The Trump agenda fiscal agenda has focused on tax reform, and especially the scope for cutting taxes. However, the esteemed Brookings Institute reminds us that despite the recent sharp declines in the US Federal government deficit, the USA confronts formidable fiscal challenges over the medium term. Eventually, the growth in American entitlement spending will need to be addressed. Health care reform will be crucial. So far, the ACA debate — including the repeal movement — has focused on the important issue of extending insurance coverage. At some point, however, addressing the runaways cost of care will need to be tackled.