After the longest government shutdown in U.S. history (one triggered by battles over health care funding) the core issue remains unresolved. Neither political party has produced a durable solution. The Centers for Medicare and Medicaid Services (CMS) projects U.S. health care spending will reach nearly $9 trillion by 2035, consuming 20 percent to 22 percent of GDP. The Congressional Budget Office projects that without significant changes in policy, total spending for health care will be 31 percent of GDP by 2035 and will increase to 46 percent by 2080.

Consequences include soaring insurance premiums and out-of-pocket costs; rising Affordable Care Act premiums; reduced federal investment in education, infrastructure, research, and defense; faster Medicare insolvency; suppressed wage growth; diminished global competitiveness; and the continued shift toward high-deductible plans. Demographic pressures (including rapid Medicare enrollment by the baby-boom generation) and high-cost drugs such as GLP-1s and gene therapies further accelerate spending.

Yet, as former White House Chief of Staff Rahm Emanuel suggests, moments of crisis also open political and civic space for ideas that once seemed impossible.

Accountable care cooperatives: the community-owned plan to fix U.S. health care and the economy

Accountable care cooperatives (ACCs) propose a transformative, community-owned model that restructures the U.S. health system from the ground up. These private, nonprofit, member-owned organizations unify medical care with housing, nutrition, mental health, and other social supports through a single local structure. Rooted in self-reliance, cooperation, and democratic governance, ACCs aim to solve both the health care and economic crises.

Unlike top-down federal mandates, ACCs are bottom-up, locally governed, innovative, and completely transparent on four core metrics:

• Quality of care
• Cost of care
• Health outcomes
• Member satisfaction

Purpose and urgency

This proposal leverages today’s health financing crisis to advance a durable, bipartisan reform. It argues that a national ACC system can be implemented swiftly through federal legislation, if supported by informed civic engagement.

Transforming our fragmented, costly system into one composed exclusively of ACCs would improve care quality while sharply reducing costs. The Congressional Budget Office issued a long-term estimate of about $44 trillion as the GDP in 2035.

Under an ACC-based system, total health care spending would remain at $6.3 trillion per year until 2035, falling to about 14.3 percent of GDP ($6.3 trillion/$44 trillion = 14.3 percent), a dramatic improvement over future projections. Enacting bipartisan legislation now and securing presidential assent can make this achievable.

The next Healthcare, Climate, and Society blog post will present AI-drafted legislative blueprints for U.S. House and Senate bills replacing all public and private insurance with member-owned, self-regulated ACCs.

Key features of accountable care cooperatives

1. Integration of health care and social services

ACCs will integrate medical care with social determinants of health (housing, nutrition, education, and employment) that profoundly shape social, economic, and mental health outcomes. Services such as job placement, financial counseling, legal aid, housing assistance, and mental health care can be delivered alongside medical care. For example, a patient with diabetes might receive not only medical treatment but also housing assistance, nutritional counseling, gymnasium membership, and job placement services, all within the same cooperative framework. This holistic model ensures comprehensive support for physical, mental, and social well-being.

2. Direct primary care providers

Each ACC would be anchored by direct primary care physicians, nurse practitioners, and physician assistants, serving as patient-centered medical homes. With smaller patient panels (about 750 patients per provider instead of 2,000 to 2,500 patients) direct primary care providers (PCPs) could devote more time to each individual, fostering trust, improving continuity, and enhancing satisfaction. Preventive and coordinated care reduce downstream costs while strengthening doctor-patient relationships. Research suggests that reducing patient panels allows for more personalized care, improved patient outcomes, and greater physician satisfaction.

3. Self-regulation and flexibility

Instead 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 therapies as well as telemedicine, chronic care, and rural outreach. Local control fosters responsiveness and innovation.

4. Global budgets and real cost control

Operating under capitated global budgets, ACCs would receive a fixed per-member amount to cover all health and social services. This eliminates incentives for unnecessary tests or procedures and drastically reduces 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 very likely to stay viable financially over time.

5. Transparent competition

People choose their ACC based on services, health outcomes, member satisfaction, and cost. Transparency is central: ACCs publicly report expenditures, health outcomes, and member satisfaction to foster trust and informed choice.

6. Participatory governance

Decision-making resides with members, staff, an elected board of directors, and a CEO, who collaboratively set priorities and allocate resources. This builds legitimacy and ensures that services reflect any community’s unique demographic and cultural profile.

7. Double the training of physicians and other health care providers

To provide primary care physicians, nurse practitioners, and physician assistants with manageable caseloads (750 patients per PCP instead of 2,000-2,500 per PCP) and to account for the increased number of seniors with more health care needs, enrollment in U.S. medical schools must at least double.

Funding and financial structure

ACCs would be financed through a diversified mix:

• Risk-adjusted block grants: From the U.S. 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, social services, and lower member premiums or eliminate out-of-pocket costs include stopping:

• Excessive administration: Accounting for at least 30 percent of total health care costs, including public and private insurance-related expenses and administrative burden on health care 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 percent to 10 percent of total health care spending by the National Health Care Anti-Fraud Association.

Comprehensive services

ACCs address the full continuum of need:

• Medical care: Preventive care (screenings, vaccinations), chronic disease management, dental care, and mental health/addiction services.
• Long-term care: Home-based and assisted-living support (services often excluded from Medicare and private plans).
• Social services: Housing assistance, food security, job training, and financial counseling.
• 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 model

• Universal coverage: Every U.S. resident is enrolled in an ACC, closing all gaps.
• Cost savings: Capitated funding rewards prevention and efficiency.
• Improved health outcomes: Coordinated, community-based care reduces chronic disease by addressing root causes.
• Empowered communities: Local health care and social services governance strengthen civic trust, participation, and resilience.

National fiscal impact

The ACC framework aligns with the Grand Bargains financial strategy: Freeze total government health funding at the 2026 level through 2035 while expanding universal coverage and decentralizing delivery (approx. $6.3 trillion in 2026 and annually projected to 2035, a huge jump from $5.6 trillion in 2025).

The most cited and realistic estimates project that the cost of health care in the U.S. will be around $9 trillion in 2035, consuming approximately 20 percent to 22 percent of the country’s total economic output (GDP).

With ACCs fully implemented, national health expenditures could fall to 14.3 percent of projected 2035 GDP, compared with the Congressional Budget Office projection of 20 percent-22 percent of the 2035 GDP.

Projected impact:

• ≈$5 trillion saved over 10 years
• ≈23 percent reduction in the projected federal deficit

The following decade could continue the downward trend of health care as a portion of the GDP. These savings come from tackling the largest drivers of waste, including excessive administrative overhead, unnecessary interventions, fraud, overpricing, and fragmented care.

Five-pronged waste-reduction strategy

1. 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 (chest pain), ACCs could treat with coronary artery bypass surgery, inserting stents in blocked arteries, or medical interventions such as the Dr. Dean Ornish program to reverse coronary disease (now offered by Medicare).
2. Preserve free choice of ACC for patients and providers.
3. 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).
4. Foster competition in price, quality of care, health outcomes, and member satisfaction.
5. Freeze government health care spending at 2026 levels through 2035.

Conclusion

Accountable care cooperatives represent a bold, practical reimagining of American health care, one that integrates universal access, local governance, and fiscal responsibility. ACCs can transform the current fragmented, profit-driven market into a coherent cooperative approach rooted in accountability, prevention, and human dignity.

In doing so, they advance the core mission of the Grand Bargains project: Rebuilding not just a health system, but a society grounded in solidarity, sustainability, and shared prosperity.

David K. Cundiff is a physician, author, and health care reform advocate whose work centers on transforming the U.S. health care system and addressing broader societal challenges, including climate change. He is the author of Grand Bargains: Fixing Health Care and the Economy, which proposes structural reforms to dramatically reduce health care costs while improving outcomes. His essay “Much Better Healthcare for Way Less Cost” explores accountable care cooperatives and community-based reform. Additional works include Money Driven Medicine – Tests and Treatments That Don’t Work and Whistleblower Doctor: The Politics and Economics of Pain and Dying.

From 1981 to 1998, Dr. Cundiff practiced, taught, and conducted clinical research in internal medicine and pain control at the Los Angeles County + USC Medical Center, where he directed the Cancer and AIDS Pain Service for nine years, and previously held an academic affiliation with Harbor-UCLA Medical Center. After exposing how systemic inefficiencies increased hospital utilization and revenue, he became a whistleblower, an experience documented in Whistleblower Doctor.

Outside his professional work, Dr. Cundiff values time with friends and family, including six grandchildren, and maintains his health through Hatha yoga, meditation, swimming, Zumba, biking, and a diet emphasizing minimally processed organic food.