The American health care system is broken.
Patients know it. Physicians know it. People who study health care know it. You know it. I know it.
Yet instead of doing something about it, we are told to
accept the unacceptable because changing it will be too hard and the politics too
difficult.
But isn’t time for someone
with influence to speak out and say enough is enough, we can and must do
better?
Yes, and that someone is the American College of
Physicians. Today, ACP issued a bold
call to action challenging the U.S. to implement systematic reform of the
health care system in a series of policy papers published as a supplement in Annals
of Internal Medicine.
“Better is Possible: The American College of Physicians
Vision for the U.S. Health Care System” is a comprehensive, interconnected set
of policies to guide the way to a better U.S. health care system for all. It
includes a call
to action, of which I am the corresponding author, which presents ACP’s
vision of a better health care system for all, summarizes ACP’s key
recommendation to achieve it, and challenges the U.S. not to settle for the
status quo. The additional set of ACP policy papers in the supplement address
issues related to coverage and cost of care, health care payment and delivery
systems, and barriers to care and social determinants of health, and offer
specific recommendations supported by evidence about ways the U.S. can change
the status quo and achieve a better healthcare system for all. The papers are:
“Envisioning a Better Health Care System for
All: The American College of Physicians’ Call
to Action”
“Envisioning a Better Health Care
System for All: Coverage
and Cost of Care”
“Envisioning a Better Health Care System for
All: Reducing
Barriers to Care and Addressing Social Determinants of Health”
“Envisioning a Better Health Care System for
All: Health
Care Delivery and Payment System Reform”
One of the 10 vision
statements in the Call to Action states that “ACP envisions a health care
system where everyone has coverage for and access to the care they need, at a
cost they and the country can afford.” To achieve
this, ACP recommends that the U.S. adopt either a single payer system or a public choice plan.
Under single
payer, everyone would be enrolled in the same publicly-financed and
administered plan, with little or no role for private insurance. In a public choice model, everyone would have
the option of enrolling in a publicly-financed program or keeping private
insurance that would be required to have comparable benefits as the public
option.
This is the first time that ACP has
expressly recommended either a single payer plan, or a public choice plan that
would be made available to everyone. To our knowledge, we are the first
national medical specialty society to do so; we are also the largest,
representing 159,000 internal specialist physician and medical student members.
We offered both approaches as ones we can
recommend because our examination of other countries with universal coverage
found that there are some that have a single payer system, while others have
systems where there is a mix of public and private coverage strongly regulated
by the government and where coverage is guaranteed. In other words, there
is more than one way to achieve universal coverage.
Single payer has the advantage of much lower
administrative costs and associated administrative requirements on clinicians
but is more disruptive because it would largely eliminate private insurance,
while a public choice models is less disruptive and would achieve
administrative savings compared to our current system, as more people choose
the public choice option, but less than from single payer.
Also new and notable is that ACP
recommends eliminating cost-sharing that creates barriers to high
value care; including for patients with certain chronic conditions. We
also proposed ways to control costs, including expanding global budgets and all
payer rate setting, prioritizing spending, increasing investment in primary
care, and considering comparative effectiveness in cost.
ACP didn’t just focus on coverage and
cost. We propose major reforms in payment and delivery systems to center them on patients’ needs, including redesigning value-based
payment programs that largely have not been effective in improving outcomes or
lowering costs. Specifically, we call for
Eliminating
“check the box” performance measurement reporting that take physicians’ time
away from patients without resulting in better care,
Realigning
incentives to support physician-led clinical care teams,
Eliminating
disparities in payment between physicians’ cognitive services and procedures,
Redesigning
Electronic Health Records to help physicians deliver patient-centered care.
Finally, we advocate for policies to reduce barriers to care based on where people live (social determinants),
eliminate discrimination against and disparities in care based on personal
characteristics, and devote more resources to the public health crises of
firearms-related injuries and deaths, maternal mortality, tobacco and nicotine
use, substance use disorders, and climate change.
ACP understands that our recommendations
are provocative and controversial. We
know that some of them will be fiercely opposed by those who financially
benefit from our broken system. We know
that politics will be hard. And, while
we are confident that most ACP members support us in offering a bold vision for
change, we also know that not every one of them will agree with everything we
propose, and their concerns need to be respectfully addressed.
But the alternative is accepting the
unacceptable: a broken U.S. health care system that, as we wrote in the Call to
Action, “costs too much; leaves too many behind without affordable coverage;
creates incentives that are misaligned with patients’ interests; undervalues
primary care and public health; spends too much on administration at the
expense of patient care; fails to invest and support public health approaches
to reduce preventable injuries, deaths, diseases and suffering; and fosters
barriers to care and discrimination against vulnerable individuals.’
I am so proud that ACP is offering a
vision for better health care system for all and of my contributions to making
this happen.
