Near 20:20 Vision for Health Care in 2020 - Annals of Internal Medicine: Fresh Look Blog


Wednesday, September 16, 2020

Near 20:20 Vision for Health Care in 2020

Fewer Americans have primary care than a decade ago. Life expectancy fell in 3 of the past 4 years. The average family of 4 spends $22,000 a year on health care, and even insured Americans are learning that a surprise bill could set them back thousands of dollars. On top of this, the Patient Protection and Affordable Care Act is under attack, and rampant burnout is harming our workforce and increasing costs.


There must be a better way.


Right on cue—in this election year—the American College of Physicians (ACP) released a bold and patient-forward series of articles outlining a new vision for U.S. health care (1). Appropriately titled “Better is Possible,” this vision statement is the result of a multiyear process to identify what ails our system and prescribe solutions. It all began with a simple question: What would a better health care system look like? To include multiple perspectives, ACP surveyed its members for input (receiving more than 1,000 responses) and involved all of its expert committees and policy leaders.


As a member of the ACP Council of Resident/Fellow Members, I was excited to preview and comment on these articles last year, and I encourage you to look at them now. Start with the summary document, and then cozy up with a warm beverage to read further. Yes, these papers are long and detailed, but as the Democratic debates have made clear, it’s hard to move beyond empty platitudes in a 90-second sound bite.


The call to action is organized around 4 central questions:

  1. Why do so many Americans lack coverage for the care they need?
  2. Why is U.S. health care so expensive and therefore unaffordable for many?
  3. What barriers to health care, in addition to coverage and cost, do patients face?
  4. How do delivery and physician payment systems affect costs, access, quality, and equity?

The authors—drawing on scientific literature, their own expertise, and the opinions of practicing clinicians—answer each of these questions, and then enumerate 10 vision statements to suggest a better way forward.


The major recommendation is that the United States embrace either a single-payer system or create a public option to ensure that all Americans have access to health care. Rather than endorsing one of these solutions over the other, ACP points to advantages and disadvantages of each, with single-payer offering the most cost savings but the public option being less disruptive to the approximately 180 million Americans who have private insurance.


This is a landmark recommendation from ACP—the second largest physician group in the country—and it is appropriately garnering wide media coverage. However, I found myself equally if not more interested in the report’s holistic consideration of factors affecting Americans’ health. Rather than treating social determinants as an afterthought and shying away from thorny cultural issues, the report dives into how gun violence, poverty, structural racism, and climate change can and do harm our patients. Dr. Stanley Goldfarb may not embrace the attention given to these issues, but those of us who recognize that there is more to disease than channelopathies will see a lot to like.


Of course, not all readers will agree with all of the statements made. Representing the ideas of 159,000 members is a tall task. I, for one, would have appreciated increased attention to health care information technology and the difficulty obtaining durable medical equipment for our patients. I also believe the articles missed an opportunity to explore how physician remuneration contributes to health care spending. Our "high salaries" are often scapegoated for increasing costs, and I think addressing the merits and limitations of this argument head-on could have made our other suggestions more credible.


Although you may have your own reservations about these policy recommendations, we can all agree that the status quo is unacceptable and better is certainly possible. The College has already done the hard work of charting a path forward while acknowledging that there is room for uncertainty and reasonable debate. Now, it’s time for the rest of us to channel our collective energy into disseminating, explaining, and building on this watershed publication. We have a lot to offer by sharing our expertise and informing public debate, and we should aim to be a part of solutions, rather than an obstacle to reform. If we wait for others to speak, we may not like the outcome, and our patients and workforce could suffer.



  1. Doherty R, Cooney TG, Mire RD, et al; Health and Public Policy Committee and Medical Practice and Quality Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: a call to action by the American College of Physicians. Ann Intern Med. 2020;172:S3-S6. [PMID: 31958804] doi:10.7326/M19-2411

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