, p. 4). Subsequently, with over 63% of health care expenses being paid out of pocket (Islam et al., 2023, p. 5), consumers lack affordable treatment options, face limited access to care, and, due to substandard laboratory infrastructure, do not receive reliable diagnoses.  

Praava was launched in 2018 by Sylvana Quader Sinha, after her mother’s misdiagnosis in a Bangladeshi hospital (Islam et al., 2023, p. 10). It is the first entity in Bangladesh to introduce an integrated Health Information System (HIS) digitally connecting patient care, telehealth, diagnostics, and medical record management. With the COVID-19 pandemic that began in 2020, app-based care accelerated and helped position Praava as a leader in Bangladeshi health (Islam et al., 2023, pp. 10, 21). 

Praava is addressing systemic barriers to healthcare access by integrating digital technology with physical care delivery. Grounded in international standards, its scalable “hub-and-spoke” model positions a central medical facility to support and coordinate a network of regional clinics, enabling broader reach across Bangladesh. (Islam et al., 2023, pp. 16, 24)

Foundation of Praava’s Value

The foundation of Praava’s value proposition is its hub-and-spoke model of regional clinics in Gulshan and Baridhara, anchored by a centralized location in Banani, Dhaka. With a plan to build 30 more clinics, Praava hopes to address the gap between private sector and government-supported healthcare, seeking to solve an ongoing issue that “drives patients in Bangladesh to faraway cities…to seek better treatment” (Islam et al., 2023, pp. 6, 10, 16).

Its integrated, digitally enabled Health Information System (HIS) is accessible by patients and health care professionals, supports connectivity of care, and provides greater consumer access to treatment, diagnostic, and hospital facilities. The HIS also digitally facilitates Praava’s 15-minute appointment guarantee, benefiting patients and providers with reduced wait times, flexible case management, and care consistency (Islam et al., 2023, pp. 8, 15).

For patients, the HIS provides app-based mobile access and a web-enabled consumer experience. With secure access to personal information, consumers can be actively involved in their care management, schedule visits, facilitate telehealth, review medical records, lab results, and prescriptions (Islam et al., 2023, pp. 3, 8, 10). 

For providers, the HIS supports centralized continuity in care between its spoke and hub locations, reduces redundant administrative tasks, streamlines appointment management, and supports efficient communication with patients, specialists, and labs (Islam et al., 2023, pp. 8, 9, 16, 18). 

Patient Retention

Patient retention is built on a foundation of credibility, facilitated by accessible care, and sustained through positive clinical outcomes. To discourage patients from seeking treatment abroad, Praava has aligned its services with international benchmarks. These efforts include accreditation from the Bangladesh Accreditation Board (BAB), attainment of ISO 15189:2012 certification—the global standard for medical laboratory quality—and the formation of strategic partnerships with Harvard University and Life Track, a U.S.-based network of board-certified radiologists. Additionally, Praava has established an international advisory board comprising experts in healthcare delivery and technology. (Islam et al., 2023, p. 17; Praava Health, n.d.)

By promoting a patient-centric delivery methodology, Praava has personalized its services to increase patient retention with individualized care and its “family health care program,” offering “ family medicine doctors, gynecologists, pediatricians, dentists, ophthalmologists, physiotherapists, nutritionists, health coaches, counseling and psychological services, and visiting specialists” (Islam et al., 2023, p. 15). 

To further build retention and loyalty for its services, Praava targets one-time patients with membership plans for its clinics, ranging from “BDT 4,500 to BDT 28,000” annually. And subscription packages for home care plans, including single to unlimited visits (Islam et al., 2023, p. 16).

With credibility from international sources, family-focused physicians, and incentives to drive repeat visits, Praava has placed ongoing relationships as a priority. Their providers can understand patient needs, account for local customs, and offer face-to-face, continuous care that builds trust, loyalty, and improves long-term health outcomes. 

Praava’s Hub-and-Spoke Treatment Model

Praava’s hub-and-spoke model directly aligns with Sustainable Development Goals (SDGs), which promote “peace and prosperity for people and the planet” (United Nations, n.d.). According to Process Innovation in Healthcare Delivery at Praava Health, Bangladesh, three SDG in particular are supported: SDG 3, Good Health and Well-Being, SDG 8, Decent Work and Economic Growth, and SDG 9, Industry, Innovation, and Infrastructure (Islam et al., 2023, p. 16).  

Praava supports SDG 3, Good Health and Well-Being, by efficiently connecting consumers with providers through a mobile app, offering 15-minute appointment guarantees, and telehealth consultation within their hub-and-spoke model. With regional spokes, patients have efficient access to quality healthcare, including diagnostics, consultation, and follow-up. These clinics ensure timely care through connection to their centralized facility in Banani. And, reduce diagnostic errors by offering access to specialists, laboratories, and expedient test results (Islam et al., 2023, pp. 15, 16, 19).

Praava contributes to SDG 8, Decent Work and Economic Growth, by creating new employment opportunities, including clinical, IT, laboratory, and administrative positions. Praava’s private approach to care is supported through partnerships with Harvard and other entities and elevates local economies through training initiatives, international connectivity, and exposure to global standards of care (Islam et al., 2023, pp. 16, 17).  Private sector growth is fueled by its local investments.

With its digital infrastructure and app-based access, Praava advances SDG 9, Industry, Innovation, and Infrastructure by investing in its modern, digitally-enabled infrastructure to support care delivery within Bangladesh’s emerging economy. By offering a scalable model, Praava is providing a blueprint for technology innovation, broader care reach, and stronger patient outcomes. They also offer advanced cancer treatment options with Bangladesh’s first molecular diagnostics PCR (polymerase chain reaction) lab (Islam et al., 2023, pp. 13, 16).

Discussion

The Diffusion of Innovations theory, introduced by Everett M. Rogers in 1962, outlines how innovations are adopted within a social system through five adopter categories: innovators, early adopters, early majority, late majority, and laggards (Kerner, 2024). Accelerated by the COVID-19 pandemic, Praava’s digital healthcare model has gained traction among early adopters in Bangladesh. By 2021, it had served over 200,000 patients and achieved a 60% retention rate, signaling its movement toward the early majority segment of adopters (Islam et al., 2023, pp. 16, 21).

This critical stage—known as the “chasm”—was introduced by Moore (1991) to describe the gap between early adopters and the early majority, where many innovations fail if market expectations and experiences are not aligned (Islam et al., 2023, p. 21). To successfully bridge this divide and reach mass-market acceptance, Praava is reinforcing its structured delivery model through plans to open 30 additional regional spoke clinics (Islam et al., 2023, p. 10), encouraging continuity of care with family-based health teams, and offering membership and subscription-based service packages (Islam et al., 2023, p. 16).

Challenges and Opportunities in Scaling Patient-Centered Care

With increasing urbanization and rising mobile phone use in Bangladesh, Praava’s integrated digital Health Information System (HIS), combined with a growing network of physical clinics, provides a secure and accessible platform for care. As more patients and providers engage with the system and recognize its value in delivering efficient, coordinated, and high-quality healthcare, Praava is well-positioned to scale its operations and reach a broader segment of the population.

Bangladesh’s reliance on private healthcare is largely driven by limited public access to quality medical services. Many patients, facing inadequate domestic options, often turn to international specialists and pay for treatment out of pocket (Islam et al., 2023, p. 5). As of 2019, the country had just 8.8 hospital beds per 10,000 people—significantly below neighboring India’s 16.3 (World Health Organization, n.d.). This shortage underscores the urgent need for scalable, high-quality care models tailored to the needs of Bangladesh’s growing population.

Praava’s patient-centered, digitally enabled hub-and-spoke model aims to address these gaps by expanding access, improving care outcomes, and streamlining service delivery. Its future success depends not only on technological infrastructure and clinical quality, but also on its ability to sustain patient engagement and adapt to evolving health needs.

To achieve its long-term objectives, Praava must address cultural barriers that shape healthcare-seeking behavior, develop accessible and affordable alternatives to international care, and ensure consistency of service across its expanding clinic network. Its approach offers a potential solution to Bangladesh’s strained healthcare infrastructure and high out-of-pocket spending (Islam et al., 2023, p. 24), but will require sustained effort to scale equitably.

An effective framework for evaluating Praava’s potential impact is offered by the Institute of Medicine (IOM), which defines healthcare quality through six domains: effectiveness, safety, equity, patient-centeredness, efficiency, and timeliness (Agency for Healthcare Research and Quality, n.d.). These benchmarks serve as a comprehensive lens through which to assess the value and sustainability of Praava’s model in the broader context of healthcare reform in Bangladesh.

Effectiveness and Safety 

Praava has demonstrated a clinically sound and safety-conscious strategy by modernizing care delivery and aligning with international standards. Its integrated Health Information System (HIS) elevates clinical-decision making, enhances care continuity, improves diagnostic accuracy, and reduces delay in care. Praava’s ISO 15189 accreditation (Praava Health, n.d.) and partnerships with Harvard and U.S.-certified specialists (Islam et al., 2023, p. 17) have reinforced its commitment to safety and quality, and provide a means of measurement against international standards. 

The HIS increases patient engagement, enables mobile and internet access for care management, and supports quick communication between patient and provider. Praava’s 15-minute appointment guarantee (Islam et al., 2023, p. 15), supports timely care, telehealth enhances efficiency, reduces clinical delay, and promotes a meaningful patient-provider relationship. 

There are challenges that Praava will face; many Bangladeshi patients bypass primary care and seek treatment through specialists (Islam et al., 2023, p. 5). For Praava to scale, it must promote its clinical consistency across spoke sites, adapt its model for wider reach, and address cultural and economic barriers to safe care. Praava will need to establish transparent care metrics to assess the impact of its treatments, publicly promote safety protocols in areas such as infection control and lab quality, and illustrate to consumers that Praava offers safe, error-free treatment options. 

Equity and Patient-Centeredness

Praava understands that to grow its patient base and achieve long-term growth, it must offer equitable access and true patient-centered treatment. Praava’s model supports this by offering same-day consultation with primary care physicians, app-based appointment scheduling, and telehealth (Islam et al., 2023, pp. 23, 3, 5). This emphasis on patient empowerment and relationship-based care provides ongoing familiarity, trust, and offers a benefit from not having to travel a great distance for care. 

According to Prime Minister Sheikh Hasina, Bangladesh reduced its national poverty rate from 41% in 2006 to 18.7% by 2022 (Hasina, 2023). While this progress reflects significant economic advancement, equitable access to healthcare remains a persistent challenge—particularly for low-income populations. In a system where the majority of healthcare expenses are paid out-of-pocket, expanding access and sustaining growth may be difficult if affordability is not adequately addressed.

To promote equity and long-term viability, Praava may benefit from implementing a tiered pricing model or developing partnerships with local employers and community organizations to subsidize care. Such strategies could extend services to underserved groups while reinforcing the organization’s patient-centered mission.

Additionally, the digital experience, which is central to Praava’s model, excludes individuals without a mobile phone or internet access. Without additional outreach and strategies to offer greater connectivity or additional modes to schedule appointments, the potential for true equity and patient-centric care may not be realized.

While Praava has attained 200,000 patients (Islam et al., 2023, p. 16), its hub facility, located in the affluent area of Banani (Islam et al., 2023, p. 10), may be too far to support underserved areas and increase inequity due to geographic boundaries. Even with its spoke clinics, distance may prohibit those in rural communities from seeking elevated care. 

If Praava does not augment its model with options that offer easier access, such as mobile clinics or working with local community organizations, changing consumer habits, and achieving true equity may be elusive. 

Efficiency and Timeliness

Efficiency and timely care are the products of Praava’s hybrid model that offers a digital experience supported with brick-and-mortar locations. Their hub-and-spoke physical clinics and centralized main facility optimize in-person visits, diagnostics, and pharmacy services, while their Health Information System (HIS) enables efficient appointment scheduling, telehealth, real-time access to patient records, appointment scheduling, and continuity of care (Islam et al., 2023, pp. 9, 15, 16). 

Patients and providers benefit from decreased administrative delays, shorter wait times, and same-day appointment availability. And with prompt access to lab results, diagnosis is streamlined and treatment decisions are more timely, increasing clinical effectiveness and patient satisfaction.  

Expediency must be balanced against operational risks. Challenges such as travel to Dhaka, resource bottlenecks (Islam et al., 2023, pp. 22, 24), complexity in managing staffing, and maintaining standards across a network of facilities can impact the timeliness of care. And, over-reliance on technology may reduce flexibility if systems are not fully adopted by patients or if providers experience downtime. Effective use of digital tools depends on patient and provider digital literacy and stable internet connectivity, which may vary across regions. 

Additionally, as Praava lacks inpatient capacity (Islam et al., 2023, p. 22), patients needing hospitalization must seek care elsewhere, impacting continuity and coordination. While Praava’s innovations have laid the groundwork for a more efficient care model, scaling this efficiency equitably across Bangladesh will require ongoing investment in its technology infrastructure, sustained hiring and training, and community engagement.

Conclusion

“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being…” (World Health Organization, 1946). This declaration is a foundational principle of the preamble to the WHO constitution. With insufficient, equitable public access to quality healthcare, Bangladesh consumers face sporadic, unpredictable, and often unavailable access to care. With only 255 public hospital beds and only 8.8 hospital beds per 10,000 people, compared to 27.5 in the United States (World Health Organization, n.d.), there is a significant gap in care. In an emerging economy like Bangladesh, health care is a critical aspect of development. 

Praava’s patient-centered hub-and-spoke model, supported by its integrated Health Information System (HIS) and commitment to international standards, represents a significant step toward delivering high-quality care within an emerging economy. However, achieving long-term impact requires more than innovative infrastructure. To transform healthcare delivery in Bangladesh, Praava must address cultural norms that influence care-seeking behavior, increase first-time patient engagement, foster long-term retention, and ensure that high-quality services are both affordable and locally accessible.

Success will depend on Praava’s ability to align its operations with widely recognized benchmarks of healthcare quality. The Institute of Medicine (IOM) outlines six essential domains—effectiveness, efficiency, equity, safety, timeliness, and patient-centeredness—which offer a comprehensive framework for evaluating healthcare performance. Praava’s ongoing efforts must be measured against these standards to ensure meaningful and sustainable improvements.

Sustainability will also require overcoming deeply rooted barriers, including the preference for seeking care abroad, skepticism toward local systems, and economic constraints. Building trust, expanding affordability, and consistently delivering positive health outcomes across its network will be essential. If Praava can demonstrate measurable results, maintain transparency, and continuously adapt to evolving patient needs, it has the potential to close existing care gaps and establish a scalable, patient-centric model for healthcare delivery in Bangladesh.

References

Agency for Healthcare Research and Quality. (n.d.). Understanding quality measurement. U.S. Department of Health and Human Services. https://www.ahrq.gov/patient-safety/quality-resources/tools/chtoolbx/understand/index.html

Bangladesh Investment Development Authority. (n.d.). Healthcare. Retrieved March 24, 2025, from https://bida.gov.bd/healthcare

Hasina, S. (2023, September 22). Address by Her Excellency Sheikh Hasina, Prime Minister of Bangladesh, at the General Debate of the 78th Session of the United Nations General Assembly. United Nations General Assembly. https://gadebate.un.org/sites/default/files/gastatements/78/bd_en.pdf

Henderson, B. (2017, May 7). Rogers’ diffusion curve: A graphic that explains a lot [Blog post]. Medium. https://medium.com/@bhenders/rogers-diffusion-curve-a-graphic-that-explains-a-lot-65e3d8f0c65d

Islam, Q. T., Gazi, M. A., Iqbal, R., Haque, K. L., & Haque, M. (2023). Process innovation in healthcare delivery at Praava Health, Bangladesh. SAGE Business Cases. https://doi.org/10.4135/9781529611618

Kerner, S. M. (2024, December 6). Diffusion of innovations theory: Definition and examples. TechTarget. https://www.techtarget.com/whatis/feature/Diffusion-of-innovations-theory-Definition-and-examples

Moore, G. A. (1991). Crossing the Chasm (1st ed.). Harper Business Essentials.

Praava Health. (n.d.). About Praava. Retrieved March 24, 2025, from https://www.praavahealth.com/about/

Rogers, E. M. (2003). Diffusion of innovations (5th ed.). Free Press.

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Navigating Fragmented Care: Patient Experience Across Urgent, Emergency, and Primary Services

Michael Baler, December 2024

Abstract

This paper examines how fragmentation within the U.S. healthcare system forces patients to navigate urgent, emergency, and primary care decisions without adequate coordination or support. It explores structural barriers such as the primary care physician shortage, lack of interoperability, and insurance-based referral requirements, which disrupt continuity of care and contribute to delays, inefficiencies, and cost burdens. The rise of urgent care centers and overuse of emergency departments are contextualized as responses to these systemic issues, offering speed and accessibility but often failing to support long-term health outcomes. A patient case study illustrates the challenges individuals face when seeking timely and appropriate care in the absence of integrated services. The analysis concludes that while alternative care models fill immediate gaps, they are not substitutes for coordinated, patient-centered care. Structural reforms must prioritize improved access, data sharing, and affordability to create a more responsive and equitable healthcare system.

Seeking Care: Urgent, Emergency, and Primary

The U.S. healthcare system is increasingly fragmented, costly, and complex. A significant contributor to this dysfunction is the absence of universally implemented best practices that promote coordinated, longitudinal care across provider networks. Patients often engage with multiple providers over time—across specialties, facilities, and levels of care—without a consistent framework for communication or data sharing. This can compromise safety, continuity, and overall health outcomes, especially when information about diagnoses, treatment plans, or medications is incomplete or inaccessible at the point of care. As documented in JAMA, “having multiple physicians may also lead to medical errors, unnecessary visits, avoidable hospitalizations, and suboptimal care if all of the physicians do not have complete information about the patient” (Kern et al., 2024).

This lack of integration requires patients to manage their own care continuity. They must navigate where to seek treatment, ensure the transmission of health records across siloed systems, and determine appropriate next steps, often in moments of vulnerability. As Katri et al. (2023) note in BMC Health Services Research, multilevel care coordination is impacted by individual, organizational, and system-level barriers. The absence of systemic coordination increases the likelihood of miscommunication, redundant testing, and delayed or missed diagnoses, placing a disproportionate burden on individuals at a time when they are least prepared to manage it.

Without a reliable, connected care framework, patients are forced to balance cost, convenience, and quality of care in real-time. Most individuals in the U.S. default to one of three options during an episode of illness or injury: a primary care provider (if available), an urgent care facility, or a hospital emergency department.

The Rise of Urgent Care and Emergency Departments

The growth of urgent care centers and the overutilization of emergency departments (EDs) for non-emergent conditions stem from several structural challenges. A major factor is the increasing shortage of primary care physicians (PCPs). According to the Association of American Medical Colleges (AAMC), the U.S. faces a projected shortfall of up to 86,000 physicians by 2036 (AAMC, 2024). This shortage exacerbates delays in access to routine and preventative care, prompting patients to seek timelier alternatives.

Cost is another driving force. For uninsured or underinsured individuals, urgent care facilities offer a lower-cost option compared to the high expense of emergency departments. As UnitedHealthcare (2023) highlights, “rushing to the ER can cost two to three times more than in a provider’s office.” Consumer expectations have also shifted: walk-in availability, extended hours, and service speed align more closely with on-demand experiences in other sectors.

Additionally, a lack of preventative care drives patients with chronic conditions such as diabetes or hypertension toward urgent or emergency care when symptoms worsen. The Healthcare Financial Management Association (HFMA) notes that avoiding disease progression requires proactive care and consistent PCP access—resources that remain out of reach for many (Daly, 2019).

Benefits and Limitations of Alternative Care Models

Urgent care and emergency departments offer clear benefits: convenience, speed, and broad geographic accessibility. Urgent care centers, numbering over 14,000 nationwide (Urgent Care Association, 2019), are often open during evenings and weekends, catering to individuals who cannot attend appointments during standard work hours.

Financially, urgent care centers are more affordable than emergency rooms, especially for those with high-deductible insurance plans or no coverage at all. Equipped with basic diagnostics like X-rays and labs, many urgent care centers serve as a reasonable stopgap for non-life-threatening conditions.

However, urgent care has limitations. These centers are typically not equipped for severe or complex medical conditions and often lack comprehensive patient histories. This can result in fragmented care and potential delays in appropriate treatment.

Emergency departments, while equipped for acute and life-threatening cases, face their own systemic issues. Overcrowding due to high utilization for non-emergent concerns increases wait times and system inefficiencies. JAMA reports that high-complexity, treat-and-release ED visits grew from 4.8% in 2006 to 19.2% in 2019 (Ruxin et al., 2023), signaling a misalignment between patient needs and system design.

Case Study: Navigating a Disconnected System

Consider the case of Jane Doe, a patient who recently lost her long-time PCP to retirement. She secures an initial appointment with a new physician, but the first available date is six months away. In December, Jane slips on ice and injures her knee and ankle. With limited options, she chooses a local urgent care clinic over the emergency department due to cost concerns.

After waiting two hours, Jane is evaluated by a physician assistant who suspects a severe sprain and potential fracture but cannot confirm the diagnosis due to a lack of imaging equipment. Jane is discharged with crutches, a short course of pain medication, and a recommendation to see an orthopedic specialist. However, because she has not yet been seen by her new PCP, her insurance requires a referral before she can book a specialist appointment.

Jane is now trapped in a bureaucratic loop—unable to obtain timely imaging or specialist care, and responsible for navigating coverage restrictions alone.

Structural Barriers to Continuity

Jane’s experience illustrates four major systemic failures:

Treatment Delays

A lack of timely access to imaging and specialist referral delays diagnosis and appropriate treatment. Research shows that unreliable healthcare access is associated with late-stage diagnoses and worse health outcomes (Ratnapradia et al., 2023).

Fragmented Care

The urgent care clinic is not part of a larger network and lacks EHR interoperability. As Lindquist (2024) explains, technical limitations, cost barriers, and competing systems hinder seamless health information exchange.

PCP Shortage

Jane’s difficulty in accessing her new PCP reflects a broader primary care crisis. Studies show that only 54% of patients secure a new PCP within 12 months of their former provider’s retirement (Hedden et al., 2021).

Cost Barriers

The financial implications of care decisions shape access. Jane avoids the ED due to high costs, even though it could provide the imaging and specialist referrals she needs. According to Fay (2024), ER visits can be up to ten times more expensive than urgent care.

Finding Resolution in a Fragmented System

Jane’s situation highlights how care fragmentation places an unreasonable burden on patients. Several steps could improve her care pathway:

Emergency Department Use

Though costly, the ED could offer rapid diagnostics and direct specialist access. Under current insurance law, prior approval is not required for emergency care (Healthcare.gov, 2024).

Expedited PCP Access

Jane may advocate for a faster appointment using documentation from urgent care. Practices using “advanced access” models have the flexibility to see patients urgently if needed (Murray, 2005).

Direct Specialist Contact

Some insurance plans permit patients or providers to request expedited referral exceptions in urgent situations (NAIC, 2024).

Conclusion

The fragmentation of the U.S. healthcare system leaves patients like Jane to navigate care transitions without coordination or guidance. A shortage of PCPs, poor interoperability, and insurance requirements create delays and inefficiencies that negatively affect health outcomes. While urgent care and emergency departments serve a critical function, they are not substitutes for comprehensive, continuous care. To improve patient experience and system performance, structural reform must prioritize access, integration, and affordability across all levels of care.

References

American Association of Medical Colleges. (2024, March 21). New AAMC report shows continuing projected physician shortage [Press release]. https://www.aamc.org/news/press-releases/new-aamc-report-shows-continuing-projected-physician-shortage

Daly, R. (2019, February 11). Preventable ED use costs $8.3 billion annually: Analysis. Healthcare Financial Management Association. https://www.hfma.org/payment-reimbursement-and-managed-care/payment-trends/63247/

Fay, B. (2024, July 23). Urgent care vs. emergency room: Hospital emergency rooms are more expensive than urgent care centers. Integrity Urgent Care. https://integrityuc.com/cost-of-urgent-care-vs-emergency-room/#:~:text=An%20urgent%20care%20visit%20is,are%2030%20minutes%20or%20less

Healthcare.gov. (2024). Using your health coverage. https://www.healthcare.gov/using-marketplace-coverage/getting-emergency-care/

Hedden, L., Ahuja, M. A., Lavergne, M. R., McGrail, K. M., Law, M. R., Cheng, L., & Barer, M. L. (2021). How long does it take patients to find a new primary care physician when theirs retires: a population-based, longitudinal study. Human resources for health, 19(1), 92. https://doi.org/10.1186/s12960-021-00633-9

Kern, L. M., Bynum, J. P. W., & Pincus, H. A. (2024). Care Fragmentation, Care Continuity, and Care Coordination: How They Differ and Why It Matters. JAMA Internal Medicine, 184(3), 236–237. https://doi.org/10.1001/jamainternmed.2023.7628

Khatri, R., Endalamaw, A., Erku, D., Wolka, E., Nigatu, F., Zewdie, A., & Assefa, Y. (2023). Continuity and care coordination of primary health care: a scoping review. BMC health services research, 23(1), 750. https://doi.org/10.1186/s12913-023-09718-8

Lindquist, M. (2024, June 24). Interoperability in healthcare explained. Oracle. https://www.oracle.com/health/interoperability-healthcare/

Murray, M. (2005). Answers to your questions about same-day scheduling. American Academy of Family Physicians. https://www.aafp.org/pubs/fpm/issues/2005/0300/p59.html

National Association of Insurance Commissioners. (2024). Consumer insight: Understanding health insurance referrals and prior authorizations. https://content.naic.org/article/consumer-insight-understanding-health-insurance-referrals-and-prior-authorizations

Ratnapradipa, K. L., Jadhav, S., Kabayundo, J., Wang, H., & Smith, L. C. (2023). Factors associated with delaying medical care: a cross-sectional study of Nebraska adults. BMC health services research, 23(1), 118. https://doi.org/10.1186/s12913-023-09140-0

Ruxin, T., Feldmeier, M., Addo, N., & Hsia, R. Y. (2023). Trends by acuity for emergency department visits and hospital admissions in California, 2012 to 2022. JAMA Network Open, 6(12), e2348053. https://doi.org/10.1001/jamanetworkopen.2023.48053

UnitedHealthcare. (2023, March 3). ER, urgent care or virtual visit? https://www.uhc.com/news-articles/benefits-and-coverage/care-options

Urgent Care Association. (2023, August). Urgent care industry white paper: The essential nature of urgent care in the healthcare ecosystem post-COVID-19. Urgent Care Association. https://urgentcareassociation.org/wp-content/uploads/2023-Urgent-Care-Industry-White-Paper.pdf

Healthcare.gov: A Retrospective Lesson in the Failure of Project Stakeholders

Michael Baler, December 2024

Abstract

The launch of HealthCare.gov in 2013, intended as the digital front door to the Affordable Care Act’s insurance marketplace, became a widely publicized failure marked by crashes, long wait times, and system unavailability. This paper explores the root causes of that failure through the lens of project management principles. Key issues included a compressed development timeline, lack of stakeholder alignment, poor technical architecture, absence of a centralized governance structure, and insufficient risk planning. Drawing from government reports and industry analysis, the discussion evaluates how mismanagement of scope, time, cost, and risk contributed to the system breakdown. Recommendations include establishing a Project Management Office (PMO), adopting hybrid Agile and RAD methodologies, assigning technical executive leadership, and utilizing project tracking tools to support risk mitigation and cross-functional coordination. The experience of HealthCare.gov underscores the importance of integrating policy goals with scalable technology infrastructure and structured leadership to ensure the successful delivery of large-scale digital public services.

Technology Meets Policy: The ACA’s First Major Test

This paper examines the failed rollout of HealthCare.gov as a cautionary example of how inadequate project leadership, stakeholder misalignment, and poor technical design can undermine large-scale public digital initiatives. HealthCare.gov was launched on October 1, 2013, as the online portal for Americans to access health insurance under the Affordable Care Act (ACA), signed into law in 2010. The site was intended to serve millions of users across 33 states. However, it experienced immediate dysfunction.

According to CBS News correspondent Wyatt Andrews, “The millions of people flooding the system on HealthCare.gov cause[sic] the website to briefly brake under the strain, causing it to go from ‘apply now’ to ‘please wait’ to ‘please try again later’” (Andrews & Werner, 2013). White House Chief Technology Officer Todd Park later revealed that the platform “collapsed because 250,000 people tried to use it at the same time” (Brill, 2014).

The launch, which was expected to showcase a transformative healthcare policy, instead revealed deep structural and technical failures. A compressed development timeline, siloed teams, limited testing, and lack of centralized oversight contributed to the site’s breakdown. The administration ultimately had to call in private-sector experts to resolve the crisis, but the damage to public confidence and political credibility had already been done.

Background

The Affordable Care Act was signed into law on March 23, 2010. Its most visible digital component, HealthCare.gov, was designed to facilitate access to affordable health coverage. While the law passed in 2010, contracts to build the website were not awarded until September 2011. Even more critically, technical specifications were not released to vendors until March 2013—just seven months before launch (Lee & Brumer, 2017).

President Obama reportedly emphasized the importance of the website’s functionality, concluding meetings with his staff by stating, “This only works if the technology works” (Brill, 2014, p. 36). Despite this awareness, organizational structure and leadership roles remained unclear. Key stakeholders included White House Chief of Staff Denis McDonough, HHS Secretary Kathleen Sebelius, CMS Administrator Marilyn Tavenner, and Deputy Director Jeanne Lambrew. The lead technology vendor, CGI Federal, worked alongside other contractors and technology officers such as Todd Park. Coordination between these groups proved insufficient.

By the time of launch, critical components had not been stress-tested, dashboards were not operational, and no clear reporting mechanisms were in place. President Obama publicly addressed the system’s failures on October 21, 2013, and brought in industry experts from Google, Civis Analytics, and elsewhere to triage the platform. It was not until December 1, 2013, that HealthCare.gov was deemed functional.

Evaluation and Discussion

Laudon and Laudon (2021) note that large-scale systems projects fail at significantly higher rates than smaller efforts, primarily due to issues in scope, cost, time, quality, and risk management (p. 538). HealthCare.gov’s rollout illustrates how each of these factors—if poorly managed—can derail mission-critical platforms. Key areas of failure included:

• Business Objectives Misaligned with Technical Design: The ACA’s strategic policy goals were not translated into functional system architecture. Time was heavily spent on legislation and policy formation, but minimal focus was given to building a robust, scalable technology solution.

• Stakeholder Engagement: Decision-making was decentralized and fractured. Roles were unclear, and critical technical staff were excluded from early planning meetings.

• Lack of Executive Oversight: Leadership was reactive rather than proactive. There were no escalation protocols, no clear indicators of project readiness, and no high-level ownership of technical outcomes.

• Change Management Failures: Political sensitivity led to an emphasis on optics rather than substance. There was no structured change management plan to deal with risks or delays.

• Technical Execution: The platform lacked scalability. Core functions—like caching, user ID generation, and cross-platform testing—were either inadequately developed or entirely absent (Brill, 2014, p. 16).

Contributing Factors

Invisibility of Progress and Readiness

Internal White House staff reportedly had no visibility into whether the technology was working. There were no operational dashboards or reporting frameworks to monitor system status in real-time, leading to a catastrophic “go-live” decision based on assumptions rather than data (Brill, 2014, p. 18).

Compressed Timeline

Although the law passed in 2010, meaningful specifications were delayed until March 2013, leaving just seven months to build the system (Lee & Brumer, 2017). This timeframe was incompatible with the complexity of a platform meant to serve millions of users with varying eligibility and insurance needs.

Siloed Teams

The White House policy team, CMS, HHS, and vendors operated in isolated “swim lanes,” with minimal cross-functional collaboration. Reports indicated that White House Chief Technology Officer Todd Park was left out of key planning meetings (Brill, 2014, p. 18), limiting the influence of technical oversight.

Lack of Scalable Architecture

Performance features such as caching and load balancing were either not implemented or failed under pressure. The IBM Center for the Business of Government reported that CMS underestimated operational requirements and selected technologies that had not been tested at scale (Lee & Brumer, 2017).

No Central Governance

Multiple contractors and so-called “war rooms” were used to coordinate the work, but no centralized project management office (PMO) was established. This lack of governance increased complexity and obscured accountability.

Going Forward: Lessons and Recommendations

As Laudon and Laudon (2021) explain, introducing a major information system involves more than software—it requires an integrated strategy that includes people, processes, and culture (p. 490). To avoid repeating the errors of HealthCare.gov, several structural changes are needed:

• Executive Ownership: Appointing a senior technical leader, such as the White House CTO, to serve as the central project stakeholder ensures top-down accountability and bridges policy with technology.

• Third-Party PMO: Bringing in an experienced, neutral consulting firm to oversee the project from start to finish would reduce political bias and improve clarity in execution (PM Alliance, n.d.).

• Agile + RAD Methodology: A hybrid approach combining rapid application development (RAD) for speed and Agile for iterative testing would support faster cycles while incorporating feedback (Association for Project Management, n.d.).

• Risk Planning Tools: Using Gantt charts, Kanban boards, and Delphi techniques (Whitaker, 2016; Agile Alliance, n.d.) enables teams to track deliverables, manage bottlenecks, and prepare for contingencies.

• Post-Launch Improvements: Systematic benchmarking, user feedback collection, and continuous improvement frameworks such as Lean or ITIL can optimize performance over time (Edwards, 2022).

Turning Failure Into Framework

The failed launch of HealthCare.gov exemplifies how weak governance, compressed timelines, and technical blind spots can undermine even the most ambitious public sector initiatives. According to NBC News, internal documents revealed that only six people were able to successfully enroll on the first day (Thorp, 2013), a staggering outcome given the scale and investment of the ACA.

While the system was eventually stabilized, the initial failure underscores the need for structured project leadership, robust methodology, and stakeholder alignment from the outset. If appointed as executive sponsor, the White House CTO could have championed a unified vision connecting policy to platform. A neutral PMO, combined with hybrid project management techniques and scalable technology tools, could have transformed the ACA’s digital front door from a failure into a foundation for trust in government innovation.

References

Agile Alliance. (n.d.). What is Kanban? https://www.agilealliance.org/glossary/kanban/

Andrews, W., & Werner, A. (2013, October 1). HealthCare.gov plagued by crashes on 1st day. CBS News. https://www.cbsnews.com/news/healthcaregov-plagued-by-crashes-on-1st-day/

Association for Project Management. (n.d.). Agile project management glossary. https://www.apm.org.uk/resources/find-a-resource/agile-project-management/glossary/#:~:text=RAD%20(rapid%20application%20development)%20%E2%80%93,list%20called%20the%20’Backlog’

Association for Project Management. (n.d.). Gantt chart. https://www.apm.org.uk/resources/find-a-resource/gantt-chart/#:~:text=A%20Gantt%20chart%20is%20defined,to%20form%20a%20bar%20chart.

Brill, S. (2014, February 27). Obama’s trauma team. Time. https://time.com/10228/obamas-trauma-team/

Digital Initiative at Harvard Business School. (2016, November 16). The failed launch of www.HealthCare.gov. Harvard Business School. https://d3.harvard.edu/platform-rctom/submission/the-failed-launch-of-www-healthcare-gov/

Edwards, J. (2022, October 21). Why your IT organization needs to embrace continuous improvement. InformationWeek. https://www.informationweek.com/it-leadership/why-your-it-organization-needs-to-embrace-continuous-improvement

Kihlstrom, G. (2022, March 21). The importance of aligning people, processes, and technology amid transformation initiatives. Forbes. https://www.forbes.com/councils/forbesagencycouncil/2022/03/21/the-importance-of-aligning-people-processes-and-technology-amid-transformation-initiatives/

Laudon, K. C., & Laudon, J. P. (2021). Management information systems: Managing the digital firm (17th ed.). Pearson.

Lee, G., & Brumer, J. (2017). Managing mission-critical governance software projects: Lessons learned from the HealthCare.gov project. IBM Center for The Business of Government. https://www.businessofgovernment.org/sites/default/files/Viewpoints%20Dr%20Gwanhoo%20Lee.pdf

PM Alliance. (n.d.). Projects benefit from neutral perspectives. https://pm-alliance.com/neutral-perspectives-project-benefit/

Reuters. (2014, January 10). U.S. to part with contractor CGI for Obamacare website. https://www.reuters.com/article/usa-healthcare-cgi/update-4-u-s-to-part-with-contractor-cgi-for-obamacare-website-idUKL2N0KK1W620140110

Thorp, F. (2013, October 31). Only 6 able to sign up on Healthcare.gov’s first day, documents show. NBC News. https://www.nbcnews.com/politics/politics-news/only-6-able-sign-healthcare-govs-first-day-documents-show-flna8c11509571

Whitaker, S. (2016, September 11). Delphi technique. ProjectManagement.com. https://www.projectmanagement.com/wikis/233600/delphi-technique#=

Dobbs v. Jackson Women’s Health Organization

Michael Baler, November 6, 2025

Abstract

This paper explores the historical and legal trajectory from Roe v. Wade to Dobbs v. Jackson Women’s Health Organization, focusing on the profound implications for reproductive rights, healthcare access, medical ethics, and public policy in the United States. The decision in Dobbs marks the first time the U.S. Supreme Court has rescinded a constitutionally protected right, returning the power to regulate abortion to individual states. This shift has produced widespread and uneven impacts—threatening clinical standards, deepening disparities in care, and challenging privacy and autonomy rights. Drawing on court rulings, legal analysis, public health research, and ethical arguments, this paper assesses the consequences of Dobbs, particularly on vulnerable populations, medical providers, and the healthcare system at large. It concludes by identifying key mitigation strategies, including legal challenges, expanded telehealth, increased medical education, and national policy efforts to safeguard reproductive healthcare access in a post-Dobbs America.

The Legacy of Roe and the Reversal in Dobbs

It is 1973 in America. The nation is dealing with the aftermath of the civil rights movement, the Vietnam War is coming to an end, and Watergate dominates the headlines. On January 22, Walter Cronkite opened the CBS Evening News with a historic statement: “…the decision to end the pregnancy during the first three months belongs to the woman and her doctor, not the government. Thus, the anti-abortion laws of 46 states were rendered unconstitutional” (Miller, 2023).

Roe v. Wade was more than a Supreme Court case—it became a cultural and political touchstone. It affirmed that women have agency over their bodies and reproductive choices. For nearly five decades, the decision shaped political campaigns, judicial appointments, and the national conversation on personal freedom.

In 2022, as the world grappled with the war in Ukraine, the third year of COVID-19, and hearings on the January 6 insurrection, abortion once again seized the spotlight. On June 24, the U.S. Supreme Court ruled in Dobbs v. Jackson Women’s Health Organization that “Roe and Casey must be overruled” (Dobbs, 2022, p. 5). The Court’s majority opinion, authored by Justice Alito, signaled a devastating shift in reproductive rights and the first-ever rescission of a federally protected liberty (Kaufman et al., 2022).

This decision marked the end of constitutional protections for abortion, returning regulatory power to the states. Nearly 50 years after Roe, reproductive healthcare remains one of the most polarizing and consequential issues in American life.

The Decisions

Roe v. Wade (1973)

Jane Roe, or Norma McCorvey, was a 22-year-old unmarried woman who became pregnant and sought an abortion in Texas, where the procedure was largely banned. In 1970, she became the plaintiff in a case that would challenge the state’s abortion laws. The case reached the U.S. Supreme Court in 1973.

Writing for the majority, Justice Harry Blackmun grounded the ruling in the constitutional right to privacy, stating, “This right of privacy… is broad enough to encompass a woman’s decision whether or not to terminate her pregnancy” (Frederickson & Wurman, n.d.). The Court introduced a trimester framework, asserting that states could not interfere in the first six months of pregnancy except to ensure maternal health (Beckwith, 2006, p. 38).

Roe became a landmark for personal autonomy. Justice Ruth Bader Ginsburg later reinforced this principle during her 1993 confirmation hearing, stating, “The decision whether or not to bear a child is central to a woman’s life, to her well-being and dignity” (Hira, 2021). The ruling led to dramatic improvements in women’s health. In 1965, 17% of pregnancy-related deaths were due to unsafe illegal abortions (Gold, 1990; NCHS, 1967, as cited in Planned Parenthood, 2014). By 1985, deaths from legal abortion had declined fivefold (Council on Scientific Affairs, 1992).

Dobbs v. Jackson Women’s Health Organization (2022)

In 2018, Mississippi passed the Gestational Age Act, banning abortions after 15 weeks, except in limited circumstances. Anticipating legal challenges, Governor Phil Bryant declared, “We will probably get sued here in about a half-hour” (Clarion Ledger, 2022).

Indeed, Jackson Women’s Health Organization filed suit, challenging the law’s constitutionality under Roe. After lower courts ruled the law unconstitutional, the state appealed to the U.S. Supreme Court. The Court’s majority opinion in Dobbs asserted: “The Constitution does not confer a right to abortion… the authority to regulate abortion is returned to the people and their elected representatives” (Dobbs, 2022, syllabus, p. 1).

The opinion rejected appeals to autonomy, arguing that the Fourteenth Amendment “clearly does not protect the right to an abortion” (Dobbs, 2022, syllabus, p. 3). Justice Alito criticized Roe’s trimester structure as having “no grounding in the constitutional text, history, or precedent” (p. 5), and called Roe “egregiously wrong” from its inception.

Impact, Obstacles, and Solutions in the Wake of Dobbs

Diminished Access to Care and Uneven Standards

In the 100 days after Dobbs, 66 clinics across 15 states closed, leaving 14 states with no abortion providers (Baden, Dreweke, & Gibson, 2024). Ambassador Linda Thomas-Greenfield noted that the ruling rendered the U.S. an outlier in global reproductive rights protections (Kaufman et al., 2022).

Without a federal standard, abortion access has fractured. Legal and practical access now depends on geography, exacerbating inequality. “A coast-to-coast wave of lawsuits, legislation, and pitched political fights” has followed (Hubler & Smith, 2022). The resulting healthcare disparities particularly affect rural, low-income, and minority communities.

Threats to Women’s Health and Medical Ethics

Clinicians in restrictive states report reduced ability to provide care, including for miscarriages and pregnancy-related emergencies (Ranji, Salganicoff, & Sobel, 2024). One in five OB-GYNs report constraints on miscarriage care (Baden, Dreweke, & Gibson, 2024). In Texas, oral contraceptive prescriptions declined 28% post-Dobbs (Qato et al., 2024).

Dobbs has also contributed to the OB-GYN shortage. More than 2.2 million women live in “OB-GYN deserts,” with millions more in under-resourced areas (Weiner, 2023). 63% of surveyed OB-GYNs say they would not work in a state with abortion bans.

Criminalization and Legal Exposure

Physicians now risk legal action for both providing and withholding abortion care. Conflicts between state laws and federal mandates, such as EMTALA, create dangerous ambiguity (King & Cummings, 2023). Doctors may also fear malpractice exposure if treating miscarriages is construed as performing an illegal abortion (Rosenbaum, Jost, & Keith, 2022).

Even routine diagnostics—like imaging or anesthesia—are impacted by fear of inadvertently causing pregnancy loss (De Vos et al., 2023). In some cases, hospitals have withheld emergency care for fear of violating abortion laws (Simmons-Duffin, 2022).

Social Determinants and Privacy Erosion

The Dobbs ruling undermines public health infrastructure and increases the burden on individuals (Ahmed et al., 2023). Women of color are more likely to live in states with abortion bans and have fewer resources to travel for care (Hill et al., 2024; Narea, 2024).

Legal ambiguity also threatens patient privacy. HIPAA protections are weakened when state law enforcement seeks access to health records (Gamma Compliance, 2022; Moseley-Morris, 2024). Data from period-tracking apps and GPS logs can be used in criminal investigations (Sexton, 2023).

Where Do We Go From Here?

With a conservative majority on the Supreme Court, reversing Dobbs in the near term is unlikely. Therefore, mitigation strategies become essential:

• Expand telemedicine and digital health: Telehealth increases access and has proven especially effective for low-income populations (Koenig et al., 2023; Harvey, Larson, & Warren, 2023).

• Ensure medical training access: The AMA now supports training pathways in non-restrictive states for medical students (AMA, 2022).

• Fund legal challenges: Lawsuits in multiple states are testing bans under privacy, due process, and religious freedom clauses (Felix, Sobel, & Salganicoff, 2023).

• Support travel for care: Executive Order 14076 and state-led funds (e.g., California) help offset costs for patients crossing state lines (Families USA, 2023; Cahn & Suter, 2024).

Conclusion: Morality, Law, and a Divided Nation

Unlike other policies, abortion law crosses religious beliefs, autonomy, and healthcare access. It raises deep questions about constitutional interpretation and moral duty. While the Constitution never mentions abortion, the Fourth Amendment’s guarantee that citizens be “secure in their persons” has long implied a right to privacy (Dershowitz, 2022).

Justice Alito wrote that abortion “presents a profound moral issue” (Dobbs, 2022, p. 1). That moral tension will continue to drive the debate. As John E. Murray Jr. once noted, the law’s standards of judgment are found in “the morality of duty” (Murray, 1965, p. 625).

Can compromise be found? Pew Research Center data shows that while 63% of Americans believe abortion should be legal in some form, many also support limits based on timing or parental consent (Pew Research Center, 2022). The conversation remains highly personal—one NPR interviewee described her emotional transformation from anti-abortion advocate to someone who chose abortion, stating: “Even after the procedure, I felt that I had committed a murder” (Martin, Haney, & Kennedy, 2022).

The story of Dobbs is not over. It will continue to evolve—legally, politically, and socially—as Americans wrestle with what it means to be free, secure, and morally accountable in a pluralistic democracy.

References

Ahmed, A., Evans, D., Jackson, J., Mason Meier, B., & Tomori, C. (2023). Dobbs v. Jackson Women’s Health: Undermining public health, facilitating reproductive coercion. Boston University School of Law Faculty Scholarship. https://scholarship.law.bu.edu/faculty_scholarship/3728/

American Medical Association. (2022, November 16). AMA announces new adopted policies related to reproductive health care. https://www.ama-assn.org/press-center/press-releases/ama-announces-new-adopted-policies-related-reproductive-health-care

American Bar Association. (2023, April 28). The decision heard around the world: The global impact of Dobbs v. Jackson Women’s Health Organization. https://www.americanbar.org/groups/diversity/women/publications/perspectives/2023/april/the-decision-heard-around-world-global-impact-dobbs-v-jackson-womens-health-organization/

Baden, K., Dreweke, J., & Gibson, C. (2024, May). Clear and growing evidence: Dobbs is harming reproductive health and freedom. Guttmacher Institute. https://www.guttmacher.org/2024/05/clear-and-growing-evidence-dobbs-harming-reproductive-health-and-freedom

Beckwith, F. J. (2006). The Supreme Court, Roe v. Wade, and abortion law. Baylor University Law School. https://www.baylor.edu/content/services/document.php/47418.pdf

Cahn, N., & Suter, S. (2024, June). The right to travel for abortion in a post-Dobbs world. Harvard Law Review Blog. https://harvardlawreview.org/blog/the-right-to-travel-post-dobbs/

Clarion Ledger. (2022, March 19). Mississippi Gov. Phil Bryant signs bill banning abortion after 15 weeks. https://www.clarionledger.com/story/news/2018/03/19/mississippi-abortion-bill-15-weeks/434775002/

Council on Scientific Affairs, American Medical Association. (1992). Induced termination of pregnancy before and after Roe v. Wade. JAMA, 268(22), 3231–3239.

Dasari, M. (2022, November 3). Dobbs decision will make science less diverse. Association for Women in Science. https://awis.org/resource/dobbs-decision-will-make-science-less-diverse/

De Vos, C., Heisler, M., Jaffe, W., Shah, P., Cox-Toure, T., Desai, P., Chowdhry, N., Kaufman, R., & Muqaddam, R. (2023, April 25). Oklahoma’s abortion bans violate human rights. Physicians for Human Rights. https://phr.org/our-work/resources/oklahoma-abortion-rights/

Dershowitz, A. (2022, June 22). States can’t regulate guns, but they can ban abortions — Why? The Hill. https://thehill.com/opinion/judiciary/3534784-states-cant-regulate-guns-but-they-can-ban-abortions-why/

Dobbs v. Jackson Women’s Health Organization, 597 U.S. ___ (2022). https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf

Families USA. (2023, January). Protecting access to essential reproductive health services in a post-Dobbs world: Proactive policy options for states. https://familiesusa.org/wp-content/uploads/2023/01/MCH-2022-160-MCH-Repro-Policy-Priorities.pdf

Felix, M., Sobel, L., & Salganicoff, A. (2023, January 20). Legal challenges to state abortion bans since the Dobbs decision. Kaiser Family Foundation. https://www.kff.org/womens-health-policy/issue-brief/legal-challenges-to-state-abortion-bans-since-the-dobbs-decision/

Frederickson, C., & Wurman, I. (n.d.). Roe v. Wade (1973). National Constitution Center. https://constitutioncenter.org/the-constitution/supreme-court-case-library/roe-v-wade

Gamma Compliance. (2022, April 27). The main purpose behind the HIPAA privacy rule. https://www.gammacompliance.com/compliance101/the-main-purpose-behind-the-hipaa-privacy-rule

Harvey, S. M., Larson, A. E., & Warren, J. T. (2023, April 15). The Dobbs decision - Exacerbating U.S. health inequity. The New England Journal of Medicine. https://doi.org/10.1056/NEJMp2216698

Hill, L., Artiga, S., Ranji, U., Gomez, I., & Dnugga, N. (2024, April 24). What are the implications of the Dobbs ruling for racial disparities? Kaiser Family Foundation. https://www.kff.org/womens-health-policy/issue-brief/what-are-the-implications-of-the-dobbs-ruling-for-racial-disparities/

Hira, E. (2021, November 9). The government has a long history of controlling women—One that never ended. Brennan Center for Justice. https://www.brennancenter.org/our-work/analysis-opinion/government-has-long-history-controlling-women-one-never-ended

Hubler, S., & Smith, M. (2022, June 28). After Roe, the new battlefront over abortion rights: State courts. The New York Times. https://www.nytimes.com/2022/06/27/us/abortion-rights-states.html

Kaufman, R., Brown, R., Martínez Coral, C., Jacob, J., Onyango, M., & Thomasen, K. (2022). Global impacts of Dobbs v. Jackson Women’s Health Organization and abortion regression in the United States. Sexual and Reproductive Health Matters, 30(1), 2135574. https://doi.org/10.1080/26410397.2022.2135574

King, C., & Cummings, D. (2023, June 14). One year after Dobbs: Are medical providers and employers still at risk for lawsuits stemming from abortion access? The Policyholder Perspective. https://www.policyholderperspective.com/2023/06/articles/insurance-general/one-year-after-dobbs-are-medical-providers-and-employers-still-at-risk/

Kliff, S. (2014, January 22). Thirteen charts that explain how Roe v. Wade changed abortion rights. The Washington Post. https://www.washingtonpost.com/news/wonk/wp/2014/01/22/thirteen-charts-that-explain-how-roe-v-wade-changed-abortion-rights/

Koenig, L. R., Becker, A., Ko, J., & Upadhyay, U. D. (2023). The role of telehealth in promoting equitable abortion access in the United States: Spatial analysis. JMIR Public Health and Surveillance, 9, e45671. https://doi.org/10.2196/45671

Martin, R., Haney, T., & Kennedy, M. (2022, June 28). A woman changed her views on abortion after she had to make the decision for herself. NPR. https://www.npr.org/2022/06/28/1108117764/a-woman-changed-her-views-on-abortion-after-she-had-to-make-the-decision-for-her

Miller, J. (2023, January 22). Roe v. Wade: The 1973 abortion ruling and its impact, 50 years later. CBS News. https://www.cbsnews.com/news/roe-v-wade-1973-abortion-ruling-50-years-cbs-news/

Moseley-Morris, K. (2024, June 3). States are already collecting more abortion data, and HIPAA won’t always keep it private. Maine Morning Star. https://mainemorningstar.com/2024/06/03/states-are-already-collecting-more-abortion-data-and-hipaa-wont-always-keep-it-private/

Murray, J. E., Jr. (1965). Introduction to the Morality of Law. Villanova Law Review, 10(4), 624–625. https://digitalcommons.law.villanova.edu/vlr/vol10/iss4/2

Narea, N. (2024, June 24). What two years without Roe looks like in 8 charts. Vox. https://www.vox.com/explainers/356314/abortion-laws-roe-wade-dobbs-decision-mifepristone-supreme-court

Pew Research Center. (2022, May 6). America’s abortion quandary. https://www.pewresearch.org/religion/2022/05/06/americas-abortion-quandary/

Planned Parenthood. (2014). Roe v. Wade: Its history and impact. https://www.plannedparenthood.org/files/3013/9611/5870/Abortion_Roe_History.pdf

Qato, D. M., Myerson, R., Shooshtari, A., Guadamuz, J. S., & Alexander, G. C. (2024). Use of oral and emergency contraceptives after the US Supreme Court’s Dobbs decision. JAMA Network Open, 7(6), e2418620. https://doi.org/10.1001/jamanetworkopen.2024.18620

Ranji, U., Salganicoff, A., & Sobel, L. (2024, May 2). Dobbs-era abortion bans and restrictions: Early insights about implications for pregnancy loss. Kaiser Family Foundation. https://www.kff.org/womens-health-policy/issue-brief/dobbs-era-abortion-bans-and-restrictions-early-insights-about-implications-for-pregnancy-loss/

Rosenbaum, S., Jost, T. S., & Keith, K. (2022, June 27). Dobbs: The immediate aftermath and the coming legal morass. The Commonwealth Fund. https://www.commonwealthfund.org/blog/2022/dobbs-immediate-aftermath-and-coming-legal-morass

Sexton, M. (2023, January 22). The new front in the battle for digital privacy post-Dobbs. Third Way. https://www.thirdway.org/memo/the-new-front-in-the-battle-for-digital-privacy-post-dobbsarticle

Simmons-Duffin, S. (2022, November 23). Doctors who want to defy abortion laws say it’s too risky. NPR. https://www.npr.org/sections/health-shots/2022/11/23/1137756183/doctors-who-want-to-defy-abortion-laws-say-its-too-risky

Weiner, S. (2023, August 23). The fallout of Dobbs on the field of OB-GYN. Association of American Medical Colleges. https://www.aamc.org/news/fallout-dobbs-field-ob-gyn

Warren, T. H. (2022, June 26). Dobbs, Roe, and the myth of bodily autonomy. The New York Times. https://www.nytimes.com/2022/06/26/opinion/dobbs-roe-autonomy.html

The Impact of the ACA on the 2024 Presidential Election

Michael Baler, September 2024

Abstract

This paper explores the shifting role of healthcare in the 2024 U.S. presidential election, focusing on the diminished political prominence of the Affordable Care Act (ACA) in a race dominated by cultural and identity-driven issues. While the ACA once symbolized intense partisan conflict, it has now become embedded in the American healthcare system, with bipartisan acknowledgment of its permanence. Drawing on polling data, public policy analysis, and healthcare outcome metrics, this paper examines the ACA’s stabilizing influence, the cultural realignment of political priorities, and emerging policy challenges that remain under-addressed by both major candidates. It argues that although the ACA has reduced the urgency of healthcare reform as a campaign issue, unresolved problems such as affordability, mental health access, telehealth regulation, and health equity demand renewed focus beyond the election cycle. The conclusion emphasizes the need for sustained policy innovation to support health system resilience and population well-being amid growing political polarization.

Healthcare and the 2024 Election Cycle

Unlike previous election cycles, healthcare has faded into the background of the 2024 presidential race between Vice President Kamala Harris and former President Donald Trump. According to the Pew Research Center (2024), the current campaign is shaped by “intense debates over such topics as immigration, growing racial and ethnic diversity in the United States, the changing American family, crime, and reproductive issues.” These issues, collectively branded as “culture war” topics, have shifted the political spotlight away from traditional policy concerns such as healthcare.

This shift was evident in the September 2024 nationally televised debate, where the healthcare exchange between Harris and Trump was brief and quickly reduced to a viral meme (Weiland & Sanger-Katz, 2024). When Harris affirmed her commitment to maintaining and expanding the ACA, Trump vaguely referenced having “concepts of a plan” (ABC News, 2024).

According to the Kaiser Family Foundation (KFF), healthcare is no longer a top-tier concern for voters. While issues like the economy and inflation command 38% of voter attention, healthcare lags in the single digits. Cultural concerns—ranging from reproductive rights to gun policy and immigration—collectively dominate the political discourse (Kirzinger, Sparks, Valdes, Montalvo III, & Hamel, 2024).

The Shift to Cultural Battles

The transition away from policy-centric campaigns to culturally driven narratives has fundamentally altered political dynamics. Republicans have prioritized themes such as opposing “woke” ideology, defending traditional values, and asserting parental rights (Pew Research Center, 2024). In contrast, Democrats have emphasized reproductive autonomy, climate action, and economic equity (Nehamas, 2024).

As reported by Georgetown University’s McCourt School of Public Policy (2024), 81% of Americans believe democracy itself is under threat. This perception has reframed elections as contests over national identity and values. According to Politico’s Stanton (2021), “politics is an artifact of culture… fueled by division,” where campaigns now focus on symbolic grievances over policies like mask mandates, transgender participation in sports, or so-called “cancel culture.” Within this framework, healthcare has largely been displaced from center stage.

The ACA’s Role in Shaping Healthcare as the Status Quo

Since its passage in 2010, the ACA has significantly restructured the American healthcare landscape. Initially a polarizing reform, it has gradually gained bipartisan acceptance. Within a decade, it extended insurance coverage to over 20 million Americans, banned discrimination based on preexisting conditions, and expanded Medicaid in many states (Rapfogel, Gee, & Calsyn, 2020; U.S. Department of Health and Human Services, 2022).

Efforts to repeal the ACA—most notably during the Trump administration—have failed. Today, even Republican lawmakers acknowledge its endurance. ACA enrollment reached 21.3 million in 2024, with the most significant increases in conservative-leaning states (Axios, 2024). As Senator Lisa Murkowski observed, “If you were to walk into the room and say my No. 1 priority is to repeal and replace ObamaCare… half the people [would say], ‘What? Why? Huh?’” (Bolton, 2024). Senate Minority Leader Mitch McConnell echoed this sentiment, conceding that “the Affordable Care Act… is probably, whether we like it or not, here to stay.”

ACA’s Success in Reducing Urgency

One of the ACA’s most impactful contributions is the Patient Bill of Rights, which addressed longstanding inequities in coverage. Within a year of its passage, up to 150,000 children with preexisting conditions gained or retained health insurance (Centers for Medicare & Medicaid Services, 2011). From 2010 to 2014, the number of uninsured Americans with preexisting conditions dropped by 3.6 million (U.S. Department of Health and Human Services, 2017).

These reforms have mitigated some of the crisis conditions that once made healthcare a hot-button election issue. Public opinion now favors ACA improvement over repeal; in 2017, 78% of Americans believed President Trump should fix the law rather than let it fail (Kirzinger, DiJulio, Wu, & Brodie, 2017). As a result, Democrats have pivoted to incremental proposals rather than comprehensive overhauls, and Republicans have largely abandoned ACA repeal as a central campaign message.

Healthcare Issues That Still Demand Attention

Although healthcare may no longer drive elections, unresolved challenges continue to affect Americans’ daily lives and deserve policy attention.

Affordability and Access

According to a 2024 Gallup survey, one in three U.S. adults skipped needed care due to financial concerns. Expanding affordable insurance options, capping out-of-pocket costs, and strengthening provider networks remain urgent goals (West Health & Gallup, 2024).

Mental Health Services

Between 2008 and 2019, adult mental illness increased by nearly 30%. COVID-19 exacerbated this crisis, but access to behavioral health remains uneven and underfunded (Mayo Clinic, 2024; Center for American Progress, 2022). A national framework for mental health parity, service access, and insurance coverage is still lacking.

Telehealth and Digital Regulation

While telehealth expanded rapidly during the pandemic, regulatory frameworks have lagged behind. To facilitate care continuity, HHS relaxed HIPAA enforcement during the emergency period (U.S. Department of Health and Human Services, 2024). However, a long-term strategy for patient privacy and platform regulation remains necessary.

Healthcare Workforce Shortages

The Health Resources and Services Administration projects a shortage of 350,000 registered nurses and up to 68,000 primary care physicians by 2036 (HRSA, 2024). These shortages threaten access, quality, and health equity nationwide.

Prescription Drug Costs

Drug prices in the U.S. are approximately three times higher than in peer nations (Assistant Secretary for Planning and Evaluation, 2024). Efforts to allow Medicare drug price negotiation and promote generics must be expanded.

Health Equity and Disparities

The U.S. leads the developed world in maternal mortality, with Native Hawaiian, Pacific Islander, Black, and American Indian/Alaska Native women facing the highest rates (U.S. Department of Health and Human Services, 2024). These disparities demand systemic reforms and targeted investment.

Public Health Preparedness

Despite the COVID-19 wake-up call, public health infrastructure remains fragile. As noted by the NPS Center for Homeland Security, the U.S. must urgently decide whether to prioritize pandemic preparedness (Pohlman et al., 2021).

Conclusion

Although the ACA has stabilized key aspects of the U.S. healthcare system and reduced the political urgency for reform, it has not resolved many of the country’s most pressing healthcare challenges. Issues like affordability, mental health access, digital health regulation, workforce shortages, and persistent disparities remain critical.

Yet in the 2024 presidential race, neither major candidate has proposed sweeping healthcare changes. According to PBS News (Desjardins, 2024), Donald Trump has offered no significant healthcare platform beyond abortion. Kamala Harris has proposed lowering prescription drug prices and capping insulin costs, but her broader healthcare strategy remains limited (CNN, 2024).

Congressional gridlock, the filibuster, and industry lobbying further constrain the legislative path forward (Reynolds, 2020). Still, voters, advocates, and policymakers must elevate healthcare in the national conversation. As a defining element of American well-being, healthcare requires leadership, creativity, and a commitment to equity that transcends culture wars and partisan cycles.

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