The facts are indisputable. However you look at the data, the United States continues to be a world leader in health care spending when compared with other industrialized nations, but ranks low in regard to health status indicators and has a lower percentage of its population covered by health insurance.^1–5 People without insurance coverage are less likely to have a regular source of health care or to get the care they need, and they are sicker than people who have adequate health insurance coverage.² The health and quality of life of uninsured persons suffer. And we, as a society, suffer as a consequence of putting citizens at risk who could be healthier and more productive.

The Centers for Medicare and Medicaid Services reported in January 2003 that health spending rose by 8.7 percent in 2001—from $1.3 trillion in 2000 to $1.414 trillion in 2001, an impressive 14.1 percent of the U.S. Gross Domestic Product (GDP). Per capita spending rose to $5,035, about double that of other industrialized nations.³ Yet, according to the World Health Organization, the United States ranks 37th out of 191 countries in its overall health system performance and 72nd from the viewpoint of disease-adjusted life expectancy.⁴ Despite being a world leader in health care spending, the U.S. cannot seem to afford to bring everyone into the system—to provide health care coverage for all.

According to Families USA (March 2003), more than 30 percent of the population younger than 65 years was uninsured at some time during the previous two years, and about 25 percent of those persons had no coverage during the entire two-year period.⁵ The nearly 75 million persons without coverage do not get timely, necessary health care in the appropriate setting. Their access to preventive care is impeded, and they have poorer health outcomes than those with coverage. Tunzi describes the uninsured and their plight in a “Medicine and Society” article in this issue.⁶

Since the 1980s, the American Academy of Family Physicians (AAFP) has called for fundamental reform of the U.S. health care system to achieve health care coverage for everyone and better align the health care system with the needs of the population. The AAFP proposes a strategy for achieving basic health care coverage for all.

In a proposed first tier of basic coverage are assured services without copayments (see accompanying table). These are services such as preventive care that would be accessible to everyone without financial barrier.

In a second tier of basic coverage are assured services with copayments of 20 percent (see accompanying table). The AAFP believes it is important for patients to understand the cost of health care services and have some financial responsibility for appropriately accessing care and services.

In addition, there may be tiered copayments for persons with lower incomes who may be subsidized, partly or entirely, for required patient copayments or may be eligible to obtain “gap” coverage for services not included in the basic package. Furthermore, beneficiaries of federal, state, or private insurance programs would continue to receive other benefits not assured through the basic services package. These programs also may opt to cover required copayments for their beneficiaries.

A national health board could determine the extent of coverage (e.g., the number of outpatient mental health visits that would be allowed). Any potential amendments to the basic services would have to be based on evidence and outcomes and be determined by the national health board. Congress would determine only the level of funding available for any additional services.

In addition, the AAFP strategy acknowledges that people should be protected from becoming financially devastated by health care costs if they experience serious injury or illness. The plan therefore includes protection against extraordinary costs through limits on annual out-of-pocket expenditures.

Out-of-pocket costs could be capped at $5,000 per year for individuals and $8,000 per year for a family, with an additional 20 percent annual copayment for expenditures between $5,000 and $10,000 per individual or family. Services not included in the basic benefits package could be covered by a variety of methods, including (but not limited to) out-of-pocket payment, private health insurance (employer- or individual-based), federal or state programs, or a medical savings account.

However, the AAFP believes that individuals should have responsibility for deciding their own level of risk tolerance for services that would fall between “basic” and “extraordinary” and for any required patient cost sharing. Therefore, everyone would need to decide whether to obtain additional insurance for uncovered services and copayments.

The AAFP expects that many employers who currently offer a health insurance benefit to employees will continue to do so, insuring employees for the services not in the AAFP’s national plan. Federal and state programs could do likewise. The strategy leaves in place the current insurance market, the current arrangements for employer-based insurance, individually purchased insurance, medical savings accounts, and the choice of opting out of coverage for services other than those ensured by the basic benefits package and expenses below the extraordinary cost coverage threshold.

Financing of this plan, estimated by the Lewin Group to require total revenues of about $535.7 billion annually ($317.9 billion in new revenues),⁷ could be achieved through a national, broad-based tax mechanism. There are multiple options for the type of tax, such as sales tax, payroll tax, health insurance premium surcharge, value-added tax, additional taxes on tobacco and alcohol, etc., or any combination of these, with the government collecting and distributing the revenue for the program. State and federal programs, which would spend less as a result of this plan, would transfer to the new program their share of savings to help fund the basic package and protection from extraordinary costs. In addition, the AAFP expects that by fostering prevention, and early diagnosis and treatment, the program would result in decreased health system costs and increased productivity through healthier lives.

Thus, the AAFP’s plan envisions every American with ensured coverage for basic health services, protection against extraordinary costs, and potential coverage for the many services that fall between the basic health benefits and the extraordinary costs threshold. The AAFP’s approach recognizes that there are basic services everyone requires to support a healthier society but acknowledges that individual Americans must share responsibility for their health care. In this regard, the plan brings the system into better alignment while holding as a fundamental construct the premise that no one in the United States should be without health care coverage, ever.

The only way to achieve health care coverage for everyone in this country is for the U.S. Congress to enact legislation assuring basic health care for everyone. To emphasize this point, the AAFP and other medical specialty societies sponsored a resolution at the December 2002 American Medical Association House of Delegates that called on the discipline of medicine to pursue enactment of a “Sense of the Congress” resolution calling for legislation to be enacted by 2009 that would achieve universal health care coverage.⁸ A coalition of medical organizations now is seeking sponsorship in the Senate and House of Representatives for such a resolution. The Sense of the Congress resolution, while not binding, would set the stage for congressional action.

The United States already commits an impressive percentage of its GDP to health spending, yet lags in health outcomes and leaves millions of persons without coverage. The Institute of Medicine has concluded that broader health insurance coverage would improve the health of those who have the poorest health and are the most disadvantaged in terms of access to care and, thus, would likely reduce health disparities among racial and ethnic groups.⁹ We all will benefit from a healthier and more productive society. As a nation, we cannot afford not to achieve health care coverage for all.