The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way

February 19, 2009 | Volume 105

Authors: Commission on a High Performance Health System
Contact: Cathy Schoen
Notes: The Lewin Group's technical documentation is available at


"This integrated approach could achieve access for all, improve population health, and provide more positive patient experiences. "

Estimated Impacts

Using a set of policies to illustrate concepts proposed by the Commission, this report analyzed the potential impact of those policies. The findings indicate that if all were implemented in 2010, it would be possible to extend affordable coverage to all and improve population health, while simultaneously reducing the growth in national health spending by a cumulative $3 trillion by 2020 compared with current projections.* This substantial sum is the accumulation of incremental savings each year, with a reduction in the projected annual rate of growth in national health expenditures from 6.7 percent to 5.5 percent. Notably, even after this substantial reduction, national health spending still would exceed the projected annual growth in gross domestic product (GDP). Although the percent of GDP spent on health care would be lower in 2020 than what is currently projected—18.4 percent of GDP compared with the projected 20.8 percent—it would account for a higher share of the U.S. economy than in 2009 (16.9 percent).

*These estimates are based on an extensive modeling effort by The Lewin Group. Lewin used specifications developed to reflect each component of the Commission’s recommendations. The results based on those specifications drew from available evidence as to their potential impact on those who would be affected and their behavioral responses. The Lewin Group is one of the leading health care and human services consulting firms in the United States, with more than 35 years of experience serving organizations in the public, nonprofit, and private sectors. The Lewin Group is a wholly owned subsidiary of Ingenix, which in turn is owned by UnitedHealth Group. The Lewin Group maintains editorial independence from its owners and is responsible for the integrity of any data that it produces for the Fund.

The policies included in the analysis interact and are mutually supporting. All contribute to the net cumulative effect on potential savings and improvement in value (Exhibit ES-3). Each slows the rate of growth in national health spending compared with current projections. (See summary for policies used for purposes of modeling coverage and cost estimates.)

Path Report figure 3

These estimated impacts are contingent on their effectiveness in stimulating change in the way providers, patients, and insurers (both public and private) behave, and how they react to the new opportunities the proposed policies would create. The Commission developed the set of policies with a vision of potential dynamic change—a chain of events that interact over time. A central feature is the insurance exchange structured to expand choice of plans in the context of market rules that prohibit competition on the basis of risk selection. This design could promote competition based on value to drive innovation among insurers and better organization of care. The public plan plays a central role in harnessing markets for positive change.

The effectiveness of these reforms depends on payers becoming more prudent purchasers. Transforming Medicare into a more active purchaser of care—with innovative payment methods that move away from fee-for-service to more bundled payments and mechanisms to hold providers accountable—could stimulate and support changes in behavior that improve performance. Comprehensive insurance with premium differences reflecting value and cost-sharing, aligned with effective care and better outcomes, would provide patients with incentives to seek high-value care and promote appropriate use of resources.

Success will require that key stakeholders join together to make difficult decisions and undertake the steps necessary to transform the health care delivery system and move along the path to high performance.