The U.S. Health Care System Is Ill and Needs a Bold New Prescription
Authors: Robert M. McLean, Douglas M. DeLong, Darilyn V. Moyer
Journal: Annals of Internal Medicine (2020)

Supplement: Vision for U.S. Health Care21 January 2020The U.S. Health Care System Is Ill and Needs a Bold New PrescriptionFREERobert M. McLean, MD, Douglas M. DeLong, MD, and Darilyn V. Moyer, MDRobert M. McLean, MDPresident, American College of Physicians, Philadelphia, Pennsylvania (R.M.M.), Douglas M. DeLong, MDChair, Board of Regents, American College of Physicians, Philadelphia, Pennsylvania (D.M.D.), and Darilyn V. Moyer, MDExecutive Vice President, American College of Physicians, Philadelphia, Pennsylvania (D.V.M.)Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M19-3712 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Every day, patients suffer the inadequacies of the U.S. health care system. These patients include, but are by no means limited to, the patient with recurrent hospitalization for diabetic ketoacidosis who cannot afford insulin, the woman with a small breast lump who forgoes mammography fearing that the copayments for evaluation will be beyond her limited budget, the patient with knee osteoarthritis in need of a joint replacement whose Medicaid insurance is not accepted by any orthopedic surgeon within a day's drive, the patient battling opioid addiction who cannot access addiction therapy, the patient plagued with collection notices for laboratory bills for tests not covered by insurance, and the many uninsured patients who wander from emergency department to emergency department because they lack a relationship with a primary care practitioner.The U.S. health care system is gravely ill, and the symptoms are many: Costs are too high, many people lack affordable coverage, incentives for hospitals and physicians are misaligned with patients' interests, primary care and public health are undervalued, too much is spent on administration at the expense of patient care, and vulnerable individuals face daunting barriers to care. Health care expenses are the leading cause of private citizen bankruptcies in the United States (1).The American College of Physicians (ACP) Ethics Manual states that it is physicians' "collective responsibility to advocate for the health, human rights, and well-being of the public.…They should work toward ensuring access to health care for all persons" (2). The ACP takes this responsibility very seriously, as reflected in its mission "to enhance the quality and effectiveness of health care by fostering excellence and professionalism in the practice of medicine." Consequently, the ACP has long advocated universal access to affordable health coverage (3) and has developed many policies over past decades aimed at reforming the U.S. health care delivery system. In 2009, the ACP supported the Patient Protection and Affordable Care Act, in large part because it decreased the number of uninsured Americans (4). Although the Affordable Care Act was not perfect, it led to increased coverage of nearly 20 million patients (5). Unfortunately, legislative actions have subsequently stripped away many Affordable Care Act provisions that helped to expand coverage. In recent years, significant changes related to the roles of private and public payers, the escalating cost of prescription drugs and other components of care, and the recognition that too many patients remain uninsured or underinsured have all led ACP leadership to recognize that the U.S. system is past due for a new vision.The ACP does not have all of the answers, but we have expertise in diagnosis and development of treatment plans for complex problems. Two years ago, the ACP Board of Regents directed its committees and councils to envision a better-functioning health care system that would provide universal access; control costs; decrease administrative complexities; and appropriately support primary care and, in particular, the specialty of general internal medicine. The position papers in this special collection (6–9) outline the ACP's vision for a better U.S. health care system. This vision is powered by ACP's commitment to an evidence-based approach to policy. The U.S. health care system is like a chronically ill patient, and ACP is proposing a new prescription. Simple market solutions have been unsuccessful elsewhere, and we do not believe that health care is a commodity. Issues of health are intensely personal, and care is not an item on a store shelf.The ACP presents 4 papers with a bold "New Vision" for health care. We are not surprised that when the ACP advocates policy that will have an impact on patients and physicians, some admonish the organization not to be political. Yet, to enact policy through the legislative and regulatory arms of government, one cannot avoid politics. Policy and politics are intertwined. Renowned German pathologist Rudolf Virchow stated it well: "Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution." Physicians must engage in the political arena to optimize care for our patients. However, patient care is not a partisan issue. The ACP's vision for U.S. health care is "ACP green," not partisan red or blue.References1. Himmelstein DU, Lawless RM, Thorne D, et al. Medical bankruptcy: still common despite the Affordable Care Act. Am J Public Health. 2019;109:431-3. [PMID: 30726124] doi:10.2105/AJPH.2018.304901 CrossrefMedlineGoogle Scholar2. Sulmasy LS, Bledsoe TA; ACP Ethics, Professionalism and Human Rights Committee. American College of Physicians ethics manual: seventh edition. Ann Intern Med. 2019;170:S1-S32. [PMID: 30641552]. doi:10.7326/M18-2160 LinkGoogle Scholar3. American College of Physicians. Access to health care. Ann Intern Med. 1990;112:641-61. [PMID: 2185676] LinkGoogle Scholar4. Stubbs JW; American College of Physicians. Letter to Majority Leader Harry Reid and Chairmen Max Baucus and Tom Harkin about H.R. 3590. 22 December 2009. Accessed at www.acponline.org/acp_policy/letters/senate_vote_ppaca_2009.pdf on 1 November 2019. Google Scholar5. Kaiser Family Foundation. Key facts about the uninsured population. 7 December 2018. Accessed at www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population on 1 November 2019. Google Scholar6. 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. doi:10.7326/M19-2411 LinkGoogle Scholar7. Crowley R, Daniel H, Cooney TG, et al; Health and Public Policy Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: coverage and cost of care. Ann Intern Med. 2020;172:S7-S32. doi:10.7326/M19-2415 LinkGoogle Scholar8. Erickson SM, Outland B, Joy S, et al; Medical Practice and Quality Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: health care delivery and payment system reforms. Ann Intern Med. 2020;172:S33-S49. doi:10.7326/M19-2407 LinkGoogle Scholar9. Butkus R, Rapp K, Cooney TG, et al; Health and Public Policy Committee of the American College of Physicians. Envisioning a better U.S. health care system for all: reducing barriers to care and addressing social determinants of health. Ann Intern Med. 2020;172:S50-S59. doi:10.7326/M19-2410 LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Richard M Fleming, PhD, MD, JD (FHHI-OI-Camelot); Tapan K Chaudhuri, MD (Eastern Virginia Medical School)FHHI-OI-Camelot; EVMS18 February 2020 American Health care is best when physicians – not lawyers and politicians – are in charge. All too often there is a knee reflex response to problems and in this 2020 election year, healthcare costs and proposed solutions are no different. The introduction of Medicare-for-All or a single payer system is one such knee reflex in response to addressing a health care system in financial crisis – a crisis produced by those who now conveniently claim to have the answer. As we consider this proposed Medicare-for-All approach let us ponder the healthcare consequences found in countries using Government controlled medicine including the financial crises these countries and their patients now find themselves in. While the American health care system consists of many of the best doctors and facilities for patient care in the world, the payment of that system has been built upon the policies driven by BigPharma and it's lobbyists in Washington; CMS - the lawyer driven health care system; and the lawyer run malpractice system resulting in too many physicians practicing CYA medicine, instead of focusing on the patient. All of which have driven healthcare costs up.Concern over medical costs has now become the NUMBER ONE concern for voters in this 2020 election year. CMS – the lawyer driven Federal Government directed healthcare system, decides what doctor you can see, what hospital you can be admitted to, what tests and treatments including drugs, you can receive, and how much will be paid for all of this. The consequence of this Government control of healthcare has resulted in many physicians being unable to afford to see CMS patients. Those doctors and hospitals that continue to take CMS patients can only afford to do so by compensating and increasing medical costs to other insurance companies and people who have no insurance. Absent this compensation, many of these doctors and hospitals would be unable to financially continue to provide patient health care. The dramatic increase in healthcare costs is the direct result of the imbalance produced by the need to compensating for CMS – Medicare and Medicaid.Healthcare costs will not be controlled by surrendering final control of medicine to the politicians, lawyers, courts and bureaucrats, which produced the problem. Improvement in healthcare costs should be restored through a free market healthcare system driven by physician outcomes and evidence-based medicine. Robert M. McLean, M.D., Douglas M. DeLong, M.D., Darilyn V. Moyer, M.D.American College of Physicians20 May 2020 Authors' Response In response to the comments from Drs. Fleming and Chaudhuri, the ACP "New Vision" papers are not simply a reflexive response in an election year to a "healthcare system in financial crisis. "Our healthcare system crisis is not just financial, but rather an ongoing lack of affordable and accessible care for all of our patients. It is a problem that has been present for decades and is worsening with no clear solution in sight as the Affordable Care Act has been slowly defunded and deconstructed. The ACP presented an analysis done methodically over the previous 18 months about health systems around the country and the world.The American payment system has become complex and convoluted for many reasons which include but are not limited to the pharmaceutical industry and a problematic medical liability system on which the respondents focus. ACP states the current payments from government payors are often too low for practices or hospitals to be sustainable and that leads to dysfunctional cost shifting.ACP policies do not suggest that any solutions should involve "surrendering final control of medicine to the politicians, lawyers, courts, and bureaucrats." Rather, the "New Vision" papers state the need for explicit input from physicians. Complicated problems are unlikely to have simple solutions. ACP's analysis of experience in other countries and in parts of our country has concluded that market-based solutions "fall short of achieving our vision of affordable coverage and access to care for all." Author, Article, and Disclosure InformationAffiliations: President, American College of Physicians, Philadelphia, Pennsylvania (R.M.M.)Chair, Board of Regents, American College of Physicians, Philadelphia, Pennsylvania (D.M.D.)Executive Vice President, American College of Physicians, Philadelphia, Pennsylvania (D.V.M.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-3712.Corresponding Author: Robert M. McLean, MD, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, [email protected]net.Current Author Addresses: Drs. McLean, DeLong, and Moyer: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.This article is part of the Annals supplement "Better Is Possible: The American College of Physicians' Vision for the U.S. Health Care System." The American College of Physicians was the sole funder for this supplement. Nextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byComprehensive Geriatric AssessmentComprehensive Geriatric AssessmentComprehensive Geriatric AssessmentLeaning Into Whole Health: Sustaining System Transformation While Supporting Patients and Employees During COVID-19Ethical Use of Electronic Health Record Data and Artificial Intelligence: Recommendations of the Primary Care Informatics Working Group of the International Medical Informatics Association 21 January 2020Volume 172, Issue 2_SupplementPage: S1-S2KeywordsDisclosureHealth careHealth care policyOpioid addictionPatientsPrimary careResearch laboratoriesSurgeonsVision ePublished: 21 January 2020 Issue Published: 21 January 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...