cans against the costs of ill health, to achieve health outcomes commensurate with the resources expended for health services, and to encourage broad risk sharing among the well and the ill.

Reform that maintains a major role for employment-based health benefits is certainly not the only option for the United States, as witnessed by proposals for a single government program, on the one hand, or for a market based on the individual purchase of insurance, on the other. Some members of the Institute of Medicine study committee believe that improving the employment base has more pragmatic and philosophical appeal than abandoning it. Other committee members disagree and believe this base is too structurally flawed to ever meet basic access, quality, and cost objectives. In any case, no one should expect that a significantly more equitable and cost-effective system of employment-based health benefits can be obtained without major adjustments in current arrangements.

In examining today's structure of employment-based health benefits, the committee had two basic tasks, one empirical, the other evaluative. The first task—to understand and describe the current system—provided the focus of the preceding chapters. This task was a challenge given the system's variability, its bent for change, and the limited evidence to distinguish the consequences of employment-based health benefits from those of third-party payment in general or from other features of health care financing and delivery in this country.

The committee's second task gives rise to this concluding chapter, which presents the committee's assessments and findings. What follows is (1) a brief recapitulation of themes to this point, (2) a characterization and assessment of key features of this country's system of voluntary employment-based health benefits, (3) a set of findings and recommendations about how this system might be improved, (4) a few comments on practical and technical challenges, and (5) a number of suggestions for future research.

The findings reported here do not constitute a blueprint for health care reform, even for reform that seeks to build on voluntary employment-based health benefits. In particular, the findings do not address the most effective means to limit the rapid escalation in health care costs and define the appropriate role of advanced technologies, two issues that trouble all economically developed countries, regardless of their system of medical expense protection. In addition, the discussion here does not touch directly on the problems facing Medicare, Medicaid, and other public programs, although the committee recognizes that efforts to resolve these problems cannot go forward in isolation from the system examined here.

Instead, this chapter sets forth some steps that government, business, individuals, and health care practitioners and providers could take to alleviate certain problems related to the link between the workplace and health benefits. These steps are grouped into two divisions: one that assumes the



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