Dozens of members of Congress, presidential candidates, and state policymakers have released and debated proposals to make access to health coverage universal—or to make strides toward that goal. Proponents of a public, single-payer system argue that to achieve true universal health care, we must take private insurers out of the picture entirely, and provide universal coverage through a system such as Medicare. Others argue that the nation can approach or achieve universal coverage by the introduction of a public option or by expanding the ability of people to buy into existing public insurance. Regardless of which path wins out, the next iteration of health care reform must focus on both providing affordable, comprehensive coverage for individuals and boldly supporting better access to quality care, particularly for marginalized communities. 

Below are ten guidelines to direct policymakers looking to build on the gains of the Affordable Care Act and move boldly toward achieving a truly universal, comprehensive, and equitable health care system:  

  •  Protect and expand access to insurance coverage and comprehensive benefits by reversing Trump deregulation attempts and bolstering the ACA benefit provisions and nondiscrimination guarantees. The Affordable Care Act created a set of private market reforms designed to end blatant discrimination against women, people with preexisting conditions and health status more broadly, and people in protected classes. All new reform efforts must not only reverse Trump administration efforts to weaken both protections against explicit discrimination and baseline coverage standards, but also further codify protections that ensure that benefit inclusion and design decisions do not result in limiting access to care for people by health status or protected class. It must also use evidence-based strategies to build on the essential health benefits package to address, for example, long-term care needs. 
  •  Provide access to health care for U.S. residents, regardless of immigration status. Noncitizens are almost five times as likely to be uninsured (though just as likely to be in a family with an employed individual), making up one-quarter of the total uninsured population—in large part due to limited access to employer coverage and explicit barriers to public and individual coverage. Our country’s uninsured rate will never reach zero if health reform does not address those barriers.
  •  Make any premiums or out-of-pocket costs affordable for consumers across the income spectrum. Achieving universal coverage will require both significant public investments and provider payment restructuring to bring down premiums to affordable amounts at every income level. In order to make coverage a practical way to access health care, reform efforts must also limit out-of-pocket costs, such as deductibles, surprise bills, high prescription drug costs, and other point-of-service charges. Efforts that provide advances on premiums without addressing out of pocket costs may achieve universal coverage but may fall short of universal access to care, particularly for communities with low- and moderate-median income and/or limited wealth.
  • Ensure that consumers have access to quality providers, which means both anticipating increased demand and addressing existing provider shortages and hospital closures. Health reform efforts must make any new access to coverage usable in practice—in particular, people in both low-income communities of color and rural communities, who currently have limited options, must be able to see a doctor or get to a hospital nearby—and those care options must be of quality. Additionally, a larger insured population may result in an increase in demand for care, and therefore requires transitional planning to ensure that the health care workforce pipeline expands and diversifies.
  • Support the development of a robust, diverse, and culturally competent health care workforce. Ensuring a health care workforce that is robust, diverse, well-trained and culturally competent is essential to health reform efforts. Diversity should be encouraged and facilitated throughout the health care system and care teams, including physicians, nurses, and medical specialists, as well as community health workers and paraprofessionals. All staff and personnel should be adequately trained on an ongoing, periodic basis to ensure cultural competency. Payment rates and coverage guidelines for health care coverage, including coverage under a public option or safety net program, should be developed in a way that supports fair, living wages and pay equity in the health care professions and jobs. 
  • Promote health equity by adequately addressing racism, bias, discrimination, and other systemic barriers within the health care system. Structural racism and discrimination plague communities of color and pose barriers to attaining quality health care. Black and Hispanic patients with chronic health conditions are more likely to report experiencing discrimination in health care. Health reform efforts must promote health equity and acknowledge the historical foundations of racism in this country, particularly against African Americans, indigenous people, and those of Latin descent, while also incorporating mechanisms to adequately address discrimination. Health care providers, personnel, and staff should be trained to recognize and eliminate both explicit and implicit bias. Trainings should be substantive and take place at regular intervals. Health reform plans should also include accountability measures at both the individual and systems levels, including measures that link payment to quality and professional certification and licensure. 
  • Incorporate evidence-based tools to adequately address health disparities that focus on quality of care and extend beyond health insurance coverage. Health insurance coverage is just one aspect in helping to ensure that all people have the highest attainment of health and well-being, not the full picture. How a country performs in addressing health disparities is a measure of progress toward achieving health equity, and the United States continues to fall short. Across health conditions, people of color experience worse health outcomes than whites. Health disparities also exist based on income level. Health reform efforts must build upon the work to address health disparities as implemented under the Affordable Care Act, and be steadfast in focussing on both insurance coverage and the quality of health care. This must include taking into account the social determinants of health and working across sectors to support individuals and families at greatest risk for poor health outcomes. Any health reform plan must hold providers accountable for reducing health disparities and providing all people, regardless of income-level, race/ethnicity, gender, disability, or sex, with high quality, compassionate health care.      
  • Promote the destigmatization of mental health conditions and increase meaningful access to mental health care by better integration within the health care system, ensuring the availability of a diverse mental health workforce and affordable coverage. According to the American Psychological Association, mood disorders and rates of suicide have significantly increased in the United States. Despite some integration of mental health screenings into other health care services and better insurance coverage under the Affordable Care Act, it is still woefully challenging to find a mental health care provider and cover the out-of-pocket costs associated with this care for many people in the country. Indeed, these burdens fall hardest on low-income communities and people of color. Health reform efforts must prioritize ensuring the availability of mental health care, including support for a diverse mental health workforce. For people of color, culturally competent care is critical in the true attainment of physical, mental, and emotional health. Mental health providers must be accessible and new insurance options must cover nontraditional service provision, such as through telehealth in lieu of in-person visits, in order to support care for hard-to-reach populations, including rural communities. Public and private health insurers also have a responsibility to help promote the destigmatization of mental health care by ensuring adequate coverage for mental health services within health plans and minimal cost-sharing.   
  • Strengthen access to trusted community-based providers currently available through safety net programs. Safety net programs such as Medicaid, Medicare, the Children’s Health Insurance Program, and Title X have helped to ensure health care coverage and access for low-income people for decades. Community-based health care providers, which are also key components of the safety net, work on the frontlines to serve individuals and families with or without health insurance. These providers often reflect the demographics of the communities they serve and offer basic health care services at free or reduced cost. Health reform plans should ensure continued access to these vital sources of care, as well as seamless coordination with health insurance payers for people with coverage. Regardless of the health reform vehicle or structure, safety net programs will always be important to ensuring health care access for marginalized communities.   
  • Guarantee comprehensive coverage of sexual and reproductive health care, including insurance coverage of abortion. The Affordable Care Act helped to revolutionize the provision of comprehensive, affordable women’s health care. Contraception, maternity care, well-woman visits, screenings for reproductive cancers, breastfeeding supports, and a host of other services are supported under the law without cost-sharing. The Affordable Care Act also made it illegal to charge women more than men for health insurance coverage. Unfortunately, insurance coverage of abortion was not included in the package of women’s health services supported under the Affordable Care Act. Health reform plans must maintain these critical women’s health care supports and finally treat abortion as the health care it is by covering it without restriction or onnerous administrative burdens in all plans, regardless of the payer. 

The Affordable Care Act has helped transform insurance coverage and the delivery of health care for millions of people in this country. And while it is important to reflect on the progress made, it is equally important to build on coverage gains and improvements in health outcomes. Health care reform has been central to the national debate on how best to move the country forward. Regardless of the structure or vehicle, the guidelines outlined in this document chart the way forward for a health reform that not only focuses on ensuring universal health insurance coverage, but also promotes health equity and proactively addresses better access to quality, affordable health care for all. In order to realize truly universal coverage and health care access, the U.S. health care system must work for and adequately serve all people in this country.