In the search for solutions to improve the health care system, experts target three primary concerns: quality, access, and cost or value (Goldman and McGlynn, 2005). Substantial reforms designed to reshape and realign the major features of the entire health care system are needed to redress deficiencies in these three areas.


Despite unsustainable growth in health care spending in the United States (discussed below), the care received by individuals can often be too much, too little, too late, or too haphazard. Moreover, substantial geographic variations exist in the intensity of care provided across the nation, with attendant differences in quality, as well as cost (Fisher et al., 2009). The quality improvement movement in health care has grown significantly since the publication of two IOM reports: To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2000, 2001). These reports helped shift discussions about quality away from assigning all responsibility and accountability to individual health professionals. They showed that improving quality requires an understanding of how such elements as systems and processes of care, equipment design, and organizational structure can fundamentally enhance or detract from the quality of care. Researchers also have emphasized the importance of building interprofessional teams and establishing collaborative cultures to identify and sustain continuous improvements in the quality of care (Kim et al., 2010; Knaus et al., 1986; Pronovost et al., 2008).


Although the Affordable Care Act (ACA) provides insurance coverage for an additional 32 million Americans, millions of Americans will still lack coverage in 2019 (CBO, 2010). Even for those with insurance, out-of-pocket expenses, such as deductibles and copays, as well as limited coverage for necessary services and medications, create financial burdens that can limit access to care (Doty et al., 2005; Himmelstein et al., 2009). Other significant barriers to access include a lack of providers who are accepting new patients, especially those covered by Medicaid; a lack of providers who offer appointments outside of typical business hours; and for some a lack of transportation to and from appointments. Also hindering access is the above-discussed rapid growth of populations with limited English proficiency (U.S. Census Bureau, 2010), as well as limited health literacy among fluent English speakers.

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