US needs universal access to health care, American College of Physicians says

BMJ 2007; 335 doi: (Published 13 December 2007) Cite this as: BMJ 2007;335:1228
  1. Janice Hopkins Tanne
  1. 1New York

    The American College of Physicians says that the United States needs a healthcare system that provides care for everyone, either through a universal health insurance system, such as the UK NHS, or through a pluralistic system that involves the government and private organisations.

    The college’s three-part position paper was published on its website ( It will appear in the 1 January issue of the Annals of Internal Medicine. The college has 124 000 members and is second only to the American Medical Association in membership.

    The college released the report “to provoke a national discussion, during this critical election year, on how to make the US the best performing healthcare system in the world . . . our country’s current pluralistic system without universal healthcare coverage is unacceptable and puts us behind other countries.”

    It proposed two possible ways to achieve universal health coverage for Americans.

    A single payer, government run system would cover everyone, without barriers, based on ability to pay. Single payer systems are more equitable; have lower administrative costs; greater user satisfaction; and better quality and access, the report said. However, such a system may restrict spending, leading to shortages of services, delays in elective treatments, and limits on the people’s freedom to choose.

    A pluralistic system that involves the government as well as private, for profit, and not for profit organisations could ensure universal access while giving consumers freedom to buy private supplemental coverage. It would have to include a guarantee that everyone has access to coverage and government subsidies for people who cannot afford to buy coverage. A pluralistic system is more likely to produce inequities in coverage and to have higher administrative costs.

    In either case, consumers should receive a core package of benefits, including preventive care, primary care that includes management of chronic illness, and protection from catastrophic healthcare costs.

    Until a national political consensus is reached on achieving universal health coverage, states should be encouraged to develop their own programmes, and several have already.

    The college’s position paper cited a study by the non-profit making Commonwealth Fund on high performing health systems, which ranked the US 66th out of 100. The best health systems had a strong primary care system, but the US faces a crisis in primary care, the report says.

    Primary care doctors are retiring early, just as the “baby boomer” generation (born in the late 1940s) is facing retirement and needing care for chronic conditions. Therefore, any national approach to universal health coverage must also include plans to ensure an adequate supply of primary care doctors and a “medical home,” in which the primary care doctor coordinates a team of health professionals to meet the patient’s needs, the college said.

    The college also called for a universal billing system to reduce costs, rather than the many different forms used by different insurance companies, and for federal funds to build an electronic health information infrastructure.

    The position paper said that although most Americans have access to high quality care without long waits, the cost is much higher than in other industrialised countries. “However, the uninsured, the underinsured, the poor, and members of underserved minorities often have poor access to health care and poor health outcomes—in some cases worse than that of residents of developing countries,” it said.

    About 43.6 million people lacked health insurance during 2006, and about 89.5 million people younger than 65 lacked health insurance for at least a month in 2006-7. Health insurance premiums have grown faster than inflation and wages, and employers are less likely to offer health insurance to workers.


    • The American College of Physicians position paper is at

    • The Commonwealth Fund’s Commission on a High Performance Health System is at

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