What are the two primary issues that prompted debate about what to do with the US health care system leading to reform?

Abstract

The mission of the American Heart Association is to be a relentless force for a world of longer, healthier lives. The American Heart Association has consistently prioritized the needs and perspective of the patient in taking positions on healthcare reform while recognizing the importance of biomedical research, providers, and healthcare delivery systems in advancing the care of patients and the prevention of disease. The American Heart Association’s vision for healthcare reform describes the foundational changes needed for the health system to serve the best interests of patients and to achieve health care and coverage that are adequate, accessible, and affordable for everyone living in the United States. The American Heart Association is committed to advancing the dialogue around healthcare reform and has prepared this updated statement of our principles, placed in the context of the advances in coverage and care that have occurred after the passage of the Affordable Care Act, the rapidly changing landscape of healthcare delivery systems, and our evolving recognition that efforts to prevent cardiovascular disease can have synergistic benefit in preventing other diseases and improving overall well-being. These updated principles focus on expanding access to affordable health care and coverage; enhancing the availability of evidence-based preventive services; eliminating disparities that limit the availability and equitable delivery of health care; strengthening the public health infrastructure to respond to social determinants of health; prioritizing and accelerating investments in biomedical research; and growing a diverse, culturally competent health and healthcare workforce prepared to meet the challenges of delivering high-value health care.

The American Heart Association (AHA) is the nation’s oldest and largest voluntary healthcare organization dedicated to reducing death and disability from cardiovascular disease (CVD). With the evolving scientific evidence that efforts to improve cardiovascular health are even more beneficial in the prevention of the development of other diseases than previously thought, the AHA has revised its mission to a new statement: to be a relentless force for a world of longer healthier lives. A healthy population is essential for economic prosperity; for a strong, productive, globally competitive workforce; and for ensuring all individuals can achieve their full potential. To that end, continuous improvement is needed in the delivery of health care and in the creation of equitable policy that ensures that health care is adequate, accessible, and affordable for everyone. The term healthcare reform has become synonymous with these efforts around delivery system improvement and policy change, which we now recognize must go even farther in affecting upstream issues that influence health outcomes.

The AHA has consistently prioritized the needs and perspective of the patient in taking positions on healthcare reform while recognizing the importance of biomedical research, providers, and healthcare delivery systems in advancing the quality care of patients and the prevention of disease. Therefore, these updated principles are offered in recognition that efforts to prevent CVD can have synergistic benefit in improving overall well-being, with acknowledgment that the health system overall must remain sustainable and effective at delivering optimal patient care.

In response to the ongoing national debate on healthcare reform, previous iterations of AHA’s Principles for Health Care Reform were published in 1993 and in 2008, just before one of the most transformative periods in US health care. Since its adoption in 2010, the Affordable Care Act (ACA) has extended access to comprehensive health coverage to millions of previously uninsured Americans through the expansion of Medicaid, the establishment of the Health Insurance Marketplace, and the creation of a number of consumer protections designed to mitigate discrimination from providers and healthcare systems and to limit insurers’ ability to deny, limit, or cancel coverage.

Initial results from the ACA lowered the number of the uninsured, now estimated at 30.4 million, or 9.4% by the Centers for Disease Control and Prevention (CDC), down 18.2 million people since the passage of the ACA in 2010.1 Recently, concerns have arisen about the sustainability of these results, including several actions, regulations, and proposals that have the potential to threaten both the availability and the adequacy of plans in the insurance marketplace. Millions of Americans remain uninsured or underinsured, with half of uninsured adults reporting the cost of coverage as the primary factor.2 Moreover, the progress made across the previous 5 decades in reducing cardiovascular death and disability has stalled, and increasingly, we are learning that striking differences in cardiovascular mortality remain across sex, gender identity, race, and ethnicity,3 driven largely by geographic locations, income levels, level of education, and other social determinants of health.4

This article presents the AHA’s principles for health care that is adequate, accessible, and affordable to all, placed in the context of the existing burden of CVD in the United States, advances in coverage and care that have occurred over the past 12 years, the rapidly changing landscape of healthcare delivery systems, and our evolving understanding of each individual’s risk for CVD and stroke, particularly the most vulnerable and those who continue to receive the least attention and resources to advance their own health and well-being.

The Burden of CVD and Stroke in the United States

The decline in death rates for CVD and stroke is one of the great successes in modern medicine and a result of synergistic advances in biomedical research, new treatments and efforts in prevention, and improved emergency response systems and coordinated systems of care. Despite this remarkable progress, CVD remains the number 1 cause of death in the United States, accounting for 840 678 deaths in the United States in 2016, or 1 in every 3 deaths.5 CVD is also the leading cause of death globally, accounting for >17.6 million deaths in 2016.5 Until 2015, there was steady improvement in cardiovascular mortality in the United States, but beginning in 2011, these improvements began to slow—<1%/y—and in 2015, the death rate from CVD, driven largely by deaths resulting from heart failure and stroke, increased for the first time since 1969.6

The prevalence of CVD and stroke is growing faster than efforts to reduce the burden imposed by it, with ≈121.5 million Americans having some form of CVD.5 Each year, 605 000 Americans will have a first heart attack, and 200 000 will have a recurrent attack, ≈1 heart attack every 40 seconds. Similarly, someone in the United States has a stroke every 40 seconds, equating to ≈795 000 new or recurrent strokes per year.5 Cardiovascular events are driven by cardiac risk factors, and the worsening profile of cardiovascular risk in America is cause for concern. Rising rates of obesity are particularly worrisome; more than one-third of American adults now have obesity, 37.7% in 2013 to 2014 versus 30.5% in 1999 to 2000.5 The obesity epidemic extends to children; 13.9% of children 2 to 5 years of age, 18.4% of children 6 to 11 years of age, and 20.6% of adolescents 12 to 19 years of age have obesity.5 Paralleling these increases in obesity are increases in the prevalence of hypertension and diabetes mellitus. Data from 2013 to 2016 indicate that 46% of US adults have hypertension, whereas 26 million adults, 9.8% of the US population, have diabetes mellitus.5

Individual habits and behaviors are an important part of cardiovascular health, and concerning trends portend increasing risk. The updated Physical Activity Guidelines for Americans7 released in 2018 reaffirmed key recommendations for aerobic and muscle-strengthening activity and reducing sedentary behavior. Unfortunately, data from NHANES (National Health and Nutrition Examination Survey) show that time spent in sedentary behavior has increased over the past decade,8 only 23% of adults meet the aerobic and muscle-strengthening recommendations in the guidelines,9 and only 26.1% of students in grades 9 through 12 are meeting the recommendation of 60 minutes of physical activity per day.10 Tobacco use remains a significant cardiovascular risk factor, the leading preventable cause of death and disability, with a concerning epidemic of youth and adolescent uptake of e-cigarette use.11,12 On the nutrition front, policy efforts have addressed diet quality for both children and adults, including changes in the food system and food labeling and improvements in government nutrition programs (school meals and competitive foods, the Child and Adult Care Food Program, the Supplemental Nutrition Assistance Program, and the Special Supplemental Program for Women, Infants, and Children).13

Adding to the apprehension about our nation’s cardiovascular health are concerns about worsening cardiovascular mortality and morbidity in our most at-risk populations. CVD and CVD risk factors affect many racial and ethnic groups disproportionately and may account for as much as 40% of the difference in life expectancy between blacks and whites in the United States.6 In additional, members of the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community disproportionately experience barriers to health care and coverage14 compared with their heterosexual peers and have a higher prevalence of CVD and risk factors.15,16

As staggering as the health consequences of CVD and stroke are, the economic burden imposed by CVDs is just as great. CVD and stroke accounted for 14% of total health expenditures in 2014 to 2015, the highest of any major diagnostic disease group. One study projected that the total cost of CVD, including direct medical costs and the cost of lost productivity resulting from the impact of disease, will reach $1.1 trillion by 2035.6

Healthcare Reform Since 2008

For decades, healthcare reform has been front and center in public and political forums, driven in large part by concerns about access, cost, quality, and the economic burden placed on patients, employers, and payers, especially compared with other developed countries. These concerns and the ensuing public debate led to legislation designed to transform the delivery of health care in the United States.

Expanding Access to Care Through the ACA

The 2010 enactment of the ACA brought significant reform to the US healthcare system, including the largest expansion of medical coverage since the creation of Medicare and Medicaid >50 years ago. The legislation included several provisions that focused on access to affordable, comprehensive health coverage and care. Notably, the ACA prevented insurance companies from declining coverage for patients with preexisting conditions or charging them more. Today, 52 million people <65 years of age have a preexisting condition that could have been a deniable condition in the pre-ACA individual market.17 The ACA also included a ban on annual and lifetime limits on coverage and required that all individual and group plans allow dependent coverage of adult children up to 26 years of age, a provision through which ≈2.3 million young adults gained health insurance between 2010 and 2013.18

Additional features of the ACA as originally enacted were a mandate that all individuals be covered by a qualified health plan or pay a fee for not being covered and the requirement that states expand eligibility for Medicaid coverage to low-income individuals at or below 138% of the federal poverty level. Through this expansion of Medicaid, thousands of previously uninsured adults with or at risk for heart disease, stroke, or other CVDs gained access to comprehensive health coverage. Since Medicaid expansion went into effect in 2014, 36 states and Washington, DC, have adopted it.*

The ACA also created state health insurance exchanges for both individuals and businesses. Exchanges provided a 1-stop marketplace for health plans that meet federal and state standards and thus are certified as qualified health plans. To bolster participation in health insurance and to make coverage more affordable for those who otherwise could not participate, the ACA offers premium tax credits and cost-sharing subsidies to lower premiums and out-of-pocket costs for people with low and modest incomes.

Among the benchmarks for qualified health plans are 10 essential health benefits: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment, prescription drugs, and rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care.19

An Evolving Emphasis on Prevention

As a result of the critical need to improve population health, the ACA included several provisions and initiatives that focused on primary and secondary prevention. These included the creation of a National Prevention Council charged with developing a comprehensive National Prevention Strategy to “guide our nation in the most effective and achievable means for improving health and well-being”20 and the Prevention and Public Health Fund to “provide expanded and sustained national investments in prevention and public health, to improve health outcomes, and to enhance health care quality.”21 The law also strengthened the role of the US Preventive Services Task Force recommendations within private and public health insurance coverage, although implementation has not been uniform.22,23 For example, nonexpansion Medicaid plans may charge copayments for some preventive services, including tobacco cessation. Evidence suggests that states that expanded Medicaid coverage experienced a sizable increase in recent smoking cessation among low-income adult smokers,24 although it must be noted that the comprehensiveness of the tobacco cessation benefit varies significantly by state and even by plan.25 The ACA also addressed access barriers to preventive care in Medicare. Although not required, if Medicare decides to cover an A (strongly recommended) or B (recommended) preventive service, the copayment is waived.26 Many Americans have gained coverage for no-cost preventive care; however, efforts to improve awareness27 and to address cost barriers are necessary for optimal uptake of this benefit.

A Shift to Value-Based Care Delivery Models

Although definitions of value in the health system vary, achieving high value for patients remains the overall goal of healthcare delivery and requires that patient preferences and other qualitative elements be taken into account. In newer value-based healthcare delivery models, providers are rewarded for efforts to help patients improve their health, either through healthier living or by reducing the incidence or effects of a disease. Typically, the delivery models provide additional payments to providers for improved outcomes and adherence to evidence-based practice guidelines known to improve care and, increasingly, less payment to providers and healthcare systems with worse outcomes or guideline adherence.

There has been sustained momentum toward value-based care, supported by the passage of the Medicare Access and CHIP (Children’s Health Insurance Programs) Reauthorization Act of 2015.28 Among the key provisions of this act was the creation of the Quality Payment Program, which replaced the sustainable growth rate formula for physician and provider payment with 2 value-based payment tracks: the Merit-Based Incentive Payment System and Advanced Alternative Payment Models. In addition, the Center for Medicare and Medicaid Innovation, established by the ACA, conducts testing and evaluation of payment and service delivery models and has authority to scale models without additional congressional action if evaluation shows they improved quality while reducing or maintaining cost. Several value-based initiatives, including the Hospital Readmissions Reduction Program, Medicare Shared Savings Program, accountable care organizations, and patient-centered medical homes, have already achieved reductions in health spending and improvements in care coordination and quality outcomes.29–32

Value-based insurance design is another tool that has emerged to encourage consumers to take advantage of high-value care by reducing consumer cost sharing for evidence-based services that yield health benefits of high value relative to their costs. By designing insurance packages that cover evidence-based preventive care, wellness visits, and certain high-value treatments (such as medications to control blood pressure) at little or no cost to consumers, health plans can promote prevention, healthy behaviors, and treatment adherence among beneficiaries, all of which may save money by reducing future expensive medical procedures and the provision of low-value care.

The Role of Biomedical Research in Improving Health Care

Government investment in biomedical research and subsequent improvements in the prevention and treatment of chronic disease have been integral in reducing CVD morbidity and mortality. Death rates for coronary disease and stroke are 60% and 70% lower than 3 generations ago, respectively.33 In addition, efforts underway by the Patient Centered Outcomes Research Institute, established as part of healthcare reform34 to fund patient-centered research, have resulted in significant investments in research on behalf of patients with CVD and stroke. However, compared with the high burden of cardiovascular morbidity and mortality and relative to other disorders, National Institutes of Health (NIH) funding for CVD is low, less than half of the funding allotted for cancer. There is also a limited pipeline of new treatments for CVD, with only 1 new cardiovascular drug approved in 2017.35

Committed to its mission, the AHA itself has funded more than $4.3 billion in research over the past 70 years, making the organization the largest funder of not-for-profit research in CVD and stroke other than the federal government. This research has involved all forms of CVD and stroke, and with the evolving recognition of the overlap between cardiovascular health and brain health, recent efforts have included research investments to understand this link. The AHA continues to invest effort and resources in translating research findings to policy, systems, and environment changes that transform population health and well-being in workplaces, schools, communities, and health systems and inform clinical guidelines that support and improve the delivery of evidence-based care.

Challenges to the ACA

Gains in coverage and access notwithstanding, the ACA has been embroiled in political debate since its passage. Although efforts to repeal and replace the law legislatively have been largely unsuccessful, its fragmented uptake and implementation and several rulings and administrative actions have hindered the ACA and weakened its impact across the country.

In one of the earliest challenges to the constitutionality of the ACA, NationalFederation of Independent Business v. Sebelius,35a the US Supreme Court upheld the individual mandate but ruled that the provision of the law authorizing the federal government to withhold federal Medicaid funds from states opting not to institute Medicaid expansion was unconstitutional, effectively allowing states to choose whether to expand coverage. Therefore, several states have not expanded Medicaid. Studies have shown that compared with nonexpansion states, states that have expanded Medicaid have experienced greater improvements in cardiovascular outcomes, including larger declines in uninsured hospitalizations for cardiovascular events36 and smaller increases in rates of cardiovascular mortality.37 Another study estimates that states with nonuniversal uptake of Medicaid expansion resulted in nearly 16 000 unnecessary deaths among the Medicaid-eligible population.38 In recent years, Medicaid waivers, including eligibility restrictions such as work requirements, have been encouraged and approved by the US Department of Health and Human Services. There is concern that such waivers create barriers to care for beneficiaries and run counter to the intent of Medicaid to provide health coverage.

Additional administrative actions allow states to pursue waivers that may weaken essential health benefit benchmarks, raise limits for consumer cost sharing, rescind protections for vulnerable populations, and promote substandard insurance products such as short-term limited-duration insurance plans, which lack critical benefits and ACA protections, including those for patients with preexisting conditions. The Kaiser Family Foundation estimated that the expansion of more loosely regulated plans, combined with the effective repeal of the individual mandate as part of the Tax Cuts and Jobs Act of 2017, resulted in insurance premiums an average of 6% higher in 2019 than otherwise would have been the case.39 In addition, reductions in marketplace enrollment assistance and outreach have affected consumers’ ability to enroll in and maintain coverage. Funding for the navigator program, which assists consumers in enrolling in ACA-compliant plans, fell 80% between 2016 and 2018, and the open enrollment period for the individual market has effectively been reduced by half.

In December 2018, a district court judge issued an initial ruling on Texas v. Azar,39a finding that the entire ACA, including premium subsidies for low- and moderate-income people, Medicaid expansion, coverage of preventive services with no cost sharing in the private market, and protections for those with preexisting conditions, should be struck down. In December 2019, the 5th US Circuit Court issued a decision on the appeal of the initial judgment, ruling the ACA’s individual mandate unconstitutional, and ordering the lower court to reconsider whether the remainder of the law can stand. As of January 2020, no final ruling has been issued.

Lack of Adequate Health Insurance

In 2018, 30.4 million people lacked health insurance,1 20.6 million with CVD or cardiovascular risk factors.40 Half of those without health insurance are eligible for coverage or ACA subsidies to help them get coverage but remain uninsured, primarily because of affordability.41 Another 4.1 million people are precluded from coverage because of immigration status or the decision by their state not to expand Medicaid.41

Although fewer people lack coverage now than before the passage of the ACA, a greater proportion are underinsured because of high out-of-pocket costs and deductibles. Of people who were insured continuously throughout 2018, an estimated 44 million were underinsured,† more than in 2010 when the ACA was passed.42 Much of the growth in the number of uninsured adults is occurring among those in employer-sponsored health plans in response to rising health costs. In 2018, employers contributed 51% more to their workers’ insurance premiums than in 2008. In the same 10-year period, contributions to premiums, deductibles, and other out-of-pocket costs for families with employer-sponsored coverage rose 67%, outpacing inflation and growth in wages.43 Lower-income beneficiaries and individuals with chronic diseases such as CVD are especially vulnerable to negative financial and health consequences associated with less robust coverage and higher cost sharing in order to carry a lower premium.

The connection between having adequate health insurance and health outcomes for the CVD population is clear and well documented. Americans with CVD risk factors who are underinsured or do not have access to health insurance have higher mortality rates and poorer blood pressure control than their insured counterparts. Uninsured patients with stroke also have greater neurological impairments, longer hospital stays, and higher risk of death than similar patients with adequate coverage. Inadequate coverage is also associated with cost-related barriers to necessary care. In 2018, 56% of underinsured adults and 59% of uninsured adults reported access problems resulting from cost, including not filling a prescription, forgoing needed specialist care, or skipping a recommended test, treatment, or follow-up.42

The AHA’s Principles for Healthcare Reform: 2020 and Beyond

In the context of the AHA’s past stated principles (Table) and the evolving landscape of the healthcare system, we now update what we believe to be the critical principles that must be satisfied to achieve health care that is adequate, accessible, and affordable for everyone living in the United States.

• All people living in the United States, regardless of health condition, should have comprehensive, understandable, and affordable health coverage.

• All people living in the United States should receive high-quality, affordable, patient-centered health care.

• All people living in the United States should have guaranteed access to evidence-based preventive services with minimal or no cost sharing, regardless of how they gain coverage.

• Race, sex, gender, and geographic disparities in health and health care must be eliminated.

• Public health infrastructure should be strengthened to effectively engage diverse stakeholders in multiple sectors, to adequately respond to social determinants of health, and to support the elimination of systemic inequities in health and health care.

• The US healthcare workforce should continue to grow and diversify through a sustained national commitment to culturally competent public health and medical education and clinical training.

• Support of biomedical and health services research should be a national priority, and inflation-adjusted funding for the NIH, CDC, and other agencies must be maintained and expanded.

Principle 1: All People Living in the United States, Regardless of Health Condition, Should Have Comprehensive, Understandable, and Affordable Health Coverage

The principal goal of health coverage is to ensure the provision of medical care for an individual when it is required because of illness or injury. For most, health coverage is also the mechanism to fund services aimed at preventing or screening for disease. Although the US healthcare system in many ways leads the world in medical education and biomedical research, the current hybrid approach to healthcare delivery and financing in the United States—consisting of multiple policies, mechanisms, and public and private programs and coverage—fails many. Nearly one-tenth of our residents are without health coverage, rising from a previous low of 27 million in 2016 to 30.4 million, or 9.4% of the population, in 2017,1 a significant portion with inadequate coverage and poorer health outcomes compared with developed countries that provide universal health coverage.45 This recent trend is worrisome; the availability of affordable, adequate health insurance is vital if we are to continue to make real progress in the prevention and treatment of chronic diseases such as CVD and stroke. To that end, health coverage that is comprehensive, affordable, and accessible to everyone living in the United States must be the first principle of a more effective US healthcare system.

Future reform efforts should not undermine the expansion of access to and adequacy of health coverage but bring us closer to meaningful health coverage for all people living in the United States. Initiatives should promote a strong, stable health system; adequate provider networks; and consumer-focused transparency of costs and coverage benefits. The provision of coverage information that is actionable, simple, and clear is critical to ensuring that the health system is navigable for patients and consumers. Coverage must facilitate access to the services and treatments needed by patients, including those with unique or complex medical needs. Patient protections currently in place, including prohibitions on preexisting condition exclusions, annual and lifetime limits, insurance policy rescissions, gender pricing, and excessive premiums for older adults, should be maintained.

Principle 2: All People Living in the United States Should Receive High-Quality, Affordable, Patient-Centered Health Care

Advances in health care that save lives or improve the quality of life do not have maximal impact if they are unaffordable, if the health benefits of these advances are disproportionately shared across populations, or if these care improvements are too complicated to access or manage.

The cost of health care to patients and the health system continues to outpace inflation and growth in wages; however, proportionate improvements in value in terms of individual or population health outcomes have not been observed. To minimize the impact of rising healthcare costs, many payers have opted to shift costs to beneficiaries in the form of higher premiums or higher out-of-pocket cost sharing, leading to indiscriminate reductions in consumers’ use of treatments and services rather than encouraging consumers to shop for lower prices.46,47 This evolving landscape illustrates a need to leverage our expanding ability to assess services on the basis of value and to explore new care delivery models that not only minimize unnecessary health spending but reduce use of low-value care48 and improve health outcomes with a lower-cost mix of resources.

In 2001, the Institute of Medicine, now the National Academy of Medicine, identified patient-centeredness as a key element of care that is safe, reliable, and responsive to patients’ needs.49 In recent years, patient-centered approaches to health care have taken on a greater importance in the development of high-quality care pathways through increased emphasis on care coordination, shared decision-making, informed consent, patient preferences and values, and other measures that integrate patients and their families into the care team. Through its Get With The Guidelines programs, the AHA develops clinical practice guidelines that support healthcare provider decision-making and integrates these guidelines into continuous quality improvement tools for use by both consumers and providers when evaluating healthcare choices. Evidence indicates that these and other similar initiatives not only improve patient satisfaction but also reduce unnecessary care use and health spending.50 Reform initiatives should ensure that health care is good quality and affordable for patients, including reasonable insurance premiums and cost sharing at the point of care, but also sustainable for the entire health system.

Recognizing the challenges facing both patients with CVD and those interested in improving their own cardiovascular health, in 2018, the AHA and the Robert J. Margolis, MD, Center for Health Policy at Duke University launched the Value in Healthcare Initiative–Transforming Cardiovascular Care to increase access to and affordability of cardiovascular treatment and to decrease barriers to care. Chief among the objectives of the initiative is to provide options for moving forward on more efficient care through multipayer-aligned payment reform for chronic disease management and value-based approaches to the use of drugs and devices.51 Health reform initiatives should consider these efforts while working to address both provider and patient roles in the use of low-value health services, assisting in enabling patients to distinguish between high- and low-value care, and supporting the provision of care that is evidence based and medically necessary.

Principle 3: All People Living in the United States Should Have Guaranteed Access to Evidence-Based Preventive Services With Minimal or No Cost Sharing, Regardless of How They Gain Coverage

Evidence-based preventive services improve health and reduce premature deaths by identifying illnesses earlier and managing them more effectively.52 Primary prevention describes medical evaluation, risk factor identification, and treatment before the onset of an illness or condition such as heart attack or stroke. Even for individuals who experience serious life-threatening cardiovascular illness or stroke, restoration of normal life expectancy can occur by living a healthy lifestyle, modifying their CVD risk factors, and receiving effective medical care after the onset of a condition or illness, commonly referred to as secondary prevention.

Among the modifiable risks for developing CVD are lifestyle and behavioral factors such as cigarette smoking, unhealthy diet and physical inactivity, and overweight and obesity. Other risk factors such as high blood pressure, elevated cholesterol, and diabetes mellitus can be prevented, identified, and treated, thereby reducing or even eliminating the risk of developing heart attack, stroke, heart failure, and associated disabilities. As with many other modifiable risk factors of serious and chronic illnesses, screenings, medical evaluation, and diagnostic testing are required to identify such risk factors and to initiate treatment and preventive interventions.

In addition to reducing recurrences and the progression of many illnesses to chronic and disabling conditions, prevention may reduce overall healthcare expenditures, particularly when viewed longitudinally across the continuum of care. Cost barriers to the use of preventive services exist and have been shown to influence use. Survey data indicate that as many as 50% of individuals without health insurance coverage of preventive services and more than one-third of individuals and families who fall below 200% of the federal poverty level avoid or postpone recommended preventive services because of costs associated with such services.27

The value of offering evidence-based preventive services free of cost to the individual in terms of better population health is undeniable. Many population health and wellness proponents and healthcare economists support rebalancing our healthcare expenditures toward “well care” from the current heavy emphasis on “sick care.” Evidence demonstrates that better preventive care will reduce chronic illnesses and disability, along with high-cost care to treat and manage chronic conditions.53 Because the current coverage of many preventive services is not uniform or always well understood by the covered population, evidence-based preventive services with minimal or no cost sharing should be a core offering within private and public healthcare coverage.

Principle 4: Race, Sex, Gender, and Geographic Disparities in Health and Health Care Must Be Eliminated

Despite significant advancements in the prevention and treatment of CVD and stroke, these benefits have not been experienced equitably. Racial and ethnic minority groups are more likely to be uninsured than whites, with Hispanics, American Indians, and Alaska Natives being most likely to lack coverage.54 In addition, racial disparities in CVD mortality have persisted for decades, with slower rates of decline in blacks than whites.55 Data from the CDC show the total 2014 to 2016 CVD death rate per 100 000 (all ages, all races/ethnicities, both sexes) was 221.8 for non-Hispanic whites compared with 289.2 for non-Hispanic blacks.56 In addition, black and Hispanic patients are disproportionately affected by poor adherence to cardiovascular medications compared with white patients.57,58 These disparities are a function of several factors, including social determinants of health, genetics, burden of traditional CVD risk factors, and even treatment bias. For example, racial minorities have received less timely evidence-based therapies and often experience worse outcomes.59,60 Revolutionary breakthroughs in drugs and therapies for several serious and chronic diseases are expected in the years to come; thus, it is imperative that reform efforts ensure equitable access to new and existing treatments, especially for underserved populations already at socioeconomic disadvantage.

Disparities also persist across sex and gender identity. Women tend to report poor communication with their healthcare providers and dissatisfaction with their care more than men. In addition, significant data show that fear of discrimination discourages LGBTQ individuals from seeking necessary health care.61–63 This supports the need for better preparedness among healthcare professionals to effectively care for patients across the continuum of sexual orientation and gender expression.64,65 Inequities affecting the LGBTQ community especially are poorly understood and underscore the need for nationally representative data on LGBTQ patients, as well as an intentional investment in research to define how gender identity, sex, sexual orientation, race, ethnicity, and socioeconomic factors interact to influence access to patient-centered, culturally competent care.

Race, sex, and gender disparities may be compounded by geography; improvements in CVD mortality in certain areas of the country have not kept pace with overall national progress, particularly in southern states66,67 and states that have not expanded Medicaid. Rural communities also face a unique set of challenges and disparities, including numerous hospital closures,68 a critical, ongoing shortage of health care professionals,69 and an expanding gap in mortality rates compared with urban and suburban communities.70 Therefore, reform initiatives should be locally informed and should consider the potential disproportionate impacts on access to comprehensive care and adoption of disease prevention and treatment, with the understanding that appropriate solutions will be multifactorial, not one size fits all.

Meaningful reform must include targeted measures to evaluate and address health disparities, socially driven health inequities, and overall quality of care. Federal and state appropriations should facilitate needs-based, culturally appropriate allocation of resources that improve population health. Patients should be supported by the health system to be active participants in their care, and clinical trial participation should be robust, diverse, and representative of America’s changing demographic composition. Minimizing the current distribution of health disparities and ensuring equitable distribution of resources will be essential for ensuring the economic and social strength of our nation.

Principle 5: Public Health Infrastructure Should Be Strengthened to Effectively Engage Diverse Stakeholders in Multiple Sectors, to Adequately Respond to Social Determinants of Health, and to Support the Elimination of Systemic Inequities in Health and Health Care

Public health infrastructure is necessary to provide communities with the capacity to prevent disease, to promote health, and to prepare for and respond to emergency and ongoing threats to health.71 Greater investment in public health and social services has the potential to improve disease mortality and morbidity and to save significant healthcare costs. A study of public health spending in 13 local public health agencies around the country found that communities with larger increases in public health spending experienced larger reductions in mortality from leading preventable causes of death, including a significant decrease in mortality associated with CVD.72 Comparisons of state-to-state spending between 2000 and 2009 showed that states with higher ratios of social service spending to healthcare spending also had better outcomes and improved health. As an example, a 20% increase in America’s median social-to-health spending ratio would equate to 85 000 fewer adults with obesity.73

The US healthcare system needs a tighter social safety net, with a greater focus on enhancing health counseling, expanding nutrition and physical activity programs, increasing the availability of quality affordable housing and public transportation, and engaging more caseworkers and community health workers in patient and consumer outreach, with potential far-reaching societal impact. Because people from underserved racial and ethnic groups are more likely to receive coverage through public programs, reimbursement for language services and the additional time involved in providing clinical care for patients with limited English proficiency or low health literacy should be provided. In addition, health programs should be resourced to support adequate responses to inequities relating to race, ethnicity, sex, gender, socioeconomic status, and cultural differences. Accountable care organizations and more recent efforts by the Centers for Medicare & Medicaid Services to create accountable health communities that reward providers on the basis of health improvements could spur experimentation with interventions that address housing, community infrastructure and economic development, nutrition, physical activity, transportation, legal services, and other social services that may improve patients’ health outcomes.74

We encourage the development and implementation of a comprehensive, nationwide public health informatics infrastructure. Effort should be made to facilitate complete and accurate capture of patient data—including race, ethnicity, socioeconomic status, and other social determinants of health—to give a more comprehensive view of the patient’s clinical, social, and behavioral risks. The availability of such patient information in electronic health records and the ability to share data with appropriate public health and healthcare stakeholders and to connect patients with necessary community services are necessary to identify, measure, and mitigate disparities and to address the upstream, and often nonclinical, factors that influence them. The use of these data to inform public health needs will require a single set of data standards and an informatics infrastructure capable of seamlessly and automatically exchanging relevant data in a bidirectional manner with any health information exchange. In addition, any efforts to leverage artificial intelligence to drive improvements in clinical decision-making across the care continuum should be not only transparent but also informed by data that are diverse, equitable, and representative.

Principle 6: The US Healthcare Workforce Should Continue to Grow and Diversify Through a Sustained National Commitment to Culturally Competent Public Health and Medical Education and Clinical Training

Looking toward the future for the delivery of health care in the United States, we continue to see significant deficits in the number and the diversity of healthcare workers available to take care of the population, especially in underresourced communities. The Association of American Medical Colleges estimates that the US population will increase by 10% and the population ≥65 years of age will increase by 48% between 2017 and 2032. Over the same time period, the predicted shortfall in the number of physicians needed to provide adequate coverage could be nearly 12 000.75 This includes a potential shortfall of 12 100 medical specialists, 23 400 surgeons, and 55 200 primary care physicians. These provider shortfalls go beyond physicians; predicted shortages of nurses, advanced practice providers, therapists, and other care team members contribute to access limitations and may accentuate disparities in care use. Scope-of-practice restrictions on nonphysician clinicians such as nurse practitioners and physician assistants and a widening disparity between where clinicians will practice also exacerbate inequities for coverage in urban and rural communities for primary, preventive, and specialty care. Moreover, trends in the recruitment of a diverse workforce that encompasses viewpoints and experiences across sex, geographic, and ethnic populations must be improved to deliver quality health care across the country.76

Racial and ethnic minority groups make up >30% of the total US population but represent only 11.5% of our clinical workforce, according to data collected from 2011 to 2015 by the Department of Health and Human Services.77 The percentages of medical school graduates by race and ethnicity have remained consistent over time, with whites and Asians making up >75% of graduates compared with 5.7% blacks and 4.6% Hispanics.78,79 Although there has been an increase in the total number of black graduates from medical schools, specifically black female graduates, the number of black male graduates declined >20% between 1996 and 2015.79 In addition, only 39% of current full-time medical faculty are female, with 4% of those females identifying as black, African American, Hispanic, Latino, or other underrepresented race or ethnicity. Furthermore, women of color represent only 3% of department chairs in academic medicine.79

Providing an environment where diversity is acknowledged, celebrated, and thought of as a strength will help improve trends in representation within the workforce. Concerted efforts have been made across the country to address the issues of diversity in our medical schools and to enhance the diversity of our clinicians and academics across all spectrums of medicine. These include significant funds specifically supported by institutions to expand the underrepresented minority faculty.80,81 Resources should also be invested in promoting diversity across advance practice professions and widening the path for medical students from low socioeconomic backgrounds and first-generation medical students to join the healthcare workforce. In addition, healthcare professionals must achieve a greater understanding of patients’ clinical and psychosocial needs and the cultural competency necessary to interact with the populations at greatest risk. It is imperative that clinicians understand not only their patients’ disease but also how their surroundings (social, economic, cultural) will influence their health outcomes. There is an acknowledgment that this awareness should now start at the beginning of medical training and become part of the formal learning and research process on patient care. Moreover, these efforts should extend beyond medical schools to include advance practice provider training programs, pharmacy programs, nursing programs, and any other traditional healthcare professionals and nontraditional stakeholders (eg, community health workers).

The recruitment of a more diverse workforce begins in our local communities and grade schools across the country, with prekindergarten for all at the community level and science/technology/engineering/mathematics programs sponsored by local colleges, medical schools, the federal government,82 and organizations like the AHA that provide students with the opportunity to learn and embrace the career paths of science and medicine. Greater opportunity for early exposure, education, and involvement should be integrated into long-term solutions to address the deficit in our workforce.

Principle 7: Support of Biomedical and Health Services Research Should Be a National Priority, and Inflation-Adjusted Funding for the NIH, CDC, and Other Agencies Must Be Maintained and Expanded

The investment by the United States in research has led to remarkable progress over the past 7 decades in reducing cardiovascular and stroke mortality, with death rates resulting from coronary heart disease falling by 32% and the death rate resulting from stroke decreasing by 16% between 2006 and 2016.5 These significant reductions in mortality outcomes were driven by investments in biomedical research that addressed the underlying mechanisms of CVD and stroke and developed new interventions to prevent or alter the course of these diseases.

The support of the federally funded NIH has been pivotal to the wide-ranging biomedical research and large-scale clinical trials that have defined the optimal care and prevention of CVD and stroke. Many of the most transformative studies of CVD and stroke have been NIH funded, including the National Heart, Lung and Blood Institute’s SPRINT (Systolic Blood Pressure Intervention Trial), which helped to inform the hypertension treatment guidelines released in 2017 by the AHA and the American College of Cardiology. These guidelines “recommended a new, lower blood pressure target to reduce deaths” resulting from heart attack and stroke, in particular among older, high-risk individuals. This and other federally supported research trials have had dramatic effects on the health and well-being of people living in the United States.

Despite renewed investments in the NIH in recent years, the relative amount of funding is still comparatively low when one considers the potential of this research to influence healthcare quality and cost. The United States spends more than $10 700 per person each year on healthcare services83 compared with only $105 per person on federally funded NIH biomedical research.84 Any efforts at healthcare reform designed to advance science and to improve the quality and effectiveness of health care will require a larger commitment to the research necessary to understand and improve the quality of health care in the United States.

Of particular concern is a decline in the number of physician-scientists; the number of physicians engaged in research in the United States is now only ≈1.5%.85 Many factors likely contribute to this trend, including increasing requirements for clinical activity, less protected time for research for physician-scientists, and difficulty in obtaining federal and nonfederal funding to support research.86,87 Consistent funding of research, both public and private, provides an important signal to existing and potential young researchers that rewarding and substantive career paths exist in the sciences. Increased federal investments in research across several federal agencies, including the NIH and CDC, and well-established programs such as the Agency for Healthcare Research and Quality, Center for Medicare and Medicaid Innovation, and Patient Centered Outcomes Research Institute are also critical to encourage a diverse pool of talented young researchers to both begin and continue careers in biomedical science. Implementation science is an exciting and important field to help in the understanding of what will be required to improve care and, just as important, what will not improve care for the individual and population. Adding to the knowledge of what should be defined as quality care through clinical redesign and the study of new and alternative pathways of care will be vital to continued healthcare reform.

Conclusions

As transformative as the past 10 years have been for the US health system, the next 10 years will be even more critical in improving the health and well-being of Americans. The groundbreaking initiatives that have come from the ACA and the robust data that define them have contributed to an enhanced understanding of the factors that must be addressed to truly bring quality health care within reach for everyone living in the United States. This enhanced understanding must be accompanied by a bipartisan ownership of the existing issues and commitment to a unified way forward, including meaningful health reforms that prioritize value in health coverage and care, enhance the ability of the health system to address social determinants of health and to mitigate disparities in health outcomes, support innovation in treatment and care delivery, and promote the growth of a healthcare workforce representative of the diverse communities we serve. The AHA welcomes the opportunity be part of the dialogue and solutions that will lead to a comprehensive elevation of health and health care for all.

* At the time the article was published, 36 states and Washington, DC, had adopted Medicaid expansion.

† Underinsured refers to adults who were insured all year but experienced one of the following: out-of-pocket costs (excluding premiums) equaled ≥10% of income; out-of-pocket costs (excluding premiums) equaled ≥5% of income if low income (<200% of poverty); or deductibles equaled ≥5% of income.

Footnotes

//www.ahajournals.org/journal/circ

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This advisory was approved by the American Heart Association Advocacy Coordinating Committee on October 22, 2019, and the American Heart Association Executive Committee on December 18, 2019. A copy of the document is available at //professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 215-356-2721 or email Meredith.[email protected]com.

The American Heart Association requests that this document be cited as follows: Warner JJ, Benjamin IJ, Churchwell K, Firestone G, Gardner TJ, Harrington RA, Johnson JC, Ng-Osorio J, Rodriguez CJ, Todman L, Yaffe K, Yancy CW; on behalf of the American Heart Association Advocacy Coordinating Committee. Advancing healthcare reform: the American Heart Association’s 2020 statement of principles for adequate, accessible, and affordable health care: a presidential advisory from the American Heart Association. Circulation. 2020;141:e601–e614. doi: 10.1161/CIR.0000000000000759

The expert peer review of AHA-commissioned documents (eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit //professional.heart.org/statements. Select the “Guidelines & Statements” drop-down menu, then click “Publication Development.”

Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at //www.heart.org/permissions. A link to the “Copyright Permissions Request Form” appears in the second paragraph (//www.heart.org/en/about-us/statements-and-policies/copyright-request-form).

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