A comprehensive set of insurance, payment and system reforms could guarantee affordable health insurance coverage, improve health outcomes and slow the growth of health spending by $3 trillion by the end of the next decade, according to a report released Feb. 19 by the Commonwealth Fund Commission on a High Performance Health System.

The report, "The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way," details the commission's recommendations for a set of policies and assesses the impacts of specific policy actions from 2010 to 2020, compared to the status quo.

A central recommendation is to create a national insurance exchange that would offer a choice of private plans and a new public plan, coupled with insurance reforms that would make coverage affordable, ensure access and lower administrative costs. The report recommended policies that would change the way the nation pays for care, invest in information systems.

The report indicated that insurance reforms would extend coverage to everyone within two years, with only 1 percent uninsured throughout the next decade. If combined with payment and system reforms initiated in 2010, the integrated approach to reform could slow the growth of national healthcare spending by a cumulative $3 trillion by 2020.

Spending would still go up but at a slower rate, according to the commission. The United States is expected to spend $42 trillion on healthcare over the next 11 years, with spending rising 6.7 percent per year. By rationalizing the care system, including payment and information system reforms, the commission said its approach could slow the increase in spending to 5.5 percent per year, while providing coverage and access for all. The savings would accrue to families, business and the public sector across all income groups.

"With our economy in crisis, health costs squeezing family budgets, and coverage deteriorating, we can't afford to continue on our current path. The commission has laid out a pragmatic strategy that could rapidly move us in more positive directions--if we start now," said Commonwealth Fund President Karen Davis.

Without new policies, the number of uninsured is projected to increase to 61 million over the next decade, not counting more than 25 million more that are underinsured--poorly protected by inadequate insurance if they become sick. Despite the coverage erosion, U.S. health spending is projected to double to $5.2 trillion by 2020, to consume 21 percent of U.S. resources.

The Commission laid out five essential strategies for reform:

• Affordable coverage for all. Build on current public-private health insurance system by establishing a health insurance exchange that offers an enhanced choice of private plans and a new public plan. The public plan would offer benefits with incentives for disease prevention and payment methods that reward results.
• Align incentives with value and effective cost control. Move away from the fee-for-service payment system toward one that emphasizes value rather than volume, enhances the value of primary care and holds providers accountable for quality and efficiency.
• Accountable, accessible, patient-centered and coordinated care.
• Aim high to improve quality and health outcomes: Infrastructure and Public Health. Invest to accelerate the adoption and effective use of healthcare IT and to provide information to support and inform healthcare decisions by patients and clinicians. Target public health initiatives on prevention to improve outcomes for chronic conditions.
• Accountable leadership and collaboration to set and achieve national goals. Establish new U.S. policies that enable leadership and foster collaboration among the public and private sectors to set and achieve new goals and carry out reforms.

The Commission said that the public plan option--with premiums at least 20 percent lower than currently charged by private fee-for-service plans for comparable benefits, especially in small group markets--would challenge private insurers to innovate and reduce administrative costs. The exchange and reforms could lower administrative costs for all plans.

In a Feb. 19 New England Journal of Medicine commentary, Davis expanded upon the report and discussed the politically difficult changes needed to transform how to pay for and deliver healthcare.

"Such a set of reforms could offset two-thirds of the cumulative federal budget costs of expanding coverage to everyone, while employers, households, and state and local governments could see substantial net savings," David wrote. He concluded that "it is time to change 'business as usual' and invest in the healthcare reforms that will benefit the public and patients and put our nation on a sounder economic footing."