When ACP released its vision for a better U.S. health care system on Jan. 21, 2020, we knew our bold recommendations would invite controversy. Yet we concluded that because the current system was leaving too many Americans behind, change was imperative, a conclusion borne out since then by the COVID-19 pandemic. In “Envisioning a Better U.S. Health Care System for All: A Call to Action by the American College of Physicians,” I wrote on ACP ‘s behalf, “The ACP rejects the view that the status quo is acceptable, or that it is too politically difficult to achieve needed change.”
Now, more than a year and half after we proposed our vision papers, we can take stock of how close we are to achieving ACP's vision of a health care system that is available and affordable to all. We have advanced many policies to move the U.S. closer to the solutions we offered, but as in de Tocqueville's times, there are men and women today who look on every new theory as a danger, every innovation as toilsome trouble, every social advance as a first step toward revolution, with some refusing to move at all.
Coverage and cost
In our recommendations on expanding coverage and lowering the cost of care, we said the U.S. should transition to a system that achieves universal coverage with essential benefits and lower administrative costs. Coverage, we said, should not be dependent on a person's place of residence, employment, health status, or income. We concluded that two options could achieve this vision: a publicly funded program (public option) that would compete with and offer an alternative to private insurance, or a single-payer system financed and administered by the federal government.
Measured by how many more people have access to affordable coverage, we have made considerable progress. The American Rescue Plan Act (ARPA), enacted by Congress and signed into law by President Joe Biden, offers greater incentives for states to expand Medicaid (although none have so far taken up the offer), an option for states to offer Medicaid postpartum coverage for 12 months following childbirth, and increased premium subsidies and eligibility to buy coverage from the health plans offered through the Affordable Care Act (ACA). The Kaiser Family Foundation estimates that the number of people eligible for subsidized ACA Marketplace coverage has increased from 18.1 million to 21.8 million, including those insured and uninsured. The administration also created a new open enrollment period for people to sign up for a plan and take advantage of the higher premium subsidies, which closed on Aug. 15; nearly one million had signed up as of April 30.
Congress is also considering additional legislation to close the Medicaid coverage gap in states still unwilling to expand the program and adding dental, vision, and hearing coverage to Medicare. Since no Republican members of Congress are expected to support these measures, congressional Democrats hope to pass them on a simple majority vote through budget reconciliation, which can't be subjected to a Senate filibuster. However, at the time this column went to press, it was unclear if the Democrats would have the votes to pull it off.
The more ambitious reforms advocated by ACP, a public option or a single-payer system, are not likely to advance. While two congressional committees sought the input of ACP and others on a public option bill, it is hard to see a pathway for it to pass any time soon, and there are not enough votes to pass single-payer legislation, even among Democrats.
Opposition from hospitals, pharmaceutical companies, and insurers to anything that threatens their business interests, as well as ideological opposition to so-called “socialized medicine,” stand in the way of achieving true universal coverage with lower costs as ACP envisions it. Millions are being spent on scare tactics to derail progress on a public option or single-payer legislation. Hospitals also came out swinging against President Biden's July executive order to require more regulatory scrutiny of hospital mergers; the prescription drug industry similarly has poured millions into blocking any policy to lower Rx prices.
ACP's vision called for everyone to have access to high-quality primary care, and others have joined with us since then. The National Academies of Sciences, Engineering, and Medicine called primary care the foundation of an effective health care system and developed a framework to invigorate it. ACP joined with other leading primary care advocates to create Primary Care for America, which hopes to change the conversation to supporting the value of primary care. Medicare implemented historic payment increases for office visits on Jan. 1, a huge step forward. Yet experience shows that more spending on primary care will be resisted if it takes dollars away from other services and clinicians.
ACP's vision called for an end to discrimination based on a person's race, ethnicity, gender, gender identity, sexual orientation, country of origin, or other personal characteristics. On this score, we've seen major progress to advance regulations, executive orders, and legislation to prohibit discrimination and advance health equity. Yet we are also seeing a backlash against even discussing the impact of racism on society and on health. Many states have passed laws to discriminate against transgender persons or deny women access to reproductive health.
Finally, ACP advocated that public health be informed by science and not politicized. The Biden administration and Congress have taken important steps to restore confidence in science and in public health and to mitigate the health impacts of climate change, including spending billions on both. Yet the unconscionable efforts by some politicians, individuals, and cable TV commentators to discredit COVID-19 vaccines, powered by false claims on social media and while attacking public health officials for doing their jobs, shows that the antiscience forces in our country remain powerfully present.
No one ever said it would be easy to achieve ACP's vision, and we can take pride in the fact that we have made major progress, despite the obstacles. Today, we must again reject the idea that the status quo is acceptable and that it is too difficult to achieve needed change. The answer to those “who may absolutely refuse to move at all” is to work even harder to advance our vision for better health care.