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Stuart Butler’s proposal for an equitable national health system

December 10, 2020

Topics: Quote of the Day

By Stuart M. Butler
Brookings, December 9, 2020


The American health system is rife with gaps and inequities. The result is inadequate or no insurance and services for millions of families and unacceptable differences in resources and health conditions related to income, race, and location. Resources are misallocated, the health care infrastructure in many communities is inadequate, and our financial support for health coverage is disjointed and inefficient.

It is time to move towards a health system in America that provides adequate, affordable, and accessible care to all U.S. residents, and that reaches this goal by refining existing programs, correcting the subsidy system, and using the power of federalism. Achieving this goal requires us to:

  • Create an effective, grassroots community health system by expanding health clinics, creating other local points of access, focusing on social determinants of health, and addressing gaps in Medicaid.
  • Reform the tax treatment of employment-based coverage to create universal subsidies that allow effective choices of coverage in an arrangement that could be described as “Medicare Advantage for All.”
  • Use program flexibility and state innovation to create a truly national system with appropriate state variation.





  • Strategic principles for action.
  • Create an effective grassroots population health system
    • Action: Expand community health centers.
    • Action: Make additional access points available.
    • Action: Focus on social determinants.
    • Action: Create an option for non-expansion states.
  • Achieve equitable subsidies for insurance: Transition from employer-sponsored insurance to Medicare Advantage for All?
    • Action: Replace the tax exclusion with universal tax credits.
    • Action: Move to Medicare Advantage for All.
    • Create a national system with state variation
    • Action: Make greater use of waivers.


A byproduct of the COVID-19 pandemic is a better understanding today of the structural weaknesses of the U.S. health system and a growing appreciation and acceptance of what a reformed system should look like. Still, Americans hesitate to embrace big change in health care, even when they agree on the need for it. Fortunately, reform does not require a wholesale abandonment of the current system and the implacable opposition that likely would be triggered if that were attempted. There are many programs and elements of the current system we can build on and make consistent. Moreover, many of the key ideas discussed in this report have their roots in both political parties, and so, with genuine outreach to leading lawmakers on Capitol Hill, the Biden Administration could achieve bipartisan progress on health reform. Moreover, structural change does not have to come in the form of one giant bill; it can be achieved through a series of bills and administrative actions. Indeed, with a clear, shared vision of the objectives, some bold leadership, and a willingness to build on or remodel some existing parts of today’s system, there is a bipartisan path to an equitable, inclusive, and comprehensive American health system.



By Don McCanne, M.D.

Many will remember that it was Stuart Butler who created the Heritage Foundation model that was used as the framework for the Affordable Care Act. It was selected by the Democrats as a model that would have the support of the Republicans because of its conservative bona fides. As it turned out, though the Republicans initially cooperated, it was decided that it was more important to deny President Obama a political success, and so the Republicans fought the measure, requiring the Democrats to make compromises that fell quite short of the equitable, comprehensive reform they intended.

Stuart Butler was not really satisfied with the result either. In the meantime, he wisely moved from the Heritage Foundation which had taken a more reactionary turn, and aligned himself with the moderate Brookings Institution. With the election of Joe Biden as president, an opportunity has arisen to repair the defects in the original ACA legislation, and so Butler presents his views here on what he believes would be “a bipartisan path to an equitable, inclusive, and comprehensive American health system.”

If you believe that reform should be based on making improvements in the Affordable Care Act, as Biden has supported, then the proposal is an effective model of expanding coverage and making it more equitable. It is important to understand it since it is likely that it, or a very similar model, will have strong support by the Biden camp, fulfilling his stated desire to work across the aisle. Just as ACA provided beneficial changes in health care financing, this expansion and correction would as well.

But there are very serious deficiencies in this proposal. Above all, it would leave in place most of the current, highly inefficient, administratively complex and costly health care financing infrastructure which is a major cause of our outrageously high health care costs. In fact, of all of the models of reform, this is perhaps the most expensive, when achieving affordability is one of the primary goals of reform.

Butler points out that his model would be bipartisan because it includes specific policies that come from each side of the political spectrum and some policies on which there is mutual agreement. Although the policies expanding health care justice would certainly be welcome, other policies that further privatize the system, such as a move towards private Medicare Advantage for All, should be rejected since private plans have been responsible for many of the injustices in health care today.

We’ve stated several times before that we need to get the policy right and then change the politics to enable enactment and implementation of those policies. Butler has it backwards. He is trying to clear the political hurdles by accepting flawed policies that would appeal to the ideological preferences of those on the right, assuming that the left will accept any compromises as long as reform is advanced, as they did with ACA.

If we want the most affordable program that is truly universal, comprehensive, and especially is equitable, then we need to enact a well designed, single payer, improved Medicare for All, but we’ll need to travel the rough political road of convincing Joe Biden that Medicare for All is what we want and need.

In the meantime, try to understand Stuart Butler’s proposal so we can explain to President Biden and everyone else why we do not want to go that route.

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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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