At the start of his campaign for health care reform, President Barack Obama acknowledged a painful truth: to expand coverage without bankrupting the country would require bending the curve of health care expenditures. Unfortunately, while the 2010 Patient Protection and Affordable Care Act1 makes substantial expansions of health insurance, it will probably do little to slow rising health care expenditures. As an early combatant in the battle to restrain excessive medical care spending—services that bring minimal or no health benefit—I was not surprised that the country is unprepared to heed the president's message, nor that political opportunists would use outrageous fear tactics, such as suggesting that giving people information on palliative care was tantamount to establishing death panels. To place cost containment efforts in historical context, I share my experiences and reflections, beginning early in my career at a time—1971—when the amount spent on medical care caused alarms because it had risen to 7.5% of gross domestic product and was headed for an “unsustainable” 10%. (It is now over 17%.) For a period of 3 decades, first as medical director of the George Washington University (GWU) medical outpatient clinics and health maintenance organization (HMO), later at the Institute for Health Policy Studies and the Division of General Internal Medicine at University of California, San Francisco (UCSF), and subsequently as president of the Robert Wood Johnson Foundation (RWJF), I observed and studied a variety of factors causing why the United States is such a big spender on medical care and why it is so hard to “bend” the curve of escalating medical expenditures.
National differences in the referral chain in health care.
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