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Importance: Recent discussion has focused on questions related to the repeal and replacement of portions of the Affordable Care Act (ACA). However, issues central to the future of health and health care in the United States transcend the ACA provisions receiving the greatest attention. Initiatives directed to certain strategic and infrastructure priorities are vital to achieve better health at lower cost.Objectives: To review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation's health and fiscal integrity.Evidence Review: Qualitative synthesis of 19 National Academy of Medicine-commissioned white papers, with supplemental review and analysis of publicly available data and published research findings.Findings: The US health system faces major challenges. Health care costs remain high at $3.2 trillion spent annually, of which an estimated 30% is related to waste, inefficiencies, and excessive prices; health disparities are persistent and worsening; and the health and financial burdens of chronic illness and disability are straining families and communities. Concurrently, promising opportunities and knowledge to achieve change exist. Across the 19 discussion papers examined, 8 crosscutting policy directions were identified as vital to the nation's health and fiscal future, including 4 action priorities and 4 essential infrastructure needs. The action priorities-pay for value, empower people, activate communities, and connect care-recurred across the articles as direct and strategic opportunities to advance a more efficient, equitable, and patient- and community-focused health system. The essential infrastructure needs-measure what matters most, modernize skills, accelerate real-world evidence, and advance science-were the most commonly cited foundational elements to ensure progress.Conclusions and Relevance: The action priorities and essential infrastructure needs represent major opportunities to improve health outcomes and increase efficiency and value in the health system. As the new US administration and Congress chart the future of health and health care for the United States, and as health leaders across the country contemplate future directions for their programs and initiatives, their leadership and strategic investment in these priorities will be essential for achieving significant progress. [ABSTRACT FROM AUTHOR]

From 2004 to 2007 the California HealthCare Foundation's Step by Step: Local Coverage Expansion initiative supported insurance coverage expansions for uninsured children and adults in thirty California counties. In this paper we describe the initiative and its achievements as well as challenges for grantees. Also, we discuss the implications of the initiative's outcomes for expanding coverage locally and more broadly. Implementing new insurance programs is possible in the most difficult settings. Although there are real challenges to sustaining these expansions and limits to what they can accomplish in the face of major unmet needs, they may lay useful groundwork for broader expansions later. [ABSTRACT FROM AUTHOR]

Most proposals to improve access for uninsured adults focus on removing financial barriers to health care. Health services researchers have long recognized, however, that access to care is a multidimensional concept consisting of both financial and nonfinancial dimensions. While financial barriers faced by those without health insurance have been well-documented, it is not known to what degree nonfinancial barriers limit access for those without coverage. In this study we sought to identify the types and frequencies of nonfinancial access barriers faced by low-income uninsured adults, as well as determine how frequently nonfinancial barriers coexist with financial access barriers in this population. We conducted a telephone survey of 1,118 low-income uninsured adults in Alameda, California, Austin, Texas, and Southern Maine who had enrolled in local access programs funded through the Robert Wood Johnson Foundation’s Communities in Charge initiative. Financial barriers were the most often cited barrier to access in each of the three groups, though nonfinancial barriers were often cited as well. Across all three populations, one-third to one-half of respondents with financial access barriers also cited one or more nonfinancial barriers as contributing to their problems accessing health care. Our results suggest that many uninsured adults face nonfinancial health care barriers in addition to their well-documented financial challenges. Health reform efforts must address both types of barriers in order to maximally improve access for the uninsured population. [ABSTRACT FROM AUTHOR]

The US healthcare delivery system, by all accounts, is the most advanced and sophisticated healthcare system in the world. Clinical advances in diagnostic and therapeutic regimens, superior performance in biomedical research, and the development and use of the latest management and medical technologies are all hallmarks of the system. While the US healthcare system has been extremely successful, concerns remain about access to care for a large segment of the population. This article examined the various approaches that have been adopted and those that are being proposed to bridge the existing gap in health insurance coverage. The underlying assumptions of the proposed strategies were examined, and the conditions necessary for the successful implementation of these strategies were also discussed. [ABSTRACT FROM AUTHOR]