centeredness, and timeliness. There is little doubt that current resources can be spent more wisely to pursue the aims set forth in this chapter.


This chapter began with a statement of purpose for the health system: “to continually reduce the burden of illness, injury, and disability, and to improve the health and functioning of the people of the United States.” The aim of equity is to secure these benefits for all the people of the United States. This aim has two dimensions: equity at the level of the population and equity at the level of the individual. At the population level, the goal of a health care system is to improve health status and to do so in a manner that reduces health disparities among particular subgroups. Equity in care implies universal access, a promise that has yet to be either made or kept. Lack of health insurance has a profound effect on access to appropriate services, and is directly associated with poor functioning, increased morbidity, and increased mortality (American College of Physicians-American Society of Internal Medicine, 2000; Baker et al., 2000; Franks et al., 1993; Haas and Goldman, 1994; Hafner-Eaton, 1993; Kasper et al., 2000). Institutions and health professionals that deliver uncompensated care to uninsured or underserved patients are at risk financially (Institute of Medicine, 2000a), and evidence suggests that the provision of uncompensated care is declining (Cunningham et al., 1999; Mann et al., 1997). The committee believes lack of access to care is a very powerful barrier to quality.

With regard to equity in care giving, all individuals rightly expect to be treated fairly by social institutions, including health care organizations. The availability of care and quality of services should be based on individuals’ particular needs and not on personal characteristics unrelated to the patient’s condition or to the reason for seeking care. In particular, the quality of care should not differ because of such characteristics as gender, race, age, ethnicity, income, education, disability, sexual orientation, or location of residence (Ayanian et al., 1999; Canto et al., 2000; Fiscella et al., 2000; Freeman and Payne, 2000; Kahn et al., 1994; Pearson et al., 1992; Philbin and DiSalvo, 1998; Ross et al., 2000; Yergan et al., 1987).

Conflicts Among the Aims

For the most part, the six aims are complementary and synergistic. At times, however, there will be tensions among them. Health care institutions, clinicians, and patients will sometimes need to work together to balance competing or conflicting objectives. Two examples are the potential conflict between the aims of patient-centeredness and effectiveness, and the need to balance the aim of equity as applied to the population with achievement of the other aims at the level of the individual.

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