Introducing Health Care Unity

The Problem

• Uniquely in the world, the American health care system is a mosaic of different funding sources, coverages, and structures. The most effective way to deliver better care and lower costs is to design reforms that recognize the reality of the system we have inherited, and improve it.
• Today the health care policy debate is too often an elite back and forth about the various ways to pay for insurance that can overlook the problems people face when they experience health care. Solutions must address the changes Americans consistently say they want: lower costs and higher quality.
• The needs of patients and individual health professionals too often take a back seat to the profit drives of monopolies that increasingly control health care. Conglomerates merge insurance and care to maximize profits and devalue patient choice. Hospital corporations corner the market in communities across America, driving up prices.
• Americans who lack coverage can glimpse the advances of modern medicine only through a locked door. Without insurance coverage, they cannot access routine care, must delay needed medicines and treatments, and worry that any illness could cost them their savings, their job, or their home.
• Our health care system also fails those who have coverage. Millions of Americans who have coverage face barriers to medical care from spiraling costs, insurance rules designed to deny care rather than improve it, and long waiting times and high costs even for basic primary care.
• The Affordable Care Act was an important step toward addressing these deep-seated problems — but it was always intended to be a “starter home,” as President Obama rightly termed it. Now is the time to upgrade that starter home by making health care work better for all Americans.

The Terrain

• Given the complexity of the American health care system, it is not surprising that people’s views on diagnosing the problems and finding solutions are complex, too. There is a “dislike the system but like my plan” dynamic at play: Although 76% of Americans are either very satisfied or somewhat satisfied with their own health coverage, 59% are either very or somewhat unsatisfied with the health care system as a whole.
  
• More Americans (34%) report trusting private insurance companies than the government (19%) to provide health care. In a recent survey conducted between Searchlight and the new media organization Zeteo, an overwhelming 70% of voters say they would rather keep their current health insurance than opt-into a government-run national health plan similar to Medicare. 
• While a majority of respondents feel that the government has a responsibility to ensure everyone has health insurance coverage (57%) and receives basic health care services (60%), opinions are divided on how the government should meet this responsibility: 24% think that there should be a single national health plan, while 30% feel there should be a mix of public and private plans, and 26% feel the government should provide coverage to the poor and to seniors.
• These findings reinforce the idea that there is no single, unitary “American health care system” — nor do most Americans want to impose one. Instead, Americans experience health care through the lens of their own coverage and health care providers.
• Our solutions should reflect that diversity by giving Americans more and better options that make health care in all their systems more available, more affordable, and more responsive to the most important people in their health care system: patients and their families.

Introducing Health Care Unity

Our approach — the Health Care Unity Agenda — addresses the varying problems of American health care by offering solutions both for those who have coverage and those who do not. Americans are searching for solutions to health care that provide better and more affordable options while putting patients and their needs over corporations and their bottom lines.

Making Health Care More Available

Having insurance coverage does not, by itself, solve the problems of American health care, but having coverage is the prerequisite for good care. Building on the inarguable success of the Affordable Care Act to make health care coverage available for millions more Americans is a foundation for other needed reforms.

Recognizing that Americans get coverage from a variety of sources, the avenues by which the Health Care Unity Agenda will make health care more available involves significant changes to both public and private sources of coverage:

1. Making primary care free for all Americans, regardless of coverage source
2. Creating a nonprofit public option, the American Health Gateway, to be available to all Americans in need
3. Restoring extended ACA subsidies responsibly by concentrating on states that have done the right thing for their people by expanding Medicaid
4. Recognizing the richness and diversity of modern families by expanding access to private health insurance for extended families
5. Reforming Medicaid to remove needless barriers to enrollment and coverage
6. Expanding the health care workforce to serve all Americans

Free Primary Care for All

Sometimes the best ideas are the simplest: Primary care should be free to patients at the point of care. Around the world, patients can walk into a doctor’s office or urgent care center and receive the primary care they need without charge to them. Americans should have the same freedom. The ACA required insurance companies to cover some needed primary care, such as vaccines and recommended preventive services. It is now time to extend that policy by requiring coverage of all primary care.

This provision will work the same way that making preventive services free at the point of care works in the ACA. No cumbersome reimbursements, no forms to fill in or apps to download. Today, when you get a vaccine or other needed preventive service, you simply don’t pay out of pocket. This provision takes the next logical step from that important provision of the ACA by making basic primary care too. Critics said the sky would fall when preventive services were made free as part of the ACA and they’ll say the same thing again now. They’ll be wrong both times.

The ACA also covered preventive services and an annual wellness visit for all Medicare beneficiaries. Millions of seniors have used this benefit to get screening and advice on keeping healthy and active. This successful model should be expanded to cover all primary care for people on Medicare or Medicaid.

The American Health Gateway

Too often in American health care, the drive for profit trumps the needs of patients. To counteract this balance, we will create the American Health Gateway, a nonprofit coverage option offered to all states.

The Affordable Care Act envisioned a nationwide expansion of Medicaid to provide a floor of coverage for all low-income Americans, with the ACA marketplaces intended to rest on top of this foundation. Forty-one states have done the right thing by expanding Medicaid to give millions of lower-income Americans better options for health care. These states will have the choice of including the Gateway within the framework of their ACA marketplaces as an additional nonprofit option for coverage.

Just as a state can choose either to operate its own ACA marketplace or default to the federal platform, states may choose whether to include Gateway plans in their state exchanges — meaning that residents of states who don’t elect to include the Gateway plans in their own exchanges could still access those plans through a federal entry point.

To help lower costs for consumers in ACA plans, we propose adjusting the current structure of the financial criteria that determine whether a person is considered to have “affordable” coverage from their employer – which makes them ineligible for tax credits. These standards are set unrealistically high at present, and we propose a graded series of reductions to ensure that working families are not caught in the impossible situation of being unable to afford employer coverage, but being unable to access tax credits for ACA plans.

Over time, the American Health Gateway will offer Medicare Advantage plans as a nonprofit competitor to the for-profit plans that now receive billions of dollars in overpayments from American taxpayers every year. This competition will be one aspect of reducing these overpayments, thus helping Medicare save money and extending the solvency of the program. Congress should enact the recommendations of the expert Medicare Payment Advisory Commission on technical improvements to the data used to calculate payments, so that payments to plans are more accurate.

In states that have shirked their responsibility to expand Medicaid, the Gateway will also provide (with no state option to decline) a statewide fallback plan separate from the marketplaces to provide Medicaid coverage for low-income adults that the state has failed to provide. States that have not done the right thing for their low-income patients would have no say in the design of the Gateway plan.

Responsibly Restoring Extended ACA Subsidies

The promise of the ACA to expand coverage options was only partially fulfilled in the law’s original form. Subsequent improvements have helped the ACA cover more Americans. Chief among these were the extended advance premium tax credits later provided under the ACA. These credits helped millions of Americans afford coverage, but they were allowed to lapse at the end of 2025. We should fully restore these expanded subsidies for those states that have done the right thing for their people by expanding Medicaid.

States such as Florida and Texas have shirked their responsibility to expand Medicaid and have instead relied on the rest of America to provide national subsidies to pay for their irresponsibility. America should not continue to subsidize states that fail to take responsibility for the health care needs of their people by providing new ACA extended premium tax credits in those states.

Recognizing The Richness And Diversity Of Families

The ACA recognized the reality of families today, which is that kids often need to be on a parent’s coverage into young adulthood. That’s why the ACA required insurers to cover young adults up to the age of 26 on a parent’s plan. But family isn’t just parents and children. Millions of Americans are responsible for the care of a parent-in-law or grandchild — or a loved one who is not related but is still family in their hearts.

Health care should recognize the richness and diversity of family relationships by building on the model of the ACA to allow people who have private health insurance to designate any loved one as a family member and include them in their coverage. 

People who are covered under an employer plan would have the option to add as many additional loved ones as are covered under the existing employer plan. Thus, a person covered under an individual-only plan could add one additional loved one. Someone covered under an individual + spouse plan could cover two, and so on. The plan would be allowed to charge an additional premium up to the cost of an additional adult or child.

Removing The Barriers To Care For Medicaid

Medicaid is a lifeline for millions of working families, but that lifeline is often placed out of reach by arcane rules and mountains of red tape that serve no purpose but to deny care. We should ensure that everyone who is entitled to Medicaid receives it by simplifying administrative processes for enrollment that are often dizzyingly complex and eliminating needless bureaucratic barriers to participation.

These policies will help millions of Americans whose income fluctuates over the year — such as gig workers, construction workers, or single parents — retain coverage and have a continuous source of care. These policies would, of course, eliminate the needless bureaucratic barriers to Medicaid participation included in the reconciliation bill of 2025.

Increased Enforcement Against Fraud And Abuse

Reforms to make Medicaid more accessible should be paired with rigorous enforcement to guard against fraud and abuse. Investment in program integrity for Medicare and Medicaid returns millions more dollars to the public than it costs, through recoveries from fraud and abuse. We should fully fund integrity and enforcement for these public programs and for plans offered through ACA marketplaces.

Who Benefits From These Reforms?

Terms such as “administrative simplification” can sound very dry and disengaged from people’s lives, but they are just the opposite. These reforms can mean the difference between staying healthy and being unable to work or care for children for millions of Americans.

Consider a construction worker who has little work in winter, so his income is at 120% of the Federal Poverty Level (FPL). He would be eligible for Medicaid at that time, but gets work in the warmer months, bringing his income to 150% of FPL. Without continuous eligibility, he would lose access to health care and perhaps needed medicines during the months when his income rises.

Simplifying the administrative processes of enrolling in Medicaid — which can be bafflingly complex — helps those who have low literacy, speak English as a second language, or have minimal access to the internet. Consider a restaurant worker who can find only part-time shifts. As a result, she moves from one apartment to another, or stays temporarily with friends to make ends meet. She may not receive mailed notices from the state Medicaid agency or may be unable to complete required forms — but she should not lose health care as a result.

Expanding The Health Care Workforce To Serve All Americans

Making quality health care a reality for millions more Americans will of course require that the workforce expands and that health care itself becomes more efficient through responsible use of technology such as telehealth and AI. We should invest in health care professionals, particularly those who practice in underserved areas.

Measures to do so include expanding the number of physician training slots, potentially reducing the time spent in medical school by improving the use of technology, strengthening loans for service programs, bringing in talented health care professionals from other countries, and encouraging non-physician professionals to utilize their skills to the fullest.

Making Health Care More Affordable

Even for Americans with insurance coverage, health care is often unaffordable and costs are constantly rising. Some cost increases are due to innovation and the increasing ability of modern medicine to treat diseases that were once incurable — but much of the rising cost of health care is due to needless inefficiencies in the way health care is delivered, inflated costs that enhance profits not value, and anti-competitive or abusive practices that drive up the cost of care. The Searchlight approach includes fundamental reforms to make health care more affordable while improving quality by:

1. Accelerating and expanding drug price negotiation;
2. Allowing greater competition in manufacturing drugs that are unaffordable
3. Protecting consumers against high out of pocket drug costs; and
4. Reducing the cost of defensive medicine, while providing quicker and fairer outcomes for injured patients.

Lowering The Cost Of Prescription Drugs

The Inflation Reduction Act allowed Medicare to do what every other major health system in the world does: negotiate for the best deal on the prices of the prescription drugs it buys. Price negotiation has already yielded major savings for American seniors, and we should build on this successful model by immediately doubling the number of drugs that are subject to price negotiation to 40, and then ramping up to 60.

People in private plans should also reap the benefits of these lower prices. To achieve this goal, manufacturers should be required to sell their drugs in private markets at the Medicare negotiated price — and if they refuse to do so, they will be subject to financial penalties and may be denied access to the Medicare market for that product. To preserve incentives to develop treatments for diseases where there are no or few existing therapies, price negotiation would not apply to drugs approved only for orphan indications. We should also ensure that the processes for negotiation do not accidentally inhibit biosimilar market entry.

Even with these price reforms, many people would still have medical needs that require thousands of dollars a year in spending on prescriptions. Under President Biden, seniors were protected from these high out of pocket costs through a $2,000 annual spending cap for prescription drug spending in Medicare. We should extend this important protection to private plans too in order to protect consumers from crushing costs for prescriptions.

Part of these reforms will be greater reporting on drug costs and measures by FDA to lower production costs for medicines by pre-certifying manufacturing facilities.

These reforms will go hand in hand with measures to end the games that drug companies play to extend patents and drive up prices, by reforming the complex patent structures that allow manufacturers to “evergreen” expensive versions of existing drugs and prevent the entry to market of lower-cost generic medicines. It will be important to pair these reforms with measures to ensure that drug formularies include generic and biosimilar medications, and do not impose unreasonable barriers to access. We should also remove barriers to access for biosimilars during care for cancer and other complex illnesses in Medicare Part B.

Ending Drug Shortages Due To Unaffordable Prices

When a needed prescription drug is unavailable due to manufacturing difficulties or other bottlenecks, FDA can declare a drug shortage, which allows a new set of manufacturers, called compounding pharmacies, to supply the drug even if it is otherwise protected by patents. When a drug is priced beyond its value and the capacity of patients to pay, it is just as unavailable as when there is a manufacturing problem. Under these circumstances, FDA should have the authority to declare a drug in shortage and allow additional manufacturers to bring the medicine to patients in need at prices they can afford.

Reducing The Cost Of Defensive Medicine

Only America tries to resolve medical errors through routine use of adversarial lawsuits that drive up costs and result in sporadic justice. To lower costs and provide compensation for injured patients more fairly, we should institute changes to the current medical malpractice system — not through arbitrary caps on damages that deny justice to injured patients, but through sensible reforms that borrow from frameworks of other countries that have instituted fairer, cheaper, and more reliable compensation systems.

Adapting the current model that applies to vaccines, we should establish a Medical Injury Compensation Program, through which injured patients would have the option to receive expedited awards under a system dedicated to evaluating claims of medical injury, so that awards are quicker, fairer, and do not cost millions in attorney fees on both sides. Compensatory and punitive damages could be awarded, with compensatory damages going to the victim of an error, and punitive damages dedicated to a fund to compensate future victims rather than flowing to any one individual.

Making sure health care serves patients, not corporations

Too often, the deck is stacked against patients and individual health care providers trying to do the right thing for the patients, because corporations dominate the health care marketplace and put profits first. Costs rise, care is denied, and patients are too often treated as commodities or profit centers rather than people.

Such monopolies also allow companies to continue offering consumers poor products. Health care is frequently a consumer hassle, involving long wait times, inefficient and archaic consumer interactions, and often deliberate barriers to care. Receiving health care is never likely to be something people look forward to — but it should not be the ordeal of denied care and unfair practices it has too often become in America. To make sure health care serves patients, not corporations, we propose the following reforms that will also lower costs:

1. Ending the power of insurance monopolies to stack the deck against patients
2. Preventing corporate hospital systems from using monopoly power to drive up costs for patients
3. Unleashing the creative power of American innovation to make health care more responsive and consumer-friendly

A Charter Of Consumer Rights To Make Sure Insurance Companies Treat Patients Fairly

Insurance should be a conduit to good health care, not a barrier, but insurance companies often place barriers between patients and the care they need by using denials of coverage systematically as a way to boost profits, particularly for low-income beneficiaries who are less likely to appeal — a practice that one expert has called “rationing by inconvenience.” The ever-expanding use of AI threatens to automate these denials to robot efficiency and scale.

Insurance companies should obey a charter of consumer rights, including time limits and transparency on prior authorization decisions, an automatic “passport to approval” for providers who achieve a high level of successful preauthorization, and automatic approvals for routine care and limits on administrative expenses. Companies should face meaningful penalties when they fail to live up to their responsibilities. Building on the model of the ACA, companies that fail to fulfill their charter obligations would face civil monetary penalties, and could ultimately be barred from participation in public programs for repeated or egregious infractions. Participation in public programs is a privilege for insurance companies, not a right. That privilege should be rescinded for companies that consistently fail to serve the public interest.

Cutting The Cost Of “Middlemen”

Health care is replete with contractors and specialists who each take a cut of the patient’s dollar. From Pharmacy Benefit Managers to Revenue Cycle Managers to Claims Re-Pricers, there is an army of specialists who intervene between patients and payment. These middlemen are meant to reduce costs by driving efficiency — but often do just the opposite. We should reform the way pharmacy benefit managers operate by ensuring that they act as fiduciaries for beneficiaries, not to the benefit of health plans. PBMs should also be required to pass on savings to consumers.

When third-party administrators are owned by the same companies that contract for their services, they have every incentive to raise costs, rather than lowering them. The Federal Trade Commission and other agencies should enforce existing antitrust and competitive statutes — adding to them where needed — to ensure that financial arrangements between insurers, hospitals, and third-party administrators that fail to serve the needs of patients are eliminated. Insurance brokers should also not be allowed to receive improper incentives to steer consumers to higher-cost plans.

Reining In The Power Of Health Care Monopolies

Companies in health care have a responsibility to put patients’ needs above profits. Too often, they do the reverse. To protect the rights of consumers, other countries apply broader community benefit criteria in their anti-monopoly laws, and the United States should adopt the same standards in health care. We need to give the government new and more powerful tools to investigate whether health care monopolies serve patients, and to take action if they do not.

We would give the Federal Trade Commission the authority to investigate insurance conglomerates and dominant hospital systems using broader standards of community benefit. If the community’s interests are not served, the FTC would have the power to require changes or force structural change. Companies that serve patients should put the interest of patients first — and if they fail to do so, they must change or be changed.

Insurance Conglomerates

Vertically integrated insurance conglomerates have engaged in unfair business practices such as spread pricing, rebate retention, preferential in-house pricing, and gag clauses, all of which drive up costs and reduce choice. We would address these and related abuses in two ways. First, there would be an immediate ban on such practices. Second, the FTC would be given new legal authority to investigate whether insurance conglomerates violate these and related standards. Companies would face fines and other disciplinary action if they fail to respond to such investigations.

Where the FTC determines that a conglomerate is harming patient interests, that finding creates a rebuttable presumption of violation — meaning the FTC could begin antitrust enforcement action. The company would then have 180 days to show why its actions are not violative. If they fail to do so, there would then be a 90-day window for the system to reach an agreement with the FTC on measures to resolve the violation. If such an agreement is not reached, the system would be referred to the Department of Justice for enforcement measures that could include required divestment. State attorneys general would also be given authority to take action in cases of violation using the same parens patriae structure that applies to other antitrust violations.

To ensure that beneficiaries in Medicare see the benefit of these reforms, the Centers for Medicare and Medicaid Services would be authorized to enforce compliance with these standards through its range of enforcement options, including banning companies that violate the standards from participating in these programs. Finally, all insurance companies would be subject to these standards, to ensure that consumers receive the maximum cost reduction.

Corporate Hospital Systems

Hospitals, doctors, and nurses are the backbone of health care, but big hospital systems often behave as big corporations in all but name, dominating local markets. The health care markets in roughly half of all major communities in the United States are controlled by only one or two health systems — and a fifth are controlled by just one. Hospitals with monopolies charge consumers more for services than hospitals in competitive markets.

As with insurance companies, we would give the FTC new powers to enforce community benefit standards on hospital monopolies, and take action if they are not followed. Where the FTC determines that a dominant hospital system charges prices that significantly and unjustifiably exceed comparable prices in comparable communities, that finding creates a rebuttable presumption of violation. This finding would trigger the same response and action process system described for insurance companies above. If hospital systems fail to justify their prices, the federal government and state attorneys general would be empowered to take action, which could include required divestment. State Certificates of Public Advantage would not be allowed to block federal enforcement of these violations.

The Same Price For The Same Service

Empowering the FTC with new resources and legal authorities is one tool to make sure hospital monopolies serve community interests. Reimbursement is another. To prevent hospital monopolies from using their market power to drive up costs, we should institute site-neutral payments for outpatient services to prevent unjustified surcharges that help big hospital systems inflate prices.

Ending Abusive Billing And Collection Practices

In return for receiving lucrative exemptions from taxation, nonprofit hospitals are meant to serve their communities, but many fail to do so. To ensure that hospitals live up to their responsibilities, there should be a 2% across-the-board requirement for nonprofit hospitals to provide charity care. Failure to do so would result in potential loss of nonprofit status.

We should also put an end to the predatory practices sometimes used to collect medical debt. Hospital systems sometimes market credit cards and payment plans with interest rates that would make a loan shark blush, or resort to wage garnishing and bank seizures to collect debts. These practices should be ended through strict enforcement of consumer protection laws, with penalties including the denial of system eligibility for Medicaid and Medicare reimbursements.

To improve health care quality, federal programs should use their market power to drive reforms such as maximum wait time standards and team-based care. Federal programs should also dismantle barriers to telemedicine and electronic communications to help make care more responsive, efficient, and cheaper.

Preventing Private Equity From Looting Hospitals And Denying Care

Across the country, private equity (PE) firms have devoured hospitals and medical practices, stripped the flesh from the bones, and left communities with only the carcass. In no other economically developed country is this behavior tolerated — and it should not be tolerated in America. To end these abuses, we should:

1. Establish a new, lower threshold for prior federal review of PE acquisitions in health care to determine whether they will have a harmful impact on the quality and availability of health care in a community;
2. Ensure ongoing compliance by creating a revocable license for engaging in PE transactions in health care, as is currently done with broker-dealer licenses; and
3. Require strong guardrails to prevent PE firms from improperly influencing medical decisions — enforced as a Condition of Participation in Medicare and through the civil and criminal penalties of the False Claims Act for PE firms.

X-Prize For Responsive Health Care

X-Prizes have been used by innovative organizations to catalyze the development of new and important technology in sectors from aviation to nanotechnology to climate change. We will throw down the gauntlet to American innovators with an X-Prize for new consumer-friendly technologies that improve access and patient satisfaction while reducing costs.

Conclusion

There is no magic wand to instantly fix all the challenges of the current health care system. Making health care work for all Americans will require a thoughtful blend of solutions that expand coverage, reduce costs, improve accessibility, and make health care fairer to consumers. The Health Care Unity Agenda acknowledges the complexity of the system and offers comprehensive solutions that consumers are more likely to feel at points of care.

Taken together, we believe the impact on the federal budget in a 10-year window would mostly be offset by sunsetting elements of the tax bill enacted in 2025 and relying on drug pricing reform, insurer accountability enforcement, middleman reform, hospital market reforms, and administrative efficiencies to generate savings.

If fully enacted, this plan would lower costs and improve quality while also providing a strong federal floor for health care — realizing a goal that has long eluded policymakers in this country.