and making it less affordable for many without being confident that it is achieving better health outcomes, greater labor productivity, or other equivalent value for its increased investment. Efforts to accumulate evidence on outcomes and to evaluate and compare the costs and benefits of alternative medical practices are increasing in number and sophistication. Nonetheless, the resources devoted to these efforts are minuscule compared with those devoted to new medical treatments and technologies, and—as noted later—this is an area in which further research is a priority.

In considering the current system of voluntary employment-based health coverage and various proposals for change, it is important to remember that coverage is not the same as access. Some who have coverage still face access problems by virtue of their location, their race or other personal characteristics, or specific characteristics of their coverage, such as low rates of payment for physician services. Likewise, even those who lack health insurance have some access to care on an emergency basis for serious illness or injury, although the financial burden of this uncompensated care is very unevenly borne across communities. Access to preventive and primary care services is much more difficult for the uninsured, although public and private outpatient programs and charity care offered by individual practitioners do help some needy individuals who lack health coverage.

Extending health insurance to the currently uninsured population would not guarantee adequate access to appropriate health services, but it almost certainly would assist them in obtaining preventive and primary care that could improve their health status and quality of life. Whether some of the currently uninsured—and some who are now insured—would be better served by direct care arrangements (such as the U.S. veterans hospitals or publicly funded preventive and primary care clinics) or some other alternative or supplement to individual health insurance is a serious question, one that is not much discussed in the current debate over health care reform.


Any concise statement of key features of the U.S. system of health care coverage and the role of employment-based health benefits must simplify and generalize from a world that is neither simple nor uniform nor static. Nonetheless, based on the descriptions and analyses presented in the first six chapters of this report, the following nine characteristics stand out:

  • Voluntary group purchase 

  • Lack of universal coverage 

  • Dispersed power and accountability 

  • Diversity

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