Critical Issues in US Health Care

Abstract

The US health care system has reached a tipping point when there is both little doubt about the kind of change that is needed and much uncertainty about how to achieve it. This issue of JAMA, a theme issue on Critical Issues in US Health Care, includes 3 scholarly Special Communications and 11 authoritative and thought-provoking Viewpoints that map out this dilemma and highlight potential solutions. The topics all relate to fundamental aspects of how the US health care system functions, with subjects selected in an iterative process involving the editorial board of JAMA. The goal was to expand the discussion beyond just cost, quality, and value. In the first of 3 SpecialCommunicationarticles,Moses and colleagues1 present a comprehensive, detailed, and extensively referenced report that documents the anatomy of the US health system. Health care expenditures exceed $2.7 trillion annually, doubling since 1980 as a percentage of the nation’s gross domestic product. This article details how the United States spends that money each year and provides information on topics ranging from the number of health care personnel to the cost of information technology. Price increases (rather than greater provision of services) are driving increased costs, even as US health outcomes have fallen behind those of other countries. The rising tide of chronic illness is posing an unprecedented challenge. There has been substantial consolidation in many industries; for example, the airline, telecommunications, and automotive sectors of the economy have coalesced into relatively few major business entities. Cutler and Scott Morton2 describe the samephenomenon inhealthcare,particularly the hospital industry. Since themid-1980s, hospitalmarkets have shifted on average from including 5 independent major hospitals to 3. These changes beganbefore implementationof the Affordable Care Act (ACA) butwill hasten as the ACA rewards the integrated care that large networks may best provide. Measurement of quality has reached an almost frenzied state.Consumergroups, insurers,payers, licensingbodies, and various national groups all require different types of measures at the physician, patient, and hospital level. Panzer and colleagues3 highlight the demands and confusion inherent in scoresof competingqualitymeasures,whichcandistract from the essential task of making care better. There is no shortage of prescriptions for improving the delivery of care, and several Viewpoints in this issue of JAMA present potential solutions for core challenges. Cortese4 provides his vision for patient-focused, coordinated care, supported by innovative technology and rewarded by financial incentives. Although this approach should serve to improve quality, there are no data yet available to know whether the mHealth movement will indeed lead to better health outcomes. In contrast, while they are awash with data, it is not certain that the new technologies will reduce or increase the workload on physicians. Lynn5 calls for a shift in the focus on end-of-life care from diseases to people and for a redesign in long-term care to respect the dignity and desires of elderly individuals. Virtually everyone, including physicians, has a painful story to tell about end-of-life care in his or her family and the struggles with how to ensure “dying with dignity” in the United States. Cooper6 confronts an issue that has been problematic for the US health care system for decades: how many physicians are needed and what is the appropriate primary care/ specialist distribution. He calls for a greater number of physicians to meet the needs of an aging and increasingly diverse society, but with a restriction on federal support for residency, resources to train these additional physicians will be difficult to find. Few would deny the promise of these approaches. Yet model programs in these areas remain the exception rather than the rule. The time may have arrived to shorten the training period from medical school to residency to fellowship. At the national level, progress in advancing health care is slowandhalting.TheCenters forMedicare&MedicaidServices is promoting accountable care andother innovations through theMedicareandMedicaidprograms.However,broadchanges arenot on thehorizon, andCongress is distractedby efforts to undo the ACA. Ironically, addressing the increasing costs of healthcarewouldreducethepressureonthefederalbudgetand make political conflicts inWashington easier to resolve. What are some reasons for the paralysis? Berwick7 relates his firsthandexperienceswith the toxic politics of health care, passionately describes the fierceness of individuals andorganizations with entrenched financial interests, and calls for health professionals to join together to overcome these obstacles. Levey8 suggests that there is broad public misunderstanding about the country’s health care challenges, with the media bearing some of the responsibility. Several Viewpoints in this issue of JAMA propose creative solutions to resolving the many dilemmas faced by the US health care system, each requiring leadership and resolve and challenging the status quo. Emanuel9 calls for a “man on themoon”–typeaudaciousnational goalof limitinghealthcare expendituregrowth to thegrowthof thenational economy.He proposes an ambitious fiscal target, such that by 2020, per capita health care costs will increase no more than the gross Opinion