**4.1 Lessons learned from past reform initiatives**

Before having any success in bringing about change, we need to better understand the forces that blocked previous attempts. It has been more than a century since Teddy Roosevelt, running as a presidential candidate on the progressive ticket in 1912, proposed universal coverage through national health insurance. These are the major lessons that we can take from every attempt to reform health care since then, including passage of the Affordable Care Act (ACA) in 2010:


A comprehensive report was published by the Institute of Medicine in 1996, *Primary Care: America's Health in a New Era*, calling for an urgent priority to prioritize primary care. But its recommendations were largely unheeded by legislators and policy makers as underinvestment in primary care continued. A recent 2021 report from the National Academies of Sciences, Engineering and Medicine again strengthened the case for primary care as the foundation of the U. S. health care system. Its 448-page report, *Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,* calls for policies that:


*Primary Care in the USA: The Long Struggle to Build its Foundational Role DOI: http://dx.doi.org/10.5772/intechopen.98792*


That report went further to recommend, with a sense of urgency, that major government programs such as Medicare and Medicaid shift money to primary care and away from the non-primary care specialties, which are so highly reimbursed in our present system. The report concluded that:

*High-quality primary care is the foundation of a robust health care system, and perhaps more importantly, it is the essential element for improving the health of the U. S. population. Yet, in large part because of chronic underinvestment, primary care in the United States is slowly dying [31].*

#### **4.2 Coalition of primary care organizations**

A coalition of 7 primary care organizations, representing 400,000 members and diplomates, has come together to emphasize the urgent need for primary care to serve as the foundation of the U. S. health care system. These include the national organizations in family practice, general internal medicine, and general pediatrics. Together, they call for a new paradigm for primary care to be established based on coordination and continuity of comprehensive person-based care for the majority of health care conditions, with the capacity to decrease disparities and inequities. They also bring a unified voice calling for payment and regulatory reform to stabilize and strengthen practice [32].

#### **4.3 Current approaches to health care reform**

Three major reform alternatives will be considered in a deeply polarized Congress with corporate lobbyists descending on Washington D. C. to try to ward off reform one more time. Here are briefly encapsuled summaries of the alternatives.

#### *4.3.1 Building on the ACA*

The ACA has been helpful as an incremental step to needed reform by bringing health insurance to some 20 million people since its passage in 2010, mostly through expansion of Medicaid in 31 states. It has also provided coverage to 8 million Americans who lost coverage during the pandemic [33].

On the other hand, these points show how far short from needed reform that this alternative is:

"It will still be just another Band-Aid on a broken system without universal coverage.

