Accountable care cooperatives: a community-owned healthcare fixAfterthe longest government shutdown in United States history—one triggered bybattles over health care funding—the core issue remains unresolved. Neitherpolitical party has produced a durable solution. The Centers for Medicare andMedicaid Services (CMS) projects U.S. healthcare spendingwill reach nearly $9 trillion by 2035, consuming 20% to 22% of GDP. The CongressionalBudget Office projects that without significant changes in policy, totalspending for health care will be 31 percent of GDP by2035 and will increase to 46 percent by 2080. Consequencesinclude soaring insurance premiums and out-of-pocket costs; rising AffordableCare Act premiums; reduced federal investment in education, infrastructure,research, and defense; faster Medicare insolvency; suppressed wage growth;diminished global competitiveness; and the continued shift towardhigh-deductible plans. Demographic pressures—including rapid Medicareenrollment by the baby-boom generation—and high-cost drugs such as GLP-1s andgene therapies further accelerate spending.Yet,as former White House Chief of Staff Rahm Emanuel suggests, moments of crisisalso open political and civic space for ideas that once seemed impossible. Accountable Care Cooperatives: The Community-Owned Plan to Fix U.S.Healthcare and the Economy Accountable Care Cooperatives (ACCs) propose atransformative, community-owned model that restructures the U.S. health systemfrom the ground up. These private, nonprofit, member-owned organizations unifymedical care with housing, nutrition, mental health, and other social supportsthrough a single local structure. Rooted in self-reliance, cooperation, anddemocratic governance, ACCs aim to solve both the healthcare and economiccrises.Unlike top-down federal mandates, ACCs are bottom-up, locallygoverned, innovative and completely transparent on four core metrics:1.   Quality of care2.   Cost of care3.   Health outcomes4.   Member satisfaction Purpose and UrgencyThisproposal leverages today’s health financing crisis to advance a durable,bipartisan reform. It argues that a national ACC system can be implementedswiftly through federal legislation—if supported by informed civic engagement.Transformingour fragmented, costly system into one composed exclusively of ACCs wouldimprove care quality while sharply reducing costs. The Congressional BudgetOffice issued a long-term estimate of about $44 trillion as the GDP in 2035.Underan ACC-based system, total healthcare spending would remain at $6.3 trillionper year until 2035, falling to about 14.3% of GDP ($6.3 trillion/$44trillion=14.3%)—a dramatic improvement over future projections. Enactingbipartisan legislation now and securing presidential assent can make thisachievable.Thenext Healthcare, Climate, and Society blog post will present AI-draftedlegislative blueprints for U.S. House and Senate bills replacing all publicand private insurance with member-owned, self-regulated ACCs. Key Features of Accountable Care Cooperatives1. Integration of Health Care and Social ServicesACCs will integrate medical care with social determinants ofhealth—housing, nutrition, education, and employment—that profoundly shape social,economic and mental health outcomes. Services such as job placement, financialcounseling, legal aid, housing assistance, and mental health care can bedelivered alongside medical care. For example, a patient with diabetes mightreceive not only medical treatment but also housing assistance, nutritionalcounseling, gymnasium membership, and job placement services—all within thesame cooperative framework.This holistic model ensures comprehensive support forphysical, mental, and social well-being.2. Direct Primary Care Providers Each ACC would be anchored by Direct Primary Care physicians,nurse practitioners, and physicians’ assistants, serving as patient-centeredmedical homes. With smaller patient panels (about 750 patients per provider insteadof 2000 to 2500 patients), Direct Primary Care Primary Care Providers (PCPs) coulddevote more time to each individual, fostering trust, improving continuity, andenhancing satisfaction. Preventive and coordinated care reduce downstream costswhile strengthening doctor–patient relationships. Research suggests thatreducing patient panels allows for more personalized care, improved patientoutcomes, and greater physician satisfaction.3. Self-Regulation and FlexibilityInstead of one-size-fits-all federal medical treatment rules,each ACC defines its own clinical guidelines, benefit packages, and priorities.Cooperatives would provide optional home-birth services and alternative therapiesas well as telemedicine, chronic care, and rural outreach. Local controlfosters responsiveness and innovation.4. Global Budgets and Real Cost ControlOperating under capitated global budgets, ACCs would receivea fixed per-member amount to cover all health and social services. Thiseliminates incentives for unnecessary tests or procedures and drasticallyreduces bureaucratic overhead. Savings are reinvested into expanded services,lower premiums, and community development initiatives. With a minimum number of“covered lives” in an ACC being at least 1,000,000 people, ACCs would be verylikely to stay viable financially overtime.5. Transparent Competition People choose their ACC based on services, health outcomes,member satisfaction, and cost. Transparency is central: ACCs publicly reportexpenditures, health outcomes, and member satisfaction to foster trust andinformed choice.6. Participatory GovernanceDecision-making resides with members, staff, an electedboard of directors, and a CEO, who collaboratively set priorities and allocateresources. This builds legitimacy and ensures that services reflect anycommunity’s unique demographic and cultural profile.7. Double the Training of Physicians and Other Healthcare ProvidersTo provide primary care physicians, nurse practitioners, andphysician assistants with manageable caseloads (750 patients per primary careprovider (PCP) instead of 2000-2500 per PCP) and to account for the increasednumber of seniors with more healthcare needs, enrollment in US medical schoolsmust at least double. Funding and Financial StructureACCs would be financed through a diversified mix: Risk-Adjusted     Block Grants: from the US Department of Health and Human     Services (e.g., Areas with higher need receive more funding.) Member     Premiums, locally adjusted by age, income, and demographics. Community     and Philanthropic Investment: for innovation, experimentation, and     infrastructure.Strategies to free resources for patient care, socialservices, and lower member premiums or eliminate out of pocket costs includestopping: Excessive     Administration: Accounting for at least 30% of total healthcare costs,     including public and private insurance-related expenses and administrative     burden on healthcare providers.  Unnecessary     or harmful medical interventions: See my book,     Money     Driven Medicine—Tests and Treatments That Don’t Work. Fraud:     Estimated to range from 3% to 10% of total healthcare spending by the National     Health Care Anti-Fraud Association.  Comprehensive ServicesACCs address the full continuum of need:1.   Medical Care: Preventive care(screenings, vaccinations), chronic disease management, dental care, and mentalhealth/addiction services.2.   Long-Term Care: Home-based andassisted-living support—services often excluded from Medicare and privateplans.3.   Social Services: Housing assistance,food security, job training, and financial counseling.4.   Alternative Therapies: E.g.,acupuncture, massage, prolotherapy, and midwife-assisted births.By integrating these services, ACCs deliver comprehensive,equitable care that addresses the full continuum of need. Benefits of the ACC ModelUniversal Coverage: Every US resident is enrolled inan ACC, closing all gaps.Cost Savings: Capitated funding rewards preventionand efficiency.Improved Health Outcomes: Coordinated,community-based care reduces chronic disease by addressing root causes.Empowered Communities: Local healthcare and socialservices governance strengthen civic trust, participation, and resilience. National Fiscal Impact The ACC framework aligns with the Grand Bargains financialstrategy: freeze total government health funding at the 2026 levelthrough 2035 while expanding universal coverage and decentralizing delivery (approx.$6.3 trillion in 2026 and annually projected to 2035, a huge jump from $5.6trillion in 2025).The most cited and realistic estimates project that the costof healthcare in the U.S. will be around $9trillion in 2035, consuming approximately 20% to 22% of thecountry's total economic output (GDP). With ACCs fully implemented, national health expenditurescould fall to 14.3% of projected 2035 GDP, compared with the CongressionalBudget Office projection of 20%-22% of the 2035 GDP. Projected impact:·      ≈$5trillion saved over 10 years·      ≈23%reduction in the projected federal deficitThe following decade could continue the downward trend ofhealthcare as a portion of the GDP. These savings come from tackling thelargest drivers of waste, including excessive administrative overhead,unnecessary interventions, fraud, overpricing, and fragmented care. Five-Pronged Waste-Reduction Strategy Decentralize     clinical practice regulation within each ACC. For all medical, surgical,     psychiatric, or other interventions, ACCs Could develop their own     policies. For example, a patient with ischemic heart disease and angina     parentheses chest pain, ACC's could treat with coronary artery bypass     surgery, inserting stints in blocked arteries, or medical interventions     such as the Dr. Dean Ornish program to reverse coronary disease (now offered     by Medicare).  Preserve     free choice of ACC for patients and providers Mandate     transparency—online disclosure of benefits, long-term care, and metabolic     health programs (i.e., addressing obesity, type 2 diabetes, high blood     pressure, and cardiovascular risks). Foster     competition in price, quality of care, health outcomes, and member     satisfaction. Freeze     government healthcare spending at 2026 levels through 2035. ConclusionAccountable Care Cooperatives represent a bold, practicalreimagining of American healthcare—one that integrates universal access, localgovernance, and fiscal responsibility. ACCs can transform the currentfragmented, profit-driven market into a coherent cooperative approach rooted inaccountability, prevention, and human dignity.
In doing so, they advance the core mission of the Grand Bargainsproject: rebuilding not just a health system, but a society grounded insolidarity, sustainability, and shared prosperity. Call to ActionPlease forward this blog to friends, family, politicians,legislators, medical media, and others who might be interested. For questions or comments, email me:grandbargainsbook@gmail.com.