摘要：Compared with other developed countries, the United States has an inefficient and expensive health care system with poor outcomes and many citizens who are denied access. Inefficiency is increased by the lack of an integrated system that could promote an optimal mix of personal medical care and population health measures. We advocate a health trust system to provide core medical benefits to every American, while improving efficiency and reducing redundancy. The major innovation of this plan would be to incorporate existing private health insurance plans in a national system that rebalances health care spending between personal and population health services and directs spending to investments with the greatest long-run returns. THE UNITED STATES HAS THE most technologically intensive medical practice in the world. 1 It also spends more than any other nation on medical care, 2 but health outcomes in the United States are inferior to those in most other developed nations. 3 – 7 This inefficiency—spending more with poorer results—stems partly from failure to provide effective access to medical care to a substantial share of the population. 8 , 9 Lack of access leads to wider disparities in health in the United States than are experienced by the populations of other developed nations. The fragmented delivery system also leads to cost shifting (insurers' attempts to transfer costs to other payers), administrative waste, and an imbalance between spending on medical care and spending on population health initiatives. There is general agreement that the US health care system should be more efficient as well as more equitable. 10 , 11 Most comprehensive proposals for reforming the system recognize the need for universal coverage that is independent of employment status, disability status, or age, although some would continue to rely on employers to collect health insurance payments. 12 Although universal insurance is important, it is not the only urgent issue. A reformed system should integrate personal preventive and therapeutic care with public health and should include population-wide health initiatives. Coordinating personal medical care with population health will require a more structured system than has ever existed in the United States. We argue that a reformed health care system not only should provide health insurance coverage for all but should also be organized and funded to take advantage of new knowledge about medical and nonmedical determinants of health. This health trust system (HTS) would (1) assess the cost of health insurance equitably, (2) promote efficiency by reducing fragmentation and relying on competitive markets, (3) allow coordination of spending on population health and personal medical care, (4) accommodate heterogeneous preferences, and (5) build on existing American health insurance and provider institutions, informed by international experience.
