Everyone who wrote a letter raised important points that should be considered by public policymakers for achieving universal health insurance coverage. The American College of Physicians identified 2 pathways for consideration: a single-payer model or a pluralistic model with legal guarantees for coverage and subsidies for those who cannot afford it. The College did not recommend one pathway over the other—it noted the advantages and disadvantages of each approach. It examined the U.S. health care system and those of 12 other countries, determined what lessons could be learned, and made recommendations for consideration to ensure that all people in the United States have equitable access to appropriate health care without unreasonable financial barriers. Although we can learn much from other health care systems, the College recognizes that our political and social culture, demographic characteristics, and form of government will shape any solution for the United States.

Overhauling our health care system will be an extremely complicated matter and should involve a thorough examination of not only the many issues raised in this position paper, but other issues that, although important, would require separate in-depth study. Several of the ideas presented in these letters have been addressed in earlier position papers from the College.

Dr. Cavale and Dr. Leff raise the issue of malpractice insurance and fear of litigation, which we did not address because differences among legal systems make it extremely difficult to develop meaningful comparisons across nations. The College supports further research and analysis of the impact of the U.S. tort system on health care, as well as alternative models in other health systems. Likewise, comprehensive study is needed concerning the widely differing pharmaceutical costs among countries and the impact on health care systems of differences in the organization and financing of medical education and training.

Drs. R.L. Cruess and S.R. Cruess raise another issue to be explored if the United States were to adopt a single-payer system: A structure would be needed for negotiating physician payments. As they correctly point out, there currently is no legal structure in the United States for collective bargaining on behalf of self-employed physicians. The College has recommended legal reforms to allow physicians to bargain collectively with payers but has also cautioned that physicians may not ethically strike or withhold services from patients (1).

The College agrees with Dr. James that physicians need to be accountable. The patient-centered medical home is one model for improving quality and efficiency that would require qualified practices to report regularly and in a transparent manner on measures of quality, efficiency, and patient satisfaction. More detailed recommendations from the College are in separate position papers on linking physician payment to quality (2) and shifting incentives away from volume-based rewards toward ones that create incentives for care coordination, prevention, and improvements in quality (3). More must be done, however, to improve accountability among all who are involved in patient care.

Dr. Zarren raises the issues of lack of adequate time for physicians to see and treat patients. This topic also was discussed at length in another College position paper (4).

We limited our study to analysis of the U.S. health care system and systems in 12 other industrialized countries that are representative of different approaches to achieving universal coverage. We did not include the MHS TRICARE plan, which has a unique mission in providing care to military personnel and their families, but we agree that there is much to learn from it.

The paper that appeared in Annals was an abridged version of the full position paper approved by the American College of Physicians' Board of Regents on 27 October 2007. The full text is available at http://www.acponline.org/advocacy/where_we_stand/access/hcs.pdf.