What is the state of American health care in this election year?

In just eight months, voters will participate in an election that could determine the course of health care for decades to come. So what do we know about the challenges facing American health care, and what are the candidates saying about them?

The American College of Physicians (ACP) released its annual report Jan. 26 on the state of the nation's health care. This year's report is a story of progress and challenges, and of a broken political culture that is perhaps the biggest obstacle to achieving consensus on needed reforms.

Health care in the United States faces enormous challenges: uneven access and quality, unsustainable cost increases, and a continued (and growing) shortage of internal medicine specialists and other primary care physicians. Progress is being made, but we still have a long way to go.

Health care costs increased by the smallest amount in over 50 years in 2009 and 2010. Although this may be partly due to people delaying needed care because of the economic downturn, annual health care costs had already been rising at a slower pace for eight consecutive years compared to previous years. Yet costs are projected to continue to rise faster than economic growth, and federal spending on health care continues to pose the greatest single challenge to the country's fiscal health.

Key measures of population health have improved significantly, including reductions in all five of the leading causes of death. Deaths from homicides are the lowest they have been in half a century. Obesity rates may be leveling off. Yet there remain substantial gaps in access to care for millions of Americans, particularly ethnic and racial minorities, the uninsured, and poorer people.

Many millions are benefiting from programs in the Affordable Care Act (ACA) to reduce barriers to insurance coverage, including young adults who can now be covered under their parents' health insurance plans, seniors who can now receive no-cost preventive services and lower prescription drug costs, and children who no longer can be denied access to affordable coverage because they have a preexisting condition like asthma. Yet 46 million Americans reported to the government that they did not have health insurance in 2011, and people without health insurance reported that they were much more likely to delay getting needed care because of cost.

Current and proposed budget cuts threaten to reverse much of the progress in expanding access and improving public health. ACP's report noted that the $1.2 trillion in across-the-board budget cuts caused by the failure of Congress' “super-committee” will do grave harm to programs intended to protect and improve public health, ensure the safety of food and drugs, support medical research, prepare for natural and manmade medical disasters, and train more primary care doctors.

ACP called on Congress to instead adopt a fiscally and socially responsible alternative that would address the real cost drivers and ensure continued funding for critical programs. The College's alternative would eliminate Medicare payment cuts to doctors caused by the sustainable growth rate (SGR) formula, create a pathway to better ways to reimburse physicians, reduce the costs of defensive medicine, promote high-value and cost-conscious care, make structural improvements in Medicare to reduce costs, and change federal tax policies to encourage individuals to consider cost in their selection of health insurance benefits.

The greatest obstacle to moving forward on such necessary reforms, though, is not the lack of good ideas. It is a broken political culture that emphasizes ideological purity and partisan warfare over compromise and that demonizes the proposals of others to score political points. It is a culture of politicians unable or unwilling to level with the American people on the difficult choices required.

ACP's report noted that Republican candidates for president and Congress have uniformly called for the ACA's repeal but have not said what they would propose to replace it, and have not leveled with the public about the benefits they would lose, such as seniors paying more for prescription drugs and preventive services, young adults being kicked off their parents' plans, and tens of millions more remaining uninsured.

President Obama and congressional Democrats have attacked the GOP's ideas about restructuring Medicare and Medicaid but have not leveled with the public that both programs are not sustainable without major changes that will require some to pay more. Nor have they explained what changes they might be willing to make to the ACA to address concerns about government overreach or to deal with the costs of defensive medicine.

ACP's report concluded with a checklist of questions that voters should ask the candidates about their plans to address the problems of uneven access and quality, unsustainable health care cost increases, and the primary care physician shortage. (More information about the presidential candidates' positions on ACP's top priorities is available from the College's election tool. )

Just 13 months after the public casts its votes in November, the ACA's key provisions to expand coverage, guarantee essential benefits, and reform insurance practices that deny or limit coverage for many will go fully into effect, unless the voters choose a different path. They have a right to know what the candidates will do if they get elected, or in the case of President Obama, what he will do if reelected to address the challenges of unsustainable costs and uneven access and quality.

Asking the right questions of them doesn't guarantee that they will respond, or if they do, that the responses will provide the level of clarity that is needed, but it is a start. And no matter how the election goes, the president and Congress must find a way to escape from a broken political culture that has made bipartisan consensus nearly impossible. Otherwise, the state of the nation's health care in 2013 and years to come will be far more troubling than it is today.