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The last 4 years have been difficult for science and medicine. The relentless attack by members of the executive and legislative branches of government on science and federal agencies that conduct science has shaken the fundamental pillars of great US institutions such as the Centers for Disease Control and Prevention, Food and Drug Administration, Environmental Protection Agency, and in some regards the National Institutes of Health (NIH). Although the 2020 NIH budget increased to almost $42 billion, more individuals are uninsured, and although health care costs have not increased substantially over the past 4 years, the financial health of most states is in shambles because of the Great Pandemic of 2020, threatening the commitment to Medicaid, which consumes almost 30% of many state budgets. In addition to Medicaid costs, states are responsible for the health care costs of their employees, and in some states many of their retirees. Moreover, the morbidity, mortality, and ubiquitous nature of COVID-19 have created unprecedented challenges for clinicians, health care systems, and public health, while some political leaders have erroneously minimized the extent, severity, and seriousness of the pandemic.
In addition, physicians and other clinicians remain frustrated at the relentless increase in administrative tasks, highlighted, for example, by the largely nonproductive contribution and lack of added value that current requirements for prior authorization make in health care. Patients are frustrated and concerned because of surprise medical bills and the high cost of drugs. Despite a national investment of more than $100 billion in electronic health records (EHRs) and health information technology in general, many EHRs remain limited, offer little in decision support, and do not allow the ability to “talk” to one another.
An increasingly important question is whether, in a country in which “profit” dominates, it will be possible to have a fair and equitable health care system. Has profit, self-interest, and greed come to dominate the landscape of US medicine? And as the Great Pandemic of 2020 has demonstrated, health care disparities remain a fundamental problem in the US health care system.
Below is a medical and scientific wish list for the coming year. These goals are not meant to be exhaustive, but reflect the clinical, scientific, and political aspects of medicine that have been discussed in the pages of JAMA over the past few years.
Respect for science, the individuals who pursue scientific discovery, and the federal agencies that support and conduct scientific research.
A comprehensive, coordinated, and effective national response to the COVID-19 pandemic, driven by science and evidence, and based on solid clinical and public health principles, including prevention and widespread vaccination.
A true national commitment to health care as a right and not a privilege.
A national debate about a single-payer (Medicare for All), universal health plan that includes private insurers, a public option, further expansion of Medicaid, and lowering the age of Medicare to 60 years.
A true commitment to interoperability of EHRs that will likely require federal legislation.
Reducing administrative costs and eliminating barriers to health care access to ensure that millions of individuals can be insured without increasing overall health care costs.
A national campaign to identify and treat every individual with hypertension in the US.
Broad agreement on a limited number of high-priority national outcome measures based on the recommendation of the US Preventive Services Task Force and professional societies that would be the focus of every clinician and health care system in the US.
A greater appreciation that simply creating more knowledge (and science) does not necessarily improve health outcomes and may exacerbate health care inequities.
That the US returns to a time of civility, healthy debate, and respect for the opinions of others.
Why is this list not longer? First, many of these goals encompass many other important issues. Second, a longer list (eg, of 50 goals) would only reduce the likelihood of success. Focus is not an attribute of the US health care system and it might be time for a change. Third, why an emphasis on hypertension (and perhaps a few other quality measures)? A recent report that detailed the decline in the appropriate treatment of patients with hypertension in recent years in the US is a profound indictment of the health care system.1 Hypertension is associated with many health outcomes, including cardiovascular disease, kidney disease, COVID-19, and dementia; the diagnosis and treatment of hypertension reside firmly within medicine; and treatment is relatively inexpensive.2,3 Yet, the US health care system has failed the task of identifying and treating patients with this disorder, with substantial differences between groups, again, highlighting important health care inequities. Fourth, the list reflects the opinion of one individual; others may have included different goals.
It is not clear that any of the above will happen in 2021. For the last 4 years, the Trump administration has offered little in the way of health care reform, except to support legal challenges to the Affordable Care Act. Health care reform is challenging, messy, and controversial. President-elect Biden must commit to a plan that ensures that all individuals in the US have health insurance. What form that coverage takes must involve a responsible, evidence-based national debate that considers, among other factors, economic implications and sustainability.
This list is my hope for 2021 and beyond: a respect for science, scientists, and public health officials, healthy and civil debate, and a fundamental commitment that no individual in the US should be without health insurance.
Corresponding Author: Howard Bauchner, MD, JAMA (Howard.Bauchner@jamanetwork.org).
Published Online: December 23, 2020. doi:10.1001/jama.2020.23346
Conflict of Interest Disclosures: None reported.
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Bauchner H. A Medical and Scientific New Year’s Wish List. JAMA. 2021;325(1):29–30. doi:10.1001/jama.2020.23346
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