Policy Strategies to Advance Cardiovascular Health in the United States—Building on a Century of Progress

The US health care system has undergone remarkable transformation over the past century. Policy proposals to create a national health insurance system date back decades and have faced multiple political headwinds but focused on similar and consistent themes: achieving universal health care coverage, containing high and rising health care costs, and increasing competition among private plans.

When President Obama came to office in 2008, his administration faced compounding health system challenges. Nearly 45 million Americans lacked health insurance coverage. Concerns that private plans were overtly prioritizing profits rather than patients had intensified. National health care costs had risen to 17% of the gross domestic product. At the same time, health outcomes in the United States were worse than comparable countries. In 2010, President Obama signed the Affordable Care Act (ACA) into law, which had 3 areas of focus: expanding coverage through public and private payers, reforming health insurance markets to be more patient-friendly, and improving quality of care and reducing spending through value-based payment programs.

The ACA addressed high noninsurance rates in the United States with an individual mandate, which required most people to obtain health insurance, and by creating government-run public marketplaces (exchanges) where individuals could obtain insurance plans, often subsidized for lower income buyers. At the same time, the ACA also expanded Medicaid coverage to all adults with incomes up to 138% of the federal poverty level. Though this was intended to be a national expansion, a later Supreme Court challenge established it as optional; consequently, 25 states (including DC) expanded Medicaid in 2014, and an additional 16 subsequently elected to do so, leaving 10 states without expansion as of January 2024. As a result of these efforts, roughly 20 million adults gained health insurance coverage.

Medicaid expansion has improved access to primary and preventive care, increased the diagnosis and treatment of cardiometabolic risk factors, and reduced catastrophic health expenditures while also narrowing racial inequities in coverage and access.¹ At the same time, states that expanded Medicaid experienced declines in uninsured cardiovascular hospitalizations and increases in access to advanced cardiovascular therapies. Perhaps most importantly, Medicaid expansion has likely improved health—one study estimated the first 4 years of expansion saved nearly 20 000 lives, driven by reductions in cardiovascular deaths.²

Another key step forward under the ACA was the requirement that private plans provide certain preventive services with zero out-of-pocket costs. This policy change had important effects on the use of preventive services for cardiometabolic conditions. The ACA also prohibited health plans from denying coverage to patients with preexisting conditions, increasing premiums based on changes in patient’s health status, and imposing waiting periods for coverage, while also requiring that plans spend 80% to 85% of premium dollars on medical care. Together, these reforms bolstered preventative care and patient protections.

Given high and rising health care spending, the ACA aimed to transition US health care financing from a volume- to value-based payment system. The Centers for Medicare and Medicaid Services (CMS) spearheaded this shift through the implementation of pay-for-performance programs and alternative payment models, which began holding health systems accountable for quality of care and spending.

Beginning in 2011, CMS required that >3000 hospitals nationwide participate in 3 pay-for-performance initiatives—the Hospital Readmissions Reduction Program, the Hospital Value-Based Purchasing Program, and the Hospital Acquired Condition Reduction Program. The Hospital Readmissions Reduction Program and the Hospital Value-Based Purchasing Program aimed to improve outcomes for cardiovascular conditions (eg, heart failure, myocardial infarction) by financially penalizing (or rewarding) hospitals based on readmission and mortality measures, respectively. Despite billions of dollars in penalties to date, these programs have been largely ineffective. The Hospital Readmissions Reduction Program has not reduced 30-day hospital revisits, and its implementation was associated with a concerning increase in heart failure mortality.³ In addition, the Hospital Value-Based Purchasing Program has not been associated with improvements in 30-day mortality for heart failure or MI. Perhaps most concerningly, these programs have disproportionately penalized safety-net and minority-serving hospitals, widening disparities in care.^4,5 Moving forward, CMS will need to grapple with the fact that these programs have achieved their goal of generating significant savings through penalties but have largely not improved outcomes while imposing administrative burdens on health systems.⁶

Alternative payment models, including Accountable Care Organizations and bundled payments, which bring groups of providers together to assume responsibility for spending and quality for an assigned population of patients, have been somewhat successful at generating savings. The number of Medicare beneficiaries in Accountable Care Organizations has grown over time—totaling nearly 13 million in 2023—and CMS is doubling down on Accountable Care Organizations over the next decade.⁵ However, there is little evidence that these programs have led to significant transformations in care delivery and quality, and because they have largely been voluntary in nature, their generalizability is unclear.

Numerous other value-based payment models have been implemented across the country by the Centers for Medicare and Medicaid Innovation. Although the Congressional Budget Office initially projected that the Centers for Medicare and Medicaid Innovation’s models would reduce federal spending by $2.8 billion from 2011 to 2020, a recent Congressional Budget Office report found that the Centers for Medicare and Medicaid Innovation increased direct spending by $5.4 billion over this period.⁷ These disappointing findings suggest that the value-based movement has not achieved its intended objectives.⁸ Thus, more transformative strategies are needed. One ambitious approach would be to put states on global budgets. Assigning annual budgets for a specified patient population would enable states to cap growth in health care spending, encourage investment in primary care and prevention, and create incentives to coordinate care and advance population health. Although CMS is beginning to explore state global budgets,⁹ the access, quality, and equity implications of doing so will need to be closely monitored.

The Inflation Reduction Act of 2022 is arguably the most important health policy legislation enacted since the ACA and aims to address the high and rising costs of prescription drugs. Under the Inflation Reduction Act, Medicare will be permitted to negotiate the price of drugs with manufacturers for the first time in US history. In addition, Medicare beneficiaries will have an out-of-pocket spending cap on prescription drugs of $2000 per year, and low-income subsidies will be expanded to further reduce drug costs.

These changes will have major implications for adults with cardiovascular conditions, who often experience cost-related barriers to medication access, especially with new classes of high-cost drugs that have become the standard of care over the past decade. Seven of the first 10 drugs selected for Medicare price negotiation treat cardiometabolic risk factors and cardiovascular diseases (atrial fibrillation and heart failure). More than 1 million older adults with cardiovascular risk factors and diseases are expected to benefit when the Inflation Reduction Act’s spending cap goes into full effect in 2025, resulting in $1.7 billion in annual savings for adults who spend >$2000 out-of-pocket per year, while another 1.3 million adults will newly qualify for low-income subsidies.¹⁰

Although the percentage of uninsured Americans has reached historic lows under the ACA, nearly one-half of working-aged adults with coverage continue to face challenges affording care due to high cost-sharing. Many experience barriers in accessing important primary care services, including cardiometabolic screenings, or choose to delay or defer care due to out-of-pocket costs with disparities evident by income, race, and ethnicity. These barriers have contributed to the higher and rising burden of cardiovascular risk factors among working-aged Americans. As a result, calls to implement universal basic coverage that provides important health services to all Americans have gained traction although debate about how to finance such a program and ensure that it is affordable for Americans, as well as associated tradeoffs, remains. Public and political momentum will be critical to ongoing efforts to provide universal coverage, whether it be at the state or national level, to ensure that more Americans have affordable access to care.

The ACA also aimed to curb health care expenditures, but spending in the United States remains substantially higher than in other countries. Although the value-based movement has focused on incentivizing reductions in utilization, it has not addressed 2 major drivers of disproportionate health care spending in the United States—the high price of health care services and hundreds of billions of dollars spent annually on wasteful administrative complexity—both of which have worsened in recent decades.¹¹ In terms of prices, as health systems have become increasingly consolidated, so has their ability to negotiate higher reimbursement prices for health services and procedures without improving quality. Similarly, consolidation in the insurance industry has allowed insurers to pass high health care prices along to consumers with few choices in terms of coverage. While the federal government has intensified efforts to monitor—and when necessary, contest—health system mergers and acquisitions, cross-market consolidation has largely been ignored. This has resulted in mega-systems delivering much of US health care. At the same time, the health sector is increasingly becoming financialized, with the influx of private equity firms focused on maximizing short-term profits through the acquisition of diverse health care entities,¹² as well as the recent surge in private Medicare Advantage plans that administer Medicare benefits and now cover half of this population. With the large and increasing number of stakeholders, the US health care landscape has become incredibly complex, resulting in an exponential rise in administrative burden and waste. Because costs of this waste are also borne by patients, in the form of high monthly premiums, there has been little pressure to reduce them. The outsized policy focus on utilization to date has obfuscated these key drivers of health spending, and it is imperative that future policy initiatives target pricing failures and administrative complexity in a meaningful way.

Finally, given that the United States has worse health outcomes than many other nations, many policymakers have focused their efforts on policy solutions to improve quality. However, a growing body of evidence suggests that the US health system largely delivers similar—if not better—care to patients with acute illnesses such as MI compared with other countries.¹³ Instead, policymakers have failed to confront factors that more likely explain poor health outcomes in the United States—pervasive disparities in access to primary and preventive care services, widening inequities in income, wealth, and education, and unequal geography of opportunity,¹⁴ which collectively contributes to the 20-year life expectancy difference across US counties. CMS has started to encourage health systems to identify health-related social needs, but broader and cross-sectoral state and federal policy actions will be required to tackle the underlying social drivers of poor health (eg, poverty), which disproportionately impacts minoritized populations in the United States.

Since the creation of Medicare and Medicaid in 1965, federal and state health policy has been a major driver of health outcomes and spending in the United States. While recent expansions in insurance and coverage have been associated with gains in health, policy efforts to improve affordability, focus our system on access and prevention, tackle ongoing drivers of high health care spending (unit prices/administrative costs, consolidation, and the financialization of health care), and address unacceptable inequities in health outcomes are crucial areas for attention in the century to come.

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Disclosures Dr Wadhera receives research support from the National Heart, Lung, and Blood Institute and serves as a consultant for Abbott, CVS Health, and Chamber Cardio, outside the submitted work. Dr Joynt Maddox reported receiving research support from the National Heart, Lung, and Blood Institute, the National Institute of Nursing Research, and the National Institute on Aging and receiving personal fees from Humana and Centene, outside the submitted work.

The American Heart Association celebrates its 100^th anniversary in 2024. This article is part of a series across the entire AHA Journal portfolio written by international thought leaders on the past, present, and future of cardiovascular and cerebrovascular research and care. To explore the full Centennial Collection, visit https://www.ahajournals.org/centennial.

The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

For Sources of Funding and Disclosures, see page 307 & 308.