 he United States spends more than any other nation on health care—well over twice the per capita average among industrialized nations. (1) Health expenditures have grown from $1.3 trillion in 2000 to $1.7 trillion in 2003, and the portion of gross domestic product consumed by the health sector over that period has increased from 13.3 percent to 15.3 percent. (2),(3) Yet it is increasingly clear that our money is not buying the best achievable care. The U.S. health care system excels in some areas, but on many basic measures of quality it delivers poor-to-middling results, according to a recent study of five English-speaking countries by a Commonwealth Fund international working group. (4) Lack of health insurance continues to be a very significant problem: between 2000 and 2003, the number of uninsured Americans grew from 39.8 million to 45.0 million, a 14 percent increase that fell hardest on working adults. (5) Health insurance premiums rose at double-digit rates each year over the same period. (6) Many Americans, especially those with low incomes or poor health, are unable to get access to affordable health care when they need it. (7)What Americans want—and, indeed, what our high spending ought to buy—is the best health care in the world. Achieving that goal will require that we transform the health system to achieve better care for all. In a global economy, the United States needs to be competitive—not just in the goods we produce, but in the services we provide to our citizens.
Transformational change is not the same as radical restructuring. We do not need to replace the current system with a single-payer, all-government system or eliminate fee-for-service methods of payment; nor do we need to eliminate public insurance or convert Medicare into competing systems of private insurers. But we do need to make sure that we are achieving commensurate value for what we spend on health care.
To begin, we will need to take an unflinching look at the performance of our existing system, put aside outdated practices and ideological assumptions, and learn from what is currently working well in the United States and internationally, both in health care financing and in improving the quality of health care services. Most important, the process will have to engage the commitment and creativity of those dedicated to change, in both private and public sectors, inside and outside the health care system.
Work by The Commonwealth Fund and others suggests a Ten-Point Strategy as a framework for change. The first point, "Agree on shared values and goals," is a place to start the work. The nine points that follow highlight strategies that could help our nation achieve those goals, address our most difficult challenges, and, at the same time, preserve the best aspects of our existing health care system.
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