Among those populations with limited access to high-quality care are those living in rural communities, representing approximately 20 percent of the American population (IOM, 2005). Associated with rural as compared with urban communities are single providers, lower rates of health insurance, poorer health behaviors, higher infant mortality, and greater incidence of chronic diseases (Kaiser Family Foundation, 2004c). The unique factors surrounding discrepancies in rural health perpetuate the inequalities of the health care system.

Americans are concerned about the state of health care. Their primary concern is health care costs: a 2002 survey indicated that 38 percent of respondents were worried about overall costs, and 31 percent were particularly troubled by prescription drug costs (Kaiser Family Foundation, 2002). At the same time, however, concerns regarding quality and safety within the health care sector are attracting increasing attention. Between 2000 and 2004, the proportion of respondents to another survey who were dissatisfied with the quality of their health care grew from 44 to 55 percent (Kaiser Family Foundation et al., 2004); 40 percent of the respondents to this survey also reported that the quality of care had deteriorated during this period.


The primary purpose of the IOM project on Redesigning Health Insurance is to accelerate the pace of change in the health system. In the 5 years since the publication of the Quality Chasm report (IOM, 2001), virtually every stakeholder group has taken important steps to improve quality in a range of areas (Leape and Berwick, 2005):

  • Information technology—The federal government has assumed a leadership role in the development of the National Health Information Network with the appointment of a National Coordinator for Health Information Technology (The White House, 2004) and the promulgation of an initial set of national data standards to facilitate the meaningful exchange of data among authorized users (U.S. DHHS, 2003a,b). In October 2004, AHRQ awarded $139 million in contracts and grants to communities and health systems to enhance information technology capabilities (AHRQ, 2004b).

  • Knowledge and tools—AHRQ has sponsored applied research projects aimed at enhancing and transferring knowledge and tools to improve quality; however, funding levels for health services research remain very low compared with those for clinical research (AHRQ, 2005; U.S. DHHS, 2005). Six states (Florida, Maryland, Massachusetts, New York, Oregon, and Pennsylvania) have established patient safety research centers

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