Most health care reform proposals focus on expanding health insurance to cover all US individuals. But the companion challenge is how to make such coverage affordable given the fragmentation, waste, and variation in quality of care of the current delivery system. Comprehensive health care reform will require proposals that both expand coverage and redesign the delivery system so as to achieve greater value for the increased investment.
At the heart of the challenge is transforming a 19th-century craft-oriented delivery system to provide 21st-century biomedical science and technology. Most physicians still practice alone, in partnerships, or in small groups. Small practices generally have less capacity to implement electronic medical records, less frequently use teams to care for patients with chronic illness, and are less able to provide statistically reliable and valid data on quality and efficiency measures. A more solid foundation of physician organizations is needed to avoid having the system crumble under the increased weight of greater demand for care and technological advances.