In a Comment published alongside the Lancet Series America: Equity and Inequality in Health in April, 2017, Senator Bernie Sanders (I-VT) wrote: “Today, we must do everything we can to prevent the repeal of the [Affordable Care Act (ACA)] and oppose attempts by the Trump administration to undermine it by failing to enforce the law or promulgating regulations that would sabotage it. Tomorrow, we must work to join the rest of the industrialised world and guarantee health care to all citizens through a Medicare-for-all single-payer system.”

The push to usher in “tomorrow” has increased momentum. On Sept 13, 2017, Sanders, along with 15 other Democratic senators, unveiled the Medicare-for-all Act. The plan proposes a complete overhaul of the US health-care system by establishing the Universal Medicare Program (UMP), a single-payer system that would end the ACA marketplaces and prohibit private health insurers. The core benefits covered by the UMP draw on the essential health benefits laid out by the ACA, including inpatient and outpatient hospital care and emergency services, primary and preventive care, prescription drugs and devices, and comprehensive reproductive and maternity care. Further, the UMP would eliminate all so-called cost sharing for consumers, such as copays and deductibles. The Medicare-for-all model would be all inclusive, covering US citizens and immigrants, as well as potentially undocumented immigrants, and, unlike the current Medicare system from which it draws its name, it would cover individuals of all ages.

For its proponents, the single-payer plan outlined by Sanders' bill is the gold standard ideal for achieving universal health coverage (UHC) in the USA. Indeed, the advantages of single-payer systems in other contexts are plain—all citizens are covered, care is affordable and accessible, and administrative waste is dramatically less. But the case for a single-payer system in the USA is a far more complex, and costly, proposition. Health care comprises about 17·8% of the GDP (US$3·2 trillion) and for the federal government to solely assume that financial burden would require substantial tax increases across the economic strata. Furthermore, health care is also the leading driver of job creation. Convincing Americans to forego that growth as well as to embrace a fledgling single-payer option in lieu of employer-provided health plans would be a huge challenge.

With varying levels of support among Democrats, however, and none from Republicans who control all three branches of government, there is wide acknowledgement that Sanders' bill, as it is formulated, cannot pass. Which has left many pundits asking whether the USA is simply not ready for a single-payer plan. Despite the dilemmas accompanying Sanders' bill, recent public polls indicate that there is moderate and growing support for a single-payer plan (33%) and surprisingly strong agreement that the federal government's responsibility is to ensure that all Americans have health coverage (60%).

Whether or not Americans favour single-payer as the route, UHC should firmly stay the goal. According to 2016 US Census Bureau data, the uninsured rate fell to 8·8%—the closest the USA has come to UHC. Barometry of public opinion aside, the ACA remains the single most critical instrument for improving the rates of coverage.

Yet even after the spectacular failures of the American Health Care Act and the Better Care Reconciliation Act earlier in 2017, Republicans are insistent on a last-ditch effort to pass legislation repealing the ACA through the process of reconciliation—which would only require a 51-vote majority—before the Sept 30 deadline.

Following the release of the Medicare-for-all bill, the Graham-Cassidy-Heller-Johnson Amendment, has taken on new urgency with the Trump administration and Senate Majority Leader Mitch McConnell (R-KY) behind it. It would shift federal funding for the ACA to block grants for the states to administer, eliminate subsidies for private insurance, and end Medicaid expansion—a move that would severely undermine the coverage gains, increased access to care, and improved health outcomes achieved, especially for low-income Americans.

Although the two major plans under consideration could not be further apart, it is important to recognise that many other health-care reform plans are currently being pitched and refined, variations on the theme that might include, for example, revisiting a public option alongside private insurers. The renewed discussion is a strong testament to the important contributions of progressive voices such as Sanders for continuing to champion a way to cover all Americans. But for now, tomorrow must also be today as legislators must work to continue to defend the ACA while helping the USA find its path to UHC.

America: Equity and Inequality in Health see Forsee http://www.thelancet.com/series/america-equity-equality-in-health Medicare-for-all Act see For thesee https://www.sanders.senate.gov/download/medicare-for-all-act?id=6CA2351C-6EAE-4A11-BBE4-CE07984813C8&download=1&inline=file single-payer public polls see For more on thesee https://www.sanders.senate.gov/download/medicare-for-all-act?id=6CA2351C-6EAE-4A11-BBE4-CE07984813C8&download=1&inline=file

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