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Instead, we advocate that the NHP fully subsidize the education of physicians, as well as that of nurses, public health professionals and other health care personnel. The NHP would cover all medically necessary prescription medications, devices and supplies. It would directly negotiate prices with manufacturers, producing substantial savings.

An expert panel would establish and update a national formulary, which would specify the use of the lowest cost medications among therapeutically equivalent drugs with exceptions where clinically required. Full drug coverage is an essential component of an NHP. Copayments reduce adherence to medications and worsen clinical outcomes. The NHP would, like other large purchasers, use its market clout and formularies to negotiate lower drug prices with manufacturers.

A single-payer system would trim administration, reduce incentives to over-treat, lower drug prices, minimize wasteful investments in redundant facilities, and eliminate almost all marketing and investor profits.

These measures would yield the substantial savings needed to fund universal care and new investments in currently under-funded services and public health activities — without any net increase in national health spending. As a result, U. Total expenditures under the NHP would be limited to approximately the same proportion of GDP as the year prior to its establishment. While the needed funds could be garnered in a variety of ways, we favor the use of progressive taxes in order to reduce income inequality — itself an important social determinant of poor health.

During a transition period, all public funds currently spent on health care — including Medicare, Medicaid, and state and local health care programs — would be redirected to the unified NHP budget. During the transition period, these additional public funds could be raised through a variety of measures, e. In the longer term, however, direct funding through progressive taxes would be fairer. By unburdening employers, the NHP would facilitate entrepreneurship while increasing the global competitiveness of American business.

The ACA embodies the hopes of many for a more just health care system. Nor will it eliminate underinsurance. Disturbingly, the ACA has facilitated the imposition of new out-of-pocket costs on Medicaid recipients, and the skimpy coverage provided by many of the plans sold through the exchanges codifies the trend towards higher cost sharing for the privately insured.

Moreover, care obtained outside of the narrow provider networks provided by many exchange plans is neither covered nor applied to the out-of-pocket cap. ACOs are now widely promoted as a solution to our health care problems. Under ACO arrangements, insurers offer bonuses to hospitals and medical groups if they reduce health care costs, and under some arrangements penalize them when costs exceed targets. Like the HMOs of a previous era, ACOs invert fee-for-service incentives to provide excess care, instead offering rewards for reducing care.

To counter the obvious risk that these inverted incentives may lead to the denial of needed care, ACO payment schemes invariably mandate extensive reporting of quality indicators, and withhold some payments unless quality targets are met. Unfortunately, experience warns that quality monitoring may not protect patients in a profit-driven medical environment. Such monitoring figured prominently in the seminal HMO proposal 31 that preceded the well-documented abuses of the s.

Many argue that rewarding providers on the basis of the value they create for patients, rather than the volume of care they deliver, will improve outcomes, contain costs, and foster innovation. Unfortunately, empiric support for this approach is lacking, and it rests on dubious assumptions about measurement and motivation. Despite decades of effort to develop inpatient risk adjustment, four widely used algorithms yield strikingly divergent rankings of hospital mortality performance.

Similarly, even excellent doctors who care for disadvantaged patients often score poorly on quality metrics. We face We face a historic crossroads in health care. One way would take us further down the path laid out by the ACA: The single-payer NHP that we advocate is a third path. It is the best way — indeed, the only practical way — to provide comprehensive care to all Americans that would be affordable over the long term.

Implementation will require a detailed transition process and pose novel problems; for instance, significant resources will be needed for job retraining and placement for displaced health insurance and billing workers. But those dislocations would be offset in part by increased employment in care delivery and in other sectors of the economy, since employers would be relieved of the burden of providing ever more expensive health insurance.

Overall, the NHP would entail far less disruption for clinicians and patients than alternative reforms. Free choice of doctor and hospital would become the norm, not a privilege for the few. Clinicians would continue treating patients in their practices, albeit with substantially reduced paperwork and administrative expenses.

The reforms we propose would improve the fairness and efficiency of medical care, but additional measures would be needed to address other critically important determinants of health. Global warming would remain a looming threat. Policies that attenuate glaring income inequalities and assure an adequate standard of living for all Americans are essential if we are to reverse widening income-based health disparities Similarly, the stain of racial inequality and racism must be addressed if we are to achieve health for all.

While the NHP would achieve savings on administration and profiteering, the benefits of these savings can only be realized if funds are redirected to currently underfunded health priorities, particularly public health Moreover, many problems within medical care would remain.

Regional health planning and capital allocation would make possible, but not assure, fair and efficient resource allocation; quality problems would persist; and areas such as long term and mental health care, and substance abuse will require new and creative solutions. Although an NHP would not solve these problems, it would establish a framework for addressing them. Over the past century, myriad health care reforms — most well-intentioned — have been proposed and attempted.

Yet continued reliance on private insurers and profit-driven providers has doomed them to fail. It is time to chart a new course, to change the system itself. By doing so, we can realize, at last, the right to health care in America. Explaining high health care spending in the United States: Commonwealth Fund Issue Brief. The Commonwealth Fund ,. Woolhandler S, Himmelstein DU. J Gen Intern Med.

Low-socioeconomic-status enrollees in high-deductible plans reduced high-severity emergency care. Delayed and forgone care for families with chronic conditions in high-deductible health plans. Health care use and decision making among lower-income families in high-deductible health plans. Medical bankruptcy in the United States, Nearly half of families in high-deductible health plans whose members have chronic conditions face substantial financial burden.

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The effect of copayments for prescriptions on adherence to prescription medicines in publicly insured populations; a systematic review and meta-analysis. Cost sharing in health insurance--a reexamination. Health care insurance, financial concerns in accessing care, and delays to hospital presentation in acute myocardial infarction.

Does free care improve adults' health? Results from a randomized controlled trial. Pharmacy benefits and the use of drugs by the chronically ill. Geographic variation in diagnosis frequency and risk of death among Medicare beneficiaries. Phasing out fee-for-service payment. Lessons from public long-term care insurance in Germany and Japan. Should Medicare adopt the Veterans Health Administration formulary? Costs of health care administration in the United States and Canada.

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