Expanding access and coverage while containing costs can only be accomplished by getting more health care value for our money. Two facts about our current system make this seem possible. First, the currently uninsured are not costless. Providing stop-gap health care to those who lack health insurance is extremely expensive -- people without formal coverage cannot afford preventive services, delay treatment of illness and face substantial barriers to reaching appropriate providers. When they receive care, it is often degrading, usually complicated and costly, and more than occasionally too late. The cost of this "uncompensated" care is borne by all of us in higher prices for our own health insurance, in taxes and in the federal deficit. Moreover, this cost is not distributed evenly, and reduces our ability to determine whether the price of our own health care is fair. In addition, the need for "last resort" care for the uninsured locks us into continued support of aging "public" health facilities that are often underequipped and inefficient.

The second characteristic of our current system is that the utilization of health care services is tremendously wasteful. Gaps in our knowledge as to what works and what doesn't, fee-for-service payment that creates incentives to do more rather than less, lack of coordination between providers, high patient expectations and fear of malpractice litigation all predispose to overutilization. We are fascinated by expensive technology, and use it uncritically. Moreover, these influences have elevated the illness-based model of care over the health-based model. As a result, a disproportionate amount of our health care budget is devoted to the treatment of acute illness, often in institutional settings, rather than to primary, preventive and long-term community and home-based care.

These observations suggest a prescription for change. Improving the cost effectiveness of health care delivery -- in particular by emphasizing preventive and primary care and adopting a more discriminating approach to the use of expensive, referral services -- can free up the resources needed to include all Americans in the health care system. This effort must be undertaken by health care providers, by communities and by government.