Health care is a human right. Achieving universal health coverage for all U.S. residents requires significant system-wide changes in financing of health care. The best, most efficient, equitable health system is a public, single-payer (SP) system. The rapid growth in national health expenditures can be addressed through a system that yields net savings over projected trends by eliminating profit and waste. With universal coverage, providers can focus on optimizing triage of services rather than working within a system covered by payers who have incentives to limit costs regardless of benefit. With SP systems, people act as their own insurers through partnerships with provider organizations wherein tax dollars work for everyone. Consumer choice is then based on best care to meet needs with no out-of-pocket payments. SP is the best option to ensure equity, fairness, and priorities aligned with medical needs. This approach benefits public health, as everyone will have universal access to needed care, with treatment plans based on what works best for the patient. Clinics and hospitals will be free to provide appropriate treatments based on need. Hospitals will accept all patients, with care reimbursed equally for all. Resolving the great discrepancy in coverage for mental health and substance use disorders relative to medical and surgical services is more likely in an SP model. Patients will partner in their care, receiving diagnosis, treatment, and prevention services without facing cost barriers. We will build a healthier nation, saving lives and reducing financial burdens while addressing inequities rooted in social, demographic, mental health, economic, and political conditions.
Relationship to Existing APHA Policy Statements
The proposed policy is an update and extension of the following APHA policy statements:
APHA Policy Statement 20007: Support for a New Campaign for Universal Health Care
APHA Policy Statement 200911: Public Health’s Critical Role in Health Reform in the United States
APHA Policy Statement LB20-06: The Importance of Universal Health Care in Improving Our Nation’s Response to Pandemics and Health Disparities
The proposed policy is supported by the following previous policy statements:
- APHA Policy Statement 6922: A Medical Care Program for the Nation (archived)
- APHA Policy Statement 7018: A National Program for Personal Health Services (archived)
- APHA Policy Statement 7107: National Health Insurance - A Choice Between Imperfect Alternatives (archived)
- APHA Policy Statement 7124(PP): Health Maintenance Organizations (archived)
- APHA Policy Statement 7405: Long Term Care Under National Health Insurance (archived)
- APHA Policy Statement 7601: Committee for a National Health Service (archived)
- APHA Policy Statement 7602: Health Insurance for Preventive Services (archived)
- APHA Policy Statement 7605: Establishment of a National Health Service (archived)
- APHA Policy Statement 7609: A Sound Basis for a National Health Program
- APHA Policy Statement 7628(PP): Improving the Organization and Financing of Ambulatory Preventive and Primary Health Services in Today’s Economy (archived)
- APHA Policy Statement 7734(PP): Criteria for Assessing National Health Service Proposals (archived)
- APHA Policy Statement 7809: National Health Insurance (archived)
- APHA Policy Statement 7901: Vision Care in a National Health Program (archived)
- APHA Policy Statement 8804: State Health Care Initiatives for the Medically Uninsured (archived)
- APHA Policy Statement 9418: Children with Special Health Care Needs under Health Care Reform (archived)
- APHA Policy Statement 9502: Toward a Comprehensive Universal National Health Program (archived)
- APHA Policy Statement 9702: Protecting Health Care Accessibility and Quality in a Profit-Oriented Marketplace (archived)
- APHA Policy Statement 9716(PP): The Issue of Profit in Health Care (archived)
- APHA Policy Statement 9934(PP): Protecting and Strengthening Medicare: Financing and Prescription Drug Issues (Position Paper)
- APHA Policy Statement 20006: Making Medicines Affordable: The Price Factor (Position Paper)
- APHA Policy Statement 201013: American Public Health Association Child Health Policy for the United States
- APHA Policy Statement 20111: Improving Access to Over the Counter Contraception by Expanding Insurance Coverage
- APHA Policy Statement 20153: Universal Access to Contraception
- APHA Policy Statement 20189: Achieving Health Equity in the United States
Rising per capita costs of health care in the United States: National health expenditure (NHE) in the United States grew by 4.6% in 2018, to $3.65 trillion ($11,172 per capita). This accounted for 17.7% of the gross domestic product (GDP) at the time.[1,2] The United States spends the most by far on health care among all 36 countries in the Organisation for Economic Co-operation and Development (OECD), both as a proportion of GDP and per capita.[3,4] Despite using fewer health care resources, the country spends $2,000 more per person than the next-highest-spending country, Switzerland, and nearly twice as much per capita on health care as the median for OECD countries.[3,5] The pricing system is inherently the single greatest driver of health care costs while providing fewer key health resources. There is also a large and widening gap in the prices that public and private payers are charged for identical services, which indicates that the rising total NHE is primarily driven by private health care insurers and pharmaceutical expenditures in particular.
U.S. pharmaceutical expenditures: U.S. prescription drug expenditures reached $335 billion in 2018, a 28% increase in a decade. The growth is expected to continue and is projected to increase 67.3% to $560 billion by 2028. In 2018, annual per capita U.S. prescription drug spending was $1,221, well above that of the United Kingdom ($526), Sweden ($534), and Germany ($884). Prescription drug expenditures alone will represent 19.7% of the U.S. GDP by 2028. Increased prescription drug expenditures will be largely driven by manufacturers’ increases in drug prices.
One of the distinctions in U.S. prescription policy is the burden of drug costs borne by patients as out-of-pocket costs. For instance, the Medicare Part D prescription drug benefit has no cap on out-of-pocket costs for beneficiaries. Drug prices are significantly higher in the United States than in any other OECD country. By contrast, the United Kingdom requires little or no cost sharing by patients. Countries that have implemented single-payer (SP) financing systems offer multiple examples of ways to reduce drug prices, including harmonization of pharmaceutical coverage, pricing over a single formulary or across formularies, exclusion of added administrative costs from pharmacy benefit managers, and leveraging of scale to negotiate prices with suppliers.
Efficiency in the United States relative to single-payer countries: While the United States spends more per capita on health care than any other OECD country, the additional spending contributes little value from either an economic or a health outcomes perspective.[3,5,10] Countries with SP spend less while their populations live longer, healthier lives. The average life expectancy and the burden of adverse health outcomes for almost all major chronic illnesses (apart from cancer treatments) in the United States also fall short of the OECD median.[7,10,11]
As far back as 2003, administrative costs of health care (including insurance, reimbursement, and other administrative tasks) accounted for nearly a third (31%) of the U.S. NHE.[12,13] By 2011, the country still spent more of its NHE on the administrative costs of the reimbursement system than any other country (8%–18% of health care spending).[4,5,14] Analyses between countries with a variety of health insurance systems showed that both SP (most optimal) and “two-tiered” systems, such as those in France and Japan, operated with lower administrative costs than the insurance-mandated systems of the United States and Switzerland. A two-tiered system involves a public insurance-and-delivery system and another based on private health insurance. Notably, the Swiss system (with the second highest NHE per capita of OECD countries) demonstrated significantly lower administrative costs than the United States, indicating that there is room for correction even within public-private systems. According to one analysis updating the 2003 analysis through 2017, excess administrative costs in the United States relative to Canada (SP) have persisted and still account for 17% of the NHE.
Excess U.S. spending is driven by the availability (not utilization) of medical technology and broad service pricing as opposed to a higher rate of health care consumption. Health care services are provided at a less efficient cost for equivalent levels of care. Neither the quantity nor quality of care is improved by the increase in U.S. spending, whether per capita or as a percentage of the GDP. The United States funded 50.9% of its NHE through private payers in 2016, as compared with the OECD median of 25.0%. While public spending on health care is also higher than in most OECD countries that have a majority (above 80%) public payer system in place, private insurers drive the largest segment of excess cost in the U.S. health care system. Furthermore, the gap between publicly and privately funded health care prices in the United States widened from 2000 to 2016, with the Medicare Payment Advisory Commission estimating that private insurers pay prices 50% higher than Medicare payments for identical services. Reducing fractionalization through consolidation of private insurers into fewer, larger, private payer organizations does not necessarily lower plan costs for individuals (premiums, copayments, deductibles) or the overall system. Instead, these mergers tend to shift profits away from the delivery system, providing cost savings to insurers without generating cost savings to society.
Access and equity issues: Lack of insurance is the primary systemic barrier to health care access in the United States, demonstrating that multiple financing systems fall short of universal coverage. Universal health coverage means that all people have access to the health services they need, when and where they need them, without financial hardship. It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care.
In addition, the high cost of health care in the United States exacerbates existing health care disparities that result in premature morbidity and mortality and intersects with race, social and socioeconomic status, age, and disability. One feature of the United States health care system is the prevalence of high-deductible health care plans. These plans, intended to incentivize patients to not overutilize health care, disproportionately affect individuals with low incomes. In the period from 2003 to 2014, when high-deductible health plans proliferated and overall increases in U.S. health care spending slowed down, health care expenditures for the wealthiest quintile grew by 20% while falling by 3.7% in the lowest quintile group, despite this group having the worst health outcomes. In addition, since health care expenses are not proportional to personal income, individuals with low incomes pay a larger percentage of their household income toward health care costs. Thus, the private health insurance market exacerbates wealth inequality by functioning in a manner similar to a regressive tax. A survey of health care expenditure data showed that this system effectively redistributes 1.7% of total income from individuals with lower incomes to those with higher incomes.
These plans produce devastating financial and health outcomes for Americans with low incomes. One American study showed that, among patients with cardiovascular disease, almost 60% of those with low incomes faced financial hardship or were unable to pay their medical bills, resulting in food insecurity and inability to take prescribed medications. Even among the insured, close to 40% of patients with insurance still faced financial hardship due to the out-of-pocket expenses associated with their plans. One study revealed that high-deductible plans led to delays in diagnosis and treatment of breast cancer in women with both high and low incomes, although the effect was more pronounced among those with low incomes. Another study showed that high-deductible plans reduce utilization of potentially high-value care such as preventive and outpatient medical visits.
Despite the passage of the Affordable Care Act (ACA), there are also persistent racial health disparities in the U.S. uninsured population.[24,25] In 2019, the rates of uninsurance among adults not qualified for Medicare were 7.8% for White, 11.4% for Black, and 20.0% for Hispanic individuals. This leads to racial and ethnic disparities in receiving recommended care; for example, one study showed that Black, Hispanic, and Asian individuals with diabetes were 23% to 53% less likely to receive annual hemoglobin A1c tests. Lack of universal health care also exacerbates health inequities based on citizenship and immigration status. One study revealed that 40 states withhold coverage of dialysis for patients with end stage renal disease (ESRD) who are undocumented immigrants. In these states, ESRD patients can access dialysis only on an emergency basis. The same study showed that, in states that did cover dialysis, there was a 14% absolute reduction in mortality and a $5,678 reduction per patient in total health care costs associated with providing this coverage to people with ESRD who are undocumented. High out-of-pocket expenses and lack of universal coverage exacerbate health disparities among people with disabilities. According to one study, older adults with disabilities are more likely to delay seeing a doctor, despite having insurance, because of out-of-pocket expenses. Multipayer insurance systems exacerbate segregation along economic, racial, immigration status, and disability lines by creating financial incentives to take care of particular patients based on their insurance status. For example, one study showed that academic medical centers, which are widely regarded as providing the highest quality of care, are much less likely to treat racial minority, Medicaid, and uninsured patients in New York City.
An examination of the current state of behavioral health care in the United States reveals even larger gaps. This is an area that has suffered from lack of financial support historically and also from the compounded cumulative negative behavioral and primary health effects of COVID-19 since 2020. Making single-payer reform work for behavioral health is possible by revisiting the lessons learned from Canada and other countries that have adopted SP systems.[15,31]
Evidence-Based Strategies to Address the Problem
APHA has called for universal coverage of health care for all U.S. residents for decades. This has included calls for a unified, nationally coordinated, and nationally funded approach (i.e., SP) to health care expenditure since the late 1970s. This goal for coverage, met by the majority of other developed countries in the world, is no longer in question, but the best approach is still being debated in policy and political spheres. In this debate, the evidence in support of SP has grown rapidly in the past decade. In addition, recent polls conducted with broad clinician samples have shown that a majority of doctors “strongly support” policy reform to implement SP. The American College of Physicians (ACP), the second largest provider organization in the United States, has also recommended that U.S. policy initiate a transition to a system of universal coverage, through either an SP or a public payer choice capable of supporting universal coverage.
Single-payer health system: In 1993, the APHA leadership and executive board developed 14 Points on Health Reform in order to organize and guide the essential criteria for reform of public health. These points continue to guide the principles of the public health field in developing proposals for national health reform. Overall, the evidence clearly demonstrates that SP is the most optimal structure for health reform in order to support these principles.
Designing, implementing, and transitioning to a single-payer system may entail significant changes in the sources and extent of coverage, provider payment mechanisms, and financing of health care services in the current U.S. health care system. The federal government could administer some functions of the single-payer health plan at the national level and delegate other functions to state and local governments. Alternatively, state governments could administer the single-payer health plan with broad federal oversight. Single-payer system implementation can be done in incremental stages starting with people who have health insurance coverage through various public sources (Medicare, Medicaid/ Children’s Health Insurance Program, Veterans Administration) who could continue to have such coverage under a single-payer system, although covered benefits and cost-sharing agreements might change. People who have private insurance (primarily employer-based insurance) may enroll in the public plan and might retain private coverage that supplements the coverage under the public plan, preserving public financing and redistributing revenues among the pools to attenuate risk selection. With regard to health insurance, several countries progressively transitioned from multiple large insurance pools to single-payer systems while building the financial and administrative capacity to establish a single insurance pool. An alternative approach would be to first standardize the health plans that can be offered in the market. All of these approaches may be slowed by legal challenges from states or business interests, but they each reflect a lower risk as changes to taxation and federal program reimbursement do not involve the constitutional rights issues posed by individual mandates to purchase private plans.
Overall, a single-payer system will significantly simplify revenue collection and benefit payouts to a single agency. Countries with single-payer systems experience significant cost savings over their multipayer counterparts through streamlining of billing and insurance procedures, creation of a more equitable and predictable spread of risk throughout the entire populace, and leveraging of bargaining power to control costs.
International evidence of quality and cost with SP: In Taiwan, the national health insurance system was introduced in 1994; the system was modeled in part on the U.S. Medicare program, although it was created to cover all citizens and foreign residents of the country, boasting a 99.9% enrollment rate. Benefits are uniform and comprehensive, covering hospital care, physician care, pharmaceuticals, and other services. Subsequent to 1994, the health system in Taiwan adopted both pay-for-performance measures and a global budget mechanism to improve quality while reducing cost of care.
Patients in Taiwan can choose their doctors or hospitals freely instead of being limited to a certain network of providers as in the United States. This enhances access to care for disadvantaged populations but also encourages providers to improve the quality, and thereby the value, of care to attract patients. Also, the government sets rates; thus, collaborating with other providers increases every provider’s market share and simultaneously mitigates the consequences of fragmentation. Beneficiaries with low incomes under the single-payer health system in Taiwan can either receive exemptions from cost sharing or directly receive their medical care. Enrolling individuals with low incomes and providing them with public health services may prevent them from using costly and unnecessary emergency care, which affects both provider and patient more heavily. It may also discourage private insurance companies and providers from securing profits through reducing coverage or even rejecting beneficiaries with low incomes.
The Canadian health system, administered by the provinces, is a funding partnership between the provincial and federal governments (similar to the shared state and federal funding in the United States). Provider, diagnostic, and hospital costs are covered based on a federally negotiated fee schedule, and providers are not allowed to receive private payments at or above those costs for any covered services. Private insurance exists only to cover services not already covered by the national system. Provinces administer billing and reimbursement services, but these services must be comprehensive (defined by the province), universal (citizens and legal residents), portable across provinces, and accessible (which means no co-pays or other user fees). Comparative analyses of physician utilization in Canada and the United States demonstrate higher utilization rates among populations that are sicker and have lower incomes in Canada, suggesting that more equitable allocation of resources in the United States could lead to improved public health.
Australia provides coverage through a hybrid SP universal health system (Medicare) available to all citizens and permanent residents. The costs of publicly funded primary and other basic health services (67% of all health spending) are shared by national, state, and local governments, with the remainder paid through individual and employer contributions. Australia and other countries using a hybrid approach mandate co-pays or deductibles for additional, private plans in order to manage use of specialist and other high-cost services and employ electronic medical record systems to track patient utilization patterns.[37,45,46]
Financial feasibility: The economic benefits of an SP system are rapidly realized by reducing the high administrative costs, primarily billing- and insurance-related costs, in the current U.S. health delivery systems, even when accounting for expanded coverage among those currently uninsured and residing in the country.[5,47] These costs emanate from the use of multiple differing insurance companies, allowable charges, reasons to deny care, coding, provider network negotiations and care restrictions, deductibles, and co-pays.[37,47] Furthermore, system-wide cost savings are realized by eliminating the processes for collecting co-pays and out-of-pocket expenses from patients.[37,48] One review estimated a mean of $556 billion in potential annual savings. Within the estimated increased federal expenditures required to support universal coverage through a public SP is the offsetting cost transfer from fewer private sector charges and projections of further increases in costs under the status quo. In a review published by the RAND Corporation, SP plans offering universal and comprehensive coverage models were projected to generate a total net savings of $121 billion annually to the NHE. Certain models with supplemental insurance options have demonstrated reductions in annual NHE by $211 billion and federal expenditures by $40 billion, even without the theorized savings from administrative efficiency. A more recent economic review showed that 20 of 22 SP proposals from the past 30 years would provide net savings within the first several years if implemented in 2020. Relative to the projected growth in health care costs under 2020 conditions and trends, all of these proposals would offer longer-term net savings.
As seen during the COVID-19 pandemic, the health of the nation relies on creating a universal, efficiently coordinated system that improves access, eliminates disincentives to preventive care, and fosters access with a streamlined approach to universal coverage. Indeed, a single-payer health system is not only financially feasible but also the most fiscally viable approach for all.
Reducing national pharmaceutical expenditures: A national drug formulary is an important tool of universal single-payer health care systems (e.g., the 2013 Medicare for All Act,[49,50] intended to rein in ever-increasing U.S. drug expenditures). A national formulary can achieve reduced drug expenditures in two ways. First, it restricts duplicative and unnecessary medications within a class of drugs while allowing waivers to provide access for the occasional exception.[49,51] Second, by supporting price negotiation at the national level, manufacturers will have substantial incentives to be included in the formulary drug category. The Veterans Administration health system exemplifies a national formulary system with a public health perspective that has been shown to change physician behavior favorably while providing substantial cost savings through price reductions from manufacturers.[49–51]
Access and equity strategies: An SP system creates new opportunities to improve racial health disparities beyond the impact of eliminating differences in rates of insurance. An SP that includes coverage for workplace injuries and illnesses could eliminate cost shifting within the workers’ compensation system that currently burdens workers with 50% of the costs, adding inequality to injury. SP would also address the socioeconomic disparities that have been described in our health care system. People who are uninsured and underinsured are more likely to have delays in medical care. Medical debt is also associated with housing instability and homelessness. Because a single-payer health system would create health care savings by creating a more efficient administrative system, as a matter of health equity, some of these savings can and should be used to address additional ways to tackle health disparities outside of insurance.
A single-payer health care system would also address the socioeconomic disparities that have been described in the United States. An SP that breaks down financial barriers to care would help resolve rationing of medical care based on socioeconomic status. A study of health care expenditures and finance in Canada showed that the country’s SP reduced income inequality between income groups by 16%, solely through more equitable health care utilization.
Clinical factors are also a source of inequities in health care services in insured populations. For example, coverage of mental health and behavioral services has not been on an equal footing with medical and surgical services in the U.S. for-profit health insurance environment. Since 2008, federal law (Mental Health Parity and Addition Equity Act) has mandated insurers to provide mental health coverage equivalent to medical surgical coverage. While substantial gains in parity have been made since the passage of the Affordable Care Act, the challenge of real mental health parity in regulating managed care for mental health remains. Publicly financed health care is far more likely to achieve real parity than a for-profit insurance industry.[4,54]
While an SP universal health care system would not immediately eliminate all of the health disparities outlined above, it would address many of the disparities caused by lack of insurance and out-of-pocket expenses, which also lead to reduced utilization of high-value, lower-cost care.[3,27,55] In addition, it would incentivize a public health response focused on reducing disparities in order to reduce the costly care that results from the acute and chronic diseases related to health disparities.[3,4,27,55]
Improving the value of care: SP health care systems have the ability to emphasize chronic and preventive care. As discussed above, enrolling individuals with low incomes in comprehensive health benefits in Taiwan decreases the need for costly emergency care. Providing comprehensive health benefits can direct patients toward less expensive scheduled care, as discussed earlier in the example of coverage of dialysis being associated with lower health care costs due to fewer emergency dialysis visits. An SP system should include funding for strategies to improve access to primary care across the country in order to shift care to low-cost, higher-value primary care. As discussed above, under the current system with high out-of-pocket expenses even among the insured, some patients are less likely to fill prescriptions or obtain needed preventive care, deferring costs. An SP system aligns the interests of the national insurer to cover preventive care upfront in order to avoid the need for costly care later.
Along with improving access to higher-value care, SP has the potential to reduce health care costs by altering payment structures to incentivize high-value care. There have been many proposals regarding alternative payment structures for health care providers to improve the value of care delivery. Although the payment structure for hospitals and physicians is not synonymous with an insurance system, these issues are closely entwined. Single-payer health insurance systems in other countries have used both fee for service (FFS) and capitation models for health care provider reimbursement. As an example, Taiwan implemented an FFS reimbursement model when it first transitioned to a single-payer health insurance system but introduced capitation to reduce the volume of care being provided as problems arose.
Evidence for the ability of capitation alone to make health care more efficient is mixed. Some studies have revealed that providers in an FFS method tend to induce more demand, for example increasing elective hospital admissions, whereas other studies have not shown that an effect. Many capitation models attempt to adjust payments by baseline health characteristics of patients or populations to minimize physician “cherry picking” of healthier patients who need less health care and thus are less likely to reach their capitation rate. Within the current U.S. system, evidence for the benefit of capitation in some of the accountable care organizations that have adopted this payment model is mixed. There has been some concern that despite efforts to avoid negative selection of unhealthier patients or of communities that traditionally suffer from health care disparities, accountable care organizations might still be less likely to profit from accepting such patients. In the absence of strong alternative evidence, value-driven payment models can and should continue to be studied after the implementation of universal health care through an SP financing model, recognizing that any payment structure to physicians and hospitals might operate differently under a new insurance system. The competitive disincentives that undermine capitation models in the current U.S. system are expected to be alleviated when all providers are held to the same reimbursement schedules and risk pools.
Education and advocacy: The scientific and economic (typically peer-reviewed) debate on SP reform is characterized by caveats[55,61] or political rationalizations[55,62] against the larger, generally overwhelming economic evidence. However, the public debate on SP reform is both more wide-ranging and more divisive in tone, taking on partisan political rhetoric.[63,64] Providing clear information from the economic debate to the public debate about the actual scientific evidence, including the caveats and political complexity of reform, is a vital step toward successful SP system transformation.
Education and advocacy campaigns directed toward the public[65,66] and representatives of the legislative and executive branches of government,[67,68] via multiple communication media and forums, have successfully demonstrated that communicating facts about policy effectiveness from trusted sources can produce shifts in public and political opinion toward the evidence over time. This can anchor the public and political debate on the details of how best to implement SP reform and move the focus away from the unfounded arguments and rhetoric[61,63] that are used to manipulate public opinion away from the evidence.
Political barriers: Calls for universal health care in the United States have been made since the beginning of the 20th century, and the legislative beginnings of the SP movement have their origin in the Wagner-Murray-Dingall bills of the 1940s to create a national health insurance system.[55,69] The fact that decades later the United States still does not have SP is a testament to the significant political barriers to implementing such a system. Lessons from history can be illustrative. The national health insurance bills of the 1940s and 1950s faced significant opposition from the American Medical Association (AMA), which launched widescale public opinion campaigns against nationalized health care using the language of the “Red Scare.”[55,69] However, opposition from medical provider groups such as the AMA and ACP has reversed course in recent years.[33,34,70]
Despite this reversal, significant opposition to SP remains among some physician groups that are important stakeholders in health policy reform. Although polls show support for SP among the general population, that support might not withstand the scrutiny the policy would receive if it were to have a serious chance of passage. For instance, one survey showed that support for the ACA decreased across many different polls after it was initially passed but before many of the provisions took effect, suggesting that the increased scrutiny of the bill in that period increased opposition.
Market forces and barriers: It is a common justification for the higher spending in the U.S. health care system that the outsized costs paid to pharmaceutical and medical technology industries in the U.S. market incentivize the greatest innovation and highest quality of care for the country’s citizens. Vested interests will also propose that market forces between private payers and providers create the best source of innovation in care delivery models through competitive pressures.[55,61,63] However, those same innovations drive the annual rise in excessive spending rates year after year. High inputs, such as material costs, only widen the disparate impact of health care–related debts in low- and high-income strata. Furthermore, government-administered health care financing can still direct the system through statutes and payment models incentivizing innovation, based on value-based metrics to achieve the most cost-effective care. The competition between provider organizations is not diminished by a level playing field in terms of reimbursement and incentive models. In fact, SP financing will only improve the quality of competition. There are other driving forces that affect pharmaceutical prices, such as regulatory costs. In fact, the general disadvantage of U.S. pharmaceutical pricing is that the prices are higher due to the lack of regulation surrounding the process.[15,47] SP provides the opportunity for pricing negotiation by federal regulators, which is currently not permitted, for both pharmaceuticals and other medical technologies. It also places the greatest possible leverage in the hands of the consolidated payment system, which will inherently improve market competition and pricing strategies and simultaneously shift the cost share of research and development operations to other large economies around the world.
In addition, critics point to the threat of rationing of health care, long wait times, and a lack of choice of health care providers.[55,61,63] As evidence that health care providers will constrict program availability, these voices sometimes point to anticipated increases in health care demand from individuals newly insured and lower reimbursement rates from Centers for Medicare & Medicaid Services (CMS) programs relative to private insurance providers.[61,64] However, in international comparisons and economic model projections, there is no evidence that adopting SP financing will lead to rationing or wait times for time-sensitive services.[3,4,15,55] Countries with SP systems do not ration primary care services or require wait times outside of elective procedures.[3,15,41] These countries also have high-functioning economies that are not made less wealthy through their support of accessible, efficient health care.[4,7] Currently, the U.S. system rations health care by withholding care from those without sufficient economic resources to access the system. Ironically, provider choice is a hallmark of the current siloed system, with many risk pools and individualized contracts between payers and providers that would be remedied by an SP financing system.[3,14,55]
Infeasibility of a single-payer health system due to cost: The primary argument in political circles is often that SP will cost the federal government more money, increasing the federal mandatory budget and leading to higher taxation or deficit spending (or both).[55,61,63] Estimates for expanding Medicare to provide universal coverage range widely, but a cumulative cost of $32.6 trillion in the first 10 years after implementation (2022–2031) is often estimated. Although there are likely to be increased federal expenditures associated with the adoption of SP, projections must also incorporate the significant reduction in costs generated by private sector payers and clients and the continued growth in health care spending trends under the status quo (see the Evidence-based strategies section). Adoption of an SP system is actually projected to both reduce annual net health care expenditure and improve the progression of the health care cost burden by income level, improving inequities in access. This impact is reflected in the lower per capita costs of coverage in every country with SP.
There are those who may suggest that adoption of a universal SP health payment system would increase the number of undocumented immigrants entering the country and seeking coverage under the new system, thereby increasing the overall NHE as a result of coverage expansion. However, neither international economic comparisons nor health service research studies have revealed evidence of changes in immigration patterns (documented and undocumented) in countries that transition to SP health delivery systems.[12,29,41,42,47] As unlikely as this shift might be, economic projections have shown that the cost savings from SP reform are significant enough to outweigh the cost of expanding coverage to currently uninsured populations, with a significant margin remaining.[4,5] It is also suggested that the transition to an SP system will have negative impacts on the medical insurance and pharmaceutical industries. While the transition may lead to reduced positions in medical insurance organizations in the short term, these organizations are already developing plans to redirect their business models toward supplemental insurance plans and roles that assist with tasks such as innovating care delivery models, care navigation, and managing care for high-risk patient pools, roles in which those organizations already excel. The pharmaceutical market will naturally balance the costs of innovation across more economies if the United States negotiates prices and implements regulatory reforms.
Sufficiency of incrementalism: Historically, incremental expansion of existing coverage mechanisms has been the traditional approach to policy development in the United States. This approach has been advocated by some in the fields of medicine, health policy, and public health as a more feasible means of making asymptotic progress toward universal coverage. In particular, the argument has been made that SP reform legislation has not succeeded so far because it is not a realistic or achievable goal and that smaller reforms with a greater likelihood of adoption are preferable. However, evidence shows that other countries have had successful transitions to systems that provide universal coverage or have nationalized health care financing through single, large, coordinated legislative efforts.[36,73] Moreover, a recent U.S. survey showed that similar levels of debtors (a majority) before and after the implementation of the ACA had medical expenses contribute to or cause their debt, suggesting that incremental reforms have not fixed this problem of social and economic disparities in access.
Since the passage of the ACA in 2010, the landscape of health care reform has been fundamentally altered. The ACA was ambitious in its goal of increasing rates of insurance coverage, attempting to bend the curve of rising health care costs and improve the quality of health care. Under the ACA, the rate of uninsurance reached a historic low of 8.8% in 2016, largely due to expanding Medicaid to include an additional 12 million people who receive insurance through Medicaid. After adjustment for inflation, annual NHE (all sources) grew at a rate of 2.7% from 2003 to 2010 and 2.8% from 2010 to 2018, indicating that the ACA has not made substantial inroads into improving health care spending.
We also know that the scope of coverage with regard to in-network behavioral health services became more comprehensive from 2013 to 2014. This reflects the positive change that occurred when the ACA and the parity requirements went into effect. Coverage appeared to improve when insurance companies reduced their exclusion lists for behavioral health conditions. In addition, knowledge of benefits returned from enhanced coverage of behavioral health conditions remains a key piece of the puzzle for optimization of the existing ACA coverage mandate.
As far as improving quality of care, the ACA also launched the Hospital Readmission Reduction Program, which incentivizes higher-quality care in order to reduce readmission rates at hospitals. However, some studies have questioned whether this program reduces readmissions at all, let alone improving quality of care. It has been suggested that many of the successes of the ACA have come from increasing access to insurance.
However, at the same time that Medicaid has expanded, the proliferation of high-cost insurance plans has grown as well. Health insurance premiums increased 4.6% in 2017 and 2018 relative to a 2.6% median increase among OECD countries.[1,2,75] According to a 2016 survey, 45% of uninsured respondents identified cost of care as the reason they did not have coverage. In addition, 44% of people with marketplace plans are considered underinsured due to the high cost of out-of-pocket expenses such as deductibles. In fact, the average deductible for a silver plan on HealthCare.gov increased from $2,425 in 2014 to $4,500 in 2020.
Waiting for future incremental gains based on the ACA provides an insufficient path toward universal health coverage. Prior to the ACA, studies estimated that almost 45,000 Americans died each year due to lack of insurance. A more recent review of available evidence concluded that the odds of death among people with insurance were between 0.71 and 0.97 relative to those without insurance. With the number of uninsured people expected to reach 31 million by 2020, any delay in achieving universal coverage will cause unnecessary and unacceptable mortality.
Not only are incremental approaches to universal health care too slow, but they are also politically vulnerable, as exemplified by the ACA. There have been more than 50 attempts to repeal the ACA in the House of Representatives since the passage of the law. In addition, many of the potential gains of the ACA have been undermined by states using work requirements to reduce Medicaid eligibility. While unsuccessful, there have also been many legal challenges to the law that have gone to the Supreme Court, which could potentially overturn the ACA.
APHA joins other national and international organizations in declaring that health care is a human right.
Furthermore, APHA holds that a national SP plan is the optimal design for simultaneously improving health and lowering the cost of care in the United States. Therefore, APHA joins Physicians for a National Health Program, Public Citizen, the Congressional Black Caucus, the American College of Physicians, the American Medical Association’s Medical Student Section, the American Medical Student Association, the American Medical Women’s Association, the American Nurses Association, and other national and international organizations in calling for legislation and administrative policy reforms to implement a national SP system.
1. Congress to enact policies directing:
- CMS to expand Medicare and Medicaid to provide universal coverage of a harmonized package of health care services (including vision, hearing aids, and behavioral health, dental, and long-term care) and pharmaceuticals without exception — regardless of race, sexual orientation and gender identity, citizenship, residency, or carceral system or institutional status — to include all of those living in the United States
- CMS to expand Medicare and Medicaid to provide reimbursement financing using a whole health focus on parity among medical, surgical, and dental care and, especially, treatment for mental health and substance use disorders
- The removal of any and all statutes, laws, rules, regulations, policies, or practices inconsistent or in conflict with universal coverage by CMS programs, including the elimination of all deductibles and copayments, so that there are no financial barriers in accessing health care
- Appropriate budgetary and revenue collection reforms of federal health care financing and CMS administration policies to create and sustain a single funding mechanism to support a whole health focus on comprehensive, universal coverage by U.S. health care providers
- The Department of Health and Human Services (DHHS) and CMS to regulate, monitor, and report on health disparities as an accountability mechanism
- State and local health care system reimbursement policies to become tied to measurable patient-centered outcomes and health equity targets
- Funding and technical assistance to be provided to state and local jurisdictions and individual health care provider organizations to:
a) reform their reimbursement practices to adjust for billing practices under an SP system
b) implement health disparity screening and reporting systems at all levels
- The creation of standards, timelines, and milestones for progress toward full interoperability of health care provider data systems across the United States
- Funding for DHHS and CMS to provide technical assistance and direct support to underserved or underresourced health care providers (e.g., low-resource tertiary care centers) to implement interoperability standards
- DHHS to update and strengthen privacy practices and the data security infrastructure for CMS while supporting interoperability goals for health care providers
- Funding for DHHS to modernize and update CMS data and data security infrastructure to facilitate the transition to single-payer health system and expansion of coverage to everyone in the United States
2. State legislatures, agencies, and other public servants to:
- Work with the full federal administration and state agencies to adopt reforms to transition their health care financing and reimbursement procedures to an SP system
3. Community partners to engage in:
- Legislative advocacy and educational campaigns to provide information to legislative and executive branch representatives and staff on the short-term and long-term benefits of SP reform
- Public education campaigns
- Community outreach and engagement to facilitate collaboration on the design and implementation of SP reform
1. Centers for Medicare & Medicaid Services. NHE fact sheet. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet. Accessed October 20, 2021.
2. Collins SR, Radley DC. The cost of employer insurance is a growing burden for middle-income families. Available at: https://www.commonwealthfund.org/publications/issue-briefs/2018/dec/cost-employer-insurance-growing-burden-middle-income-families. Accessed October 20, 2021.
3. Anderson GF, Hussey P, Varduhi P. It’s still the prices, stupid: why the US spends so much on health care, and a tribute to Uwe Reinhardt. Health Aff. 2019;38(1):87–95.
4. Yu J. Avoidable mortality and health care expenditure in OECD countries: DEA and SFA methods to health expenditure efficiency. J Adv Soc Sci Humanities. 2016;2(5):25–36.
5. Yu J, Zhang Y. Comparison of single-payer and non single-payer health care systems: a study of health administration efficiency. Modern Econ. 2017;8(6):816–833.
6. Keehan SP, Cuckler GA, Poisal JA, et al. National health expenditure projections, 2019–28: expected rebound in prices drives rising spending growth. Health Aff. 2020;39(4):704–714.
7. Organisation for Economic Co-operation and Development. Health statistics 2020. Available at: https://data.oecd.org/healthres/health-spending.htm. Accessed October 20, 2021.
8. Kesselheim AS, Avorn J, Sarpatwari A. The high cost of prescription drugs in the United State: origins and prospects for reform. JAMA. 2016;316(8):858–871.
9. Sarnak DO, Squires D, Bishop S. Paying for prescription drugs around the world: why is the U.S. an outlier? Available at: https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_2017_oct_sarnak_paying_for_rx_ib_v2.pdf. Accessed October 20, 2021.
10. Squires D, Anderson C. U.S. health care from a global perspective: spending, use of services, prices and health in 13 countries. Available at: https://www.commonwealthfund.org/sites/default/files/documents/__media_files_publications_issue_brief_2015_oct_1819_squires_us_hlt_care_global_perspective_oecd_intl_brief_v3.pdf. Accessed October 20, 2021.
11. Crowley R, Daniel H, Cooney TG, Engel LS. Envisioning a better U.S. health care system for all: coverage and cost of care. Ann Intern Med. 2020;172(suppl):S7–S32.
12. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the U.S. and Canada. N Engl J Med. 2003;349:768–775.
13. Woolhandler S, Himmelstein DU. Administrative work consumes one-sixth of U.S. physicians’ working hours and lowers their career satisfaction. Int J Health Serv. 2014;44(4):635–642.
14. Jiwani A, Himmelstein D, Woolhandler S, Kahn JG. Billing and insurance-related administrative costs in United States health care: synthesis of micro-costing evidence. BMC Health Serv Res. 2014;14:556.
15. Himmelstein DU, Campbell T, Woolhandler S. Health care administrative costs in the United States and Canada, 2017. Ann Intern Med. 2020;172(2):134–142.
16. Medicare Payment Advisory Commission. Report to the Congress: Medicare payment policy. Available at: http://medpac.gov/docs/default-source/reports/mar17_entirereport.pdf. Accessed October 20, 2021.
17. Scheffler RM, Arnold DR. Insurer market power lowers prices in numerous concentrated provider markets. Health Aff. 2017;36(9):1539–1546.
18. World Health Organization. Universal health coverage. Available at: https://www.who.int/health-topics/universal-health-coverage#tab=tab_1. Accessed October 20, 2021.
19. Dickman SL, Woolhandler S, Bor J, McCormick D, Bor DH, Himmelstein DU. Health spending for low-, middle-, and high-income Americans, 1963–2012. Health Aff. 2016;35(7):1189–1196.
20. Christopher AS, Himmelstein DU, Woolhandler S, McCormick D. The effects of household medical expenditures on income inequality in the United States. Am J Public Health. 2018;108(3):351–354.
21. Valero-Elizondo J, Khera R, Saxena A, et al. Financial hardship from medical bills among nonelderly U.S. adults with atherosclerotic cardiovascular disease. J Am Coll Cardiol. 2019;73(6):727–732.
22. Wharam JF, Zhang F, Wallace J, et al. Vulnerable and less vulnerable women in high-deductible health plans experienced delayed breast cancer care. Health Aff. 2019;38(3):408–415.
23. Brot-Goldberg Z, Chandra A, Handel BR, Kolstad JT. What does a deductible do? The impact of cost-sharing on health care prices, quantities, and spending dynamics. Q J Econ. 2017;132(3):1261–1318.
24. Kaiser Family Foundation. Uninsured rates for the nonelderly by race/ethnicity. Available at: https://www.kff.org/uninsured/state-indicator/nonelderly-uninsured-rate-by-raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D#notes. Accessed October 20, 2021.
25. Gaffney A, McCormick D. The Affordable Care Act: implications for health-care equity. Lancet. 2017;389(10077):1442–1452.
26. Canedo JR, Miller ST, Schlundt D, Fadden MK, Sanderson M. Racial/ethnic disparities in diabetes quality of care: the role of health care access and socioeconomic status. J Racial Ethn Health Disparities. 2018;5(1):7–14.
27. Nguyen OK, Vazquez MA, Charles L, et al. Association of scheduled vs emergency-only dialysis with health outcomes and costs in undocumented immigrants with end-stage renal disease. JAMA Intern Med. 2019;179(2):175–183.
28. Lee JC, Hasnain-Wynia R, Lau DT. Delay in seeing a doctor due to cost: disparity between older adults with and without disabilities in the United States. Health Serv Res. 2012;47(2):698–720.
29. Tikkanen RS, Woolhandler S, Himmelstein DU, et al. Hospital payer and racial/ethnic mix at private academic medical centers in Boston and New York City. Int J Health Serv. 2017;47(3):460–476.
30. Mechanic D. More people than ever before are receiving behavioral health care in the United States, but gaps and challenges remain. Health Aff. 2014;33(8):1416–1424.
31. Zhu JM, Zhang Y, Polsky D. Networks in ACA marketplaces are narrower for mental health care than for primary care. Health Aff. 2017;36(9):1624–1631.
32. Akhter MN. APHA policies on universal health care: health for a few or health for all? Am J Public Health. 2003;93(1):99–101.
33. Ault A. Majority of health care professionals support single-payer system, poll says. Available at: https://www.medscape.com/viewarticle/906703#. Accessed October 20, 2021.
34. Doherty R, Cooney TG, Mire RD, et al. Envisioning a better US health care system for all: a call to action by the American College of Physicians. Ann Intern Med. 2020;172:S3–S6.
35. American Public Health Association. APHA Policy Statement 200911: public health’s critical role in health reform in the United States. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/23/11/50/public-healths-critical-role-in-health-reform-in-the-united-states. Accessed October 20, 2021.
36. Rekindling Reform Steering Committee. Rekindling reform: principles and goals. Am J Public Health. 2003;93(1):115–117.
37. Congressional Budget Office. Key design components and considerations for establishing a single-payer health care system. Available at: https://www.cbo.gov/system/files/2019-05/55150-singlepayer.pdf. Accessed October 20, 2021.
38. Scheinker D, Richman BD, Milstein A, Schulman KA. Reducing administrative costs in US health care: assessing single payer and its alternatives. Health Serv Res. 2021;56(4):615–625.
39. Hussey P, Anderson GF. A comparison of single- and multi-payer health insurance systems and options for reform. Health Policy. 2003;66(3):215–228.
40. Bichay N. Health insurance as a state institution: the effect of single-payer insurance on expenditures in OECD countries. Soc Sci Med. 2020;265:113454.
41. Public Citizen. Single-payer health care in Taiwan. Available at: https://www.citizen.org/news/single-payer-health-care-in-taiwan/. Accessed October 20, 2021.
42. Cheng TM. Health care spending in the US and Taiwan: a response to It’s still the prices, stupid, and a tribute to Uwe Reinhardt. Available at: https://www.healthaffairs.org/do/10.1377/hblog20190206.305164/full/. Accessed October 20, 2021.
43. Tuohy CH. Political accommodations in multi-payer health care systems: implications for the United States. Am J Public Health. 2019;109(11):1501–1505.
44. Tikkanen R, Osborn R, Mossialos E, Warton GA. How does universal health coverage work? Available at: https://www.commonwealthfund.org/international-health-policy-center/countries/taiwan. Accessed October 20, 2021.
45. Glied SA, Black M, Lauerman W, Snowden S. Considering “single payer” proposals in the US: lessons from abroad. Available at: https://www.commonwealthfund.org/publications/2019/apr/considering-single-payer-proposals-lessons-from-abroad. Accessed October 20, 2021.
46. Slaybaugh C. International health care systems: the US versus the world. Available at: https://axenehp.com/international-health care-systems-us-versus-world/. Accessed October 20, 2021.
47. Cai C, Runte J, Ostrer I, et al. Projected costs of single-payer health care financing in the United States: a systematic review of economic analyses. PLoS Med. 2020;17(1):e1003013.
48. Liu JL. Exploring single-payer alternatives for health care reform. Available at: https://www.rand.org/content/dam/rand/pubs/rgs_dissertations/RGSD300/RGSD375/RAND_RGSD375.pdf. Accessed October 20, 2021.
49. Yeung K, Basu A, Hansen RN, Watkins JB, Sullivan SD. Impact of a value-based formulary on medication utilization, health services utilization, and expenditures. Med Care. 2017;55(2):191–198.
50. Liu JL, Brook RH. What is single-payer health care? A review of definitions and proposals in the U.S. J Gen Intern Med. 2017;32(7):822–831.
51. Huskamp HA, Epstein AM, Blumenthal D. The impact of a national prescription drug formulary on prices, market share, and spending: lessons for Medicare? Health Aff. 2003;22(3):149–158.
52. Bielenberg JE, Futrell M, Stover B, Hagopian A. Presence of any medical debt associated with two additional years of homelessness in a Seattle sample. J Health Care Organ Provision Financing. 2020;57:1–10.
53. Corscadden L, Allin S, Wolfson M, Grignon M. Publicly financed health care and income inequality in Canada. Health Care Q. 2014;17(2):7–10.
54. Frank RG. Reflections on the Mental Health Parity and Addiction Equity Act after 10 years. Milbank Q. 2018;96(4):615–618.
55. Zieff G, Kerr ZY, Moore JB, Stoner L. Universal health care in the United States of America: a healthy debate. Medicina. 2020;56(11):580.
56. Cheng SH, Chang CM, Chen CC, Shih CY, Tsai SL. Half-managed care: a preliminary assessment of a capitation program in a health care system without gatekeepers. Int J Health Serv. 2017;47(3):519–531.
57. Croxson B, Propper C, Perkins A. Do doctors respond to financial incentives? UK family doctors and the GP fundholder scheme. J Public Econ. 2001;79(2):375–398.
58. Grytten J, Sørensen R. Type of contract and supplier-induced demand for primary physicians in Norway. J Health Econ. 2001;20(3):379–393.
59. Blackstone EA, Fuhr JP. The economics of Medicare accountable care organizations. Am Health Drug Benefits. 2016;9(1):11–19.
60. Webb AR, Liaw W, Chung Y, Petterson S, Bazemore A. Accountable care organizations serving deprived communities are less likely to share in savings. J Am Board Fam Med. 2019;32(6):913–922.
61. Diamond MA. Single-payer health care; why it’s not the best answer. Am J Respir Crit Care Med. 2009;180(10):921–922.
62. Himmelstein DU, Woolhandler S. Single-payer reform: heed the evidence, not the soothsayers. Am J Public Health. 2020;110(4):447–448.
63. Baldacci M. Single-payer health care: rhetoric versus reality. Available at: https://www.heritage.org/health-care-reform/report/single-payer-health-care-rhetoric-versus-reality. Accessed October 20, 2021.
64. Yglesias M. The single-payer debate we should be having. Available at: https://www.vox.com/2016/1/15/10775050/single-payer-debate. Accessed October 20, 2021.
65. Reynolds JP, Pilling M, Marteau TM. Communicating quantitative evidence of policy effectiveness and support for the policy: three experimental studies. Soc Sci Med. 2018;218:1–12.
66. Huber RA, Wicki ML, Bernauer T. Public support for environmental policy depends on beliefs concerning effectiveness, intrusiveness, and fairness. Environ Politics. 2020;29(4):649–673.
67. Culleton K, Donnet T, Lee A, Gallegos D. Effective advocacy strategies for influencing government nutrition policy: a conceptual model. Int J Behav Nutr Phys Activity. 2018;15:83.
68. Haynes AS, Derrick GE, Reedman S, et al. Identifying trustworthy experts: how do policymakers find and assess public health researchers worth consulting or collaborating with? PLoS One. 2012;7(3):e32665.
69. Birn AE, Brown TM, Fee E, Lear WJ. Struggles for national health reform in the United States. Am J Public Health. 2003;93(1):86–91.
70. Carr D. Why doctors are fighting their professional organizations over Medicare for all. Available at: https://www.thenation.com/article/politics/ama-medicare-insurance/. Accessed October 20, 2021.
71. Blendon RJ, Benson JM. Public opinion at the time of the vote on health care reform. N Engl J Med. 2010;362(16):e55.
72. Blahous C. The Costs of a National Single-Payer Health System. Arlington, VA: Mercatus Center at George Mason University; 2018.
73. Gaffney A, Woolhandler S, Angell M, Himmelstein DU. Moving forward from the Affordable Care Act to a single-payer system. Am J Public Health. 2016;106(6):987–988.
74. Himmelstein DU, Lawless RM, Thorne D, Foohey P, Woolhandler S. Medical bankruptcy: still common despite the Affordable Care Act. Am J Public Health. 2019;109(3):431–433.
75. Crowley RA, Bornstein SS. Improving the Patient Protection and Affordable Care Act’s insurance coverage provisions: a position paper from the American College of Physicians. Ann Intern Med. 2019;170(9):651–653.
76. Antos J, Capretta J. The ACA: trillions? Yes. A revolution? No. Available at: https://www.healthaffairs.org/do/10.1377/hblog20200406.93812/full/. Accessed October 20, 2021.
77. Cowell A, Prakash S, Jones E, Barnosky A, Wedehase B. Behavioral health coverage in the individual market increased after ACA parity requirements. Health Aff. 2018;37:7.
78. Ody C, Msall L, Dafny LS, Grabowski DC, Cutler DM. Decreases in readmissions credited to Medicare’s program to reduce hospital readmissions have been overstated. Health Aff. 2019;38(1):36–43.
79. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. Health insurance and mortality in US adults. Am J Public Health. 2009;99(12):2289–2295.
80. Woolhandler S, Himmelstein DU. The relationship of health insurance and mortality: is lack of insurance deadly? Ann Intern Med. 2017;167(6):424–431.
81. McIntyre A, Song Z. The US Affordable Care Act: reflections and directions at the close of a decade. PLoS Med. 2019;16(2):e1002752.