The health care system in the United States is in crisis. Drastic cuts to Medicaid and the Affordable Care Act threaten the coverage of around 15 million Americans, while households face skyrocketing premiums. As the population ages, consumption of health care is projected to rise significantly. In 2025, nearly all jobs created were in the health care sector. But even these additions are nowhere near enough to keep up with demand. The country faces a projected physician shortage of up to 86,000 providers in a decade, and 350,000 nursing positions are currently unfilled. Almost 100 million Americans live in “health professional shortage” areas for primary care, with even higher numbers for mental health care.

Nearly 200 rural hospitals have closed since 2005, and 44 have ended inpatient services since 2023. Another 300 face acute risk of closure, with the GOP tax law putting the entire system at the precipice of breaking. Hospital beds per capita fell from 9.18 per 1,000 to just 2.75 between 1960 and 2020, dropping us from the top of wealthy nations to the bottom. Far from adding doctors to keep pace with need, the United States is losing doctors faster than we can replace them, with just 14 percent physician growth since 2000 compared to 34 percent in peer countries. More than 40 percent of physicians are over the age of 55 and likely to leave the profession within the decade.

The drop in beds and doctors coincides with the rise of for-profit and financialized health care. In 1980, for-profit hospitals made up a low of 12 percent of all hospitals, with public facilities making up one-third. By 2020, for-profits doubled their share, while public hospitals fell to 18 percent of facilities. After entering the health care space in the 1990s, private equity funds have bought up thousands of hospitals, nursing homes, emergency services, and physicians’ practices. Those acquisitions have led to worse outcomes nearly across the board, according to high-quality, peer-reviewed studies, increasing mortality and raising prices with very few observable benefits — aside from higher revenue for investors.

Intra-progressive debates about health care largely revolve around coverage: the merits of Medicare for All versus a public option, shoring up the Affordable Care Act, expanding and protecting Medicaid and Medicare. Meanwhile, conservatives and libertarians are likelier to consider the supply side of health care, though their solutions begin and end with blanket deregulation. This essay proposes that progressives take bold, aggressive action to eliminate health care supply shortages through a massive expansion of publicly owned facilities and publicly trained and employed providers. The United States should build an American Health Service.

The American Health Service would be built on three pillars: a public health care workforce pipeline to train providers in critical specialties at scale and deploy them where they are needed most; a universal primary care system the leverages existing Community Health Center (CHC) infrastructure to provide all Americans with an accessible, affordable, primary care option; and a modern day program modeled on the 1946 Hill-Burton Hospital Survey and Construction Act to build and preserve public hospitals to anchor the system. Critically, the pillars would operate as one integrated system, rather than the patchwork of programs that define American health care today.

Building A Public Health Care Workforce

The root cause of the physician shortage is no accident. It stems from a policy choice. In 1997, Congress froze Medicare-funded residency slots, artificially constraining the number of medical school graduates who can become doctors. Every year, thousands of graduates fail to match with a residency program, and efforts to increase residency slots have been met with staunch opposition by interest groups such as American Medical Association that benefit from a limited supply of doctors.

In addition to fewer overall doctors, U.S. physicians are poorly allocated geographically and by practice. Just 10 percent of doctors practice in rural areas, where 20 percent of the population lives, and more than half of rural doctors are over the age of 55, compounding an upcoming shortage when utilization is projected to rise. Just 2 percent of residency slots reach rural areas, and physicians generally practice where they complete their residencies.

The crisis in rural care is echoed by a similar trend with respect to primary care. In 1957, about half of doctors practiced primary care, matching the accepted desired ratio. Today, less than one-quarter of physicians are in family practice, general internal medicine, and pediatrics. The reason for this decline is simple: the currently constructed health care market greatly favors specialization. Medical students take on massive amounts of student debt, averaging just over $200,000 upon graduation. Primary Care Physicians (PCPs) earn 36 percent less than specialists on average, the highest gap among wealthy nations, while high-paying specialties like radiology and orthopedics bring in double what PCPs make.

Existing bipartisan legislation to increase residency slots would still leave the United States woefully short of physicians. Other supply-increasing funding is scattered across a hodgepodge of different programs with their own funding streams and requirements.

The American Health Service system must dramatically scale providers in the places and practices we need them most. This starts with lifting the cap on Medicare-funded Graduate Medical Education. However, simple deregulation won’t end the shortage on its own. The AHS will map projected shortages by specialty and geography and allocate funding to residency programs to fill them, full stop. Debt-free education, stipends, accelerated residency slots, and salaried positions at AHS facilities will be allocated to those who fill underserved needs. Community Health Centers (CHCs) will serve as teaching institutions for primary care, and new Hill-Burton hospitals will serve as teaching hospitals to ensure that public infrastructure scales to meet the new influx of providers.

Universal Primary Care

Primary care is the backbone of a national health care system. Regular screenings and preventative care can reduce the need for more complicated (and expensive) interventions later and catch health issues before they become life-threatening. Countries like Costa Rica and France with robust primary care systems see lower rates of preventable deaths from causes like heart disease, asthma, and pneumonia. The United States lags behind the OECD average on preventable and treatable mortality rates, contributing to our abysmal health outcomes compared to peer countries.

Primary care practices, traditionally independently owned and operated by physicians, have increasingly found themselves the target of acquisition by larger hospital systems and by private equity funds. Vertical integration of PCP practices has been found to increase prices, but those higher prices do not accrue to doctors—in fact, a 2022 study found that physician incomes were lower for integrated practices.

We have the beginnings of a primary care network in this country. CHCs currently provide primary care for 14 percent of the U.S. population across more than 17,000 locations. While CHCs are open to all, regardless of ability to pay, they function as safety net facilities, with 90 percent of patients below 200 percent of the federal poverty line. CHCs are chronically understaffed, particularly in high-need areas, and lack of integration with provider networks makes referrals and comprehensive care difficult. Despite serving low-income, uninsured, and underinsured populations, care costs 24 percent less than comparable treatment elsewhere.

The AHS would reimagine CHCs as anchors of primary care in communities across the country, beyond just safety net populations. New funding would build and modernize facilities, while a unified network would connect CHCs through shared electronic health records and affiliations with nonprofit or public hospital systems. Critical services, like dental, mental health, and pharmacy would be expanded to all centers. PCPs would be supported by dedicated community health teams, similar to existing models in Costa Rica, Brazil, and in the VA system, and standardized by population to ensure that every community has a community health team.

A Twenty-First Century Hill-Burton Act

In 1946, President Truman signed the Hospital Survey and Construction Act, commonly known as the Hill-Burton Act, which provided grants and loans to build and upgrade public and nonprofit hospitals. Between enactment and 1980, more than $100 billion in today’s dollars built 7,000 hospitals and 70,000 beds, reaching its stated goal of increasing beds per 1,000 from 3.2 to 4.5. Funds were allocated by need, closing service deserts that existed across broad swaths of the South and Midwest and requiring community care for low-income and uninsured patients.

The Hill-Burton Act was an aggressive response to a major market failure. Today, the market has failed patients yet again, turning hospitals into profit centers instead of care institutions. Consolidation and closures have left communities without critical services like maternity, emergency, and burn units. Hospital executives command outrageous compensation packages, while private equity takeovers drive up prices, slash staffing, and increase mortality.

Just like provider supply, deregulation won’t fix this market failure. In 2019, Florida repealed its Certificate of Need requirement, allowing hospitals to build dozens of new facilities. Instead of flowing to care deserts, new hospitals sprung up in wealthy suburbs in major metropolitan areas, chasing profits instead of need.

Instead, the AHS will revive Hill-Burton’s model of need-based public investment — an industrial policy for health care infrastructure. New public hospitals would fill gaps in capacity and anchor the AHS system. Public AHS hospitals would serve as teaching institutions, absorbing new residency slots and training physicians in the communities that need them. AHS hospitals would directly employ doctors at competitive salaries and use global budgets and Medicare-plus rates to control costs and compete against inflated prices at monopoly systems.

An Integrated, Public Health Care System

The American health care system is less a system and more a patchwork of disconnected services, frustrating paperwork, and misaligned incentives. Without connectivity between primary care and specialists, clinics and hospitals, and physical and mental health, patients get lost in a maze of complexity that leaves them worse off and allows middlemen to extract profits at every turn. A true universal, national health care program would solve the problem of coverage, but without the infrastructure to support it, care and affordability would still suffer. The AHS would build a real, integrated public system, coordinating care regionally among CHCs, public hospitals, and health workers. This isn’t a radical idea. The United States has a system just like this: the Veterans Affairs health system, which consistently receives higher patient satisfaction scores and provides better care at lower cost than the private system. We can improve patient care, doctor wellbeing, and health outcomes while reducing costs. It’s time to build.