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For almost a century, efforts to achieve universal health care in the United States raised hopes, fears, and prodigious lobbying, but yielded little beyond Medicare and Medicaid. In 2010, the Affordable Care Act (ACA; Pub L No. 111-148) ushered in a new era of reform. Last year, the Supreme Court upheld the legality of the ACA subsidies, rejecting the last serious legal challenge to President Obama's signature health care legislation. "[W]e finally declared," Obama said after the King v. Burwell decision, "that in America, health care is not a privilege for a few, but a right for all."1a
But was that the message? There's reason for skepticism. A decade from now, according to the Congressional Budget Office, 27 million Americans will remain uninsured despite full implementation of the law. Many more are underinsured or constrained by "narrow networks" of providers that limit choice and rupture longstanding therapeutic relationships. Doctors and nurses contend with growing requirements for mind-numbing electronic documentation1b in a health care marketplace increasingly tilted toward giant insurers and hospital conglomerates that amass power through consolidation. Finally, the system's administrative complexity, which robs patients and providers of time, money, and morale, was further fueled by the ACA.
There is an alternative. Over a decade ago, three of us, together with many colleagues, published a detailed proposal for a singlepayer national health program (NHP).2 Recently, single-payer reform has reemerged in the context of the presidential primaries. While the need for such reformhas not diminished, the ACA has shifted the health care landscape. For that reason, we have developed an updated proposal (available as a supplement to the online version of this editorial at http://www.ajph.org) that has thus far attracted the endorsement of more than 2200 colleagues. (Other health professionals are invited to add their endorsement at: www.pnhp.org/nhi.)
Here, we summarize the proposal, with an emphasis on how it would remedy the persistent shortcomings of the current health care system.
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Unfortunately, the ACA falls short in terms of both universality and comprehensiveness. Fewer than half of America's uninsured residents have gained coverage, and underinsurance remains ubiquitous. Employers seeking to restrain their health benefit costs have tripled deductibles since 2006,3 and the ACA's excise tax on expensive "Cadillac" plans- recently postponed until 2020- is poised to...