Healthcare in the United States has always been held up as a cautionary tale on the grim alternative to the National Health Service.

Every American has a story of navigating a complex and fragmented system.

The US is the only advanced economy in the world that does not guarantee healthcare for everyone. Some 700,000 people go bankrupt every year from health bills.

The crippling cost of care in America

Image: Healthcare suffers a great disparity in the USA

As the NHS turns 70, Donald Trump is the latest US president wrestling with the complexities and competing pressures of healthcare in America.

He vowed to repeal the Affordable Care Act, the reform passed by his predecessor and known universally as Obamacare, but has found that to be harder than he thought.


Image: Homeless patient Deborah Lumbert believes poor people are less cared for

Jonathan Gruber, the man credited with being the architect of Obamacare, told Sky News: "The number one rule when talking about healthcare in America is that nothing is easy, as our president recently discovered.

"Nothing is easy, nothing is black and white. There's no yes or no. It is all shades of grey. The thing I think is most striking to a British citizen is that many Americans don't have health insurance."

Image: Kami Harless treats patients who have jobs but can't afford healthcare

Most Americans receive their health insurance through their employer. Millions more receive government-run healthcare for the low income, elderly and military veterans, some of it almost identical to the "single payer" system like the NHS, so often demonised in the US as "socialised medicine" .

Many rely on handouts. A mobile medical unit in Seattle's Capitol Hill neighbourhood is one of many to offer basic services to the homeless, and even some who have jobs.

Image: Obamacare is being slowly unpicked, with no replacement

The unit's doctor, Kami Harless, says she helps all sorts of people.

"I have a number of clients will come on to the van and it's the first time they've seen a physician in five, 10 or 15 years. Many of the clients that come on to this fan are employed and they just are not currently sheltered."

Of the healthcare system, homeless patient Deborah Lumbert says that "if you're poor they don't really care".

"You're not going to have the best doctors knocking at your door. It is mostly designed for the wealthy."

Image: Jonathan Gruber, the man credited with being the architect of Obamacare

Even those with good health cover find themselves saddled with huge bills and piles of bureaucracy.

Diagnosed with breast cancer at 26, Allison Abbott underwent chemotherapy and a mastectomy. She estimates that she has paid $30,000 (£22,700) out of her own pocket for treatment.

Image: Dr Savitha Krishnan, a uro-gynaecologist at the El Camino hospital in Silicon Valley

"How is it fair for people that are in my position that are unable to afford health insurance to not be able to receive the same care because they can't afford the insurance?" she says. "It's not fair."

One paradox is that American healthcare also provides some of the best care in the world. The El Camino Hospital in Silicon Valley is a leader in the use of medical robotics.

Image: Allison Abbott says she has paid $30,000 for chemotherapy and a mastectomy

Dr Savitha Krishnan, a uro-gynaecologist at the hospital, says people need to be informed.

"Being an informed consumer is really important in any healthcare system. In the United States you have options in regards to where you are getting your healthcare, which physicians you are going to, you have options in regards to what your outcomes are going to be."

But dozens of uninsured people die every day in America from illnesses for which others receive treatment because they have health cover.

Image: Some hospitals in the US are the best in the world - but not everyone can afford them

"Where consumers aren't well-informed, where there's monopoly power, where certain providers can charge whatever they want because there's nowhere else to go," says Mr Gruber. "Those are what we call market failures.

"And America has been weak to address the market failures in the healthcare system."