Impact on Health Insurance Coverage
The insurance framework proposed by the Commission includes the creation of a new national insurance exchange that would offer private insurance plans and a new public plan option, expansion of existing public programs, market reforms, provisions for affordability, and requirements that all have coverage to reach universal participation. By establishing a new public plan available nationwide, the framework would also provide the basis for a new competitive dynamic in insurance markets and provide a strong foundation for payment and system reforms.

The insurance expansion would achieve near-universal coverage. The number of uninsured would drop from an estimated 48 million in 2009 (16 percent of the U.S. population) to 4 million by 2012 (1 percent of the population), with nearly everyone insured over the next decade (Exhibit ES-2). Absent new directions, the number of uninsured is projected to rise to 61 million or more by 2020.

By building on existing insurance coverage, this framework would permit individuals to keep their current coverage if it works for them while providing new choices through the insurance exchange, including a range of private plans and the new public plan. Small employers in particular would be able to offer their employees a choice of multiple plans. Large employers would gain a nationwide plan plus employee choice of regional plans. All those enrolled through the exchange would be able to keep their coverage as jobs or circumstances changed. The exchange could be open in stages to allow reasonable time to set up. In the modeling, the exchange starts out by opening to small firms and individuals, opens to midsized companies in two years, and opens to all employers by 2014. With the advantages of continuity and choice, including a public plan option, the modeling estimates that over time most of the privately insured market (about two-thirds) would elect to receive coverage through the exchange.

The new public plan option would provide a less expensive alternative for the uninsured and underinsured than what is currently available in the individual and small business insurance markets. Savings would derive from significantly lower administrative costs and use of Medicare's reformed provider payment rates. Estimates indicate premiums for the public plan would be at least 20 percent below those currently available for a comparable benefit package in the private market (Exhibit ES-4). The availability of the public plan option would thus provide a catalyst for private plans to innovate and reexamine the way they operate and pay for care.

With the flexibility to establish more integrated care networks and a variety of payment policies, private plans—by focusing on quality and value—could compete with each other and outperform the public plan, if they innovate. Provisions could encourage multipayer synchronization to ensure coherent policies and reduce administrative complexity. The goal is more vigorous, innovative, and value-driven competition focused on outcomes and a more streamlined, efficient health insurance financing system.

Impact on Care, Quality, and Outcomes
Changing the way we pay for care to align incentives with value is critical. The payment reforms proposed by the Commission would enhance the value of primary care and change the way we pay to stimulate care delivery through patient-centered medical homes with the capacity to provide access, coordinate care, and use information systems and teams to manage chronic conditions. Moving to more bundled payments, with provisions for accountability for outcomes, would align incentives with the value rather than volume of care delivered and would support hospitals, physicians, and other clinicians working together to care for patients. Building a solid infrastructure of information systems and programs to enhance prevention of disease and promote population health would emphasize innovation to meet current and future community health needs.

The Commission envisions a health system that provides patients with personal sources of care who know their medical history, ensures timely access, helps coordinate care, and uses essential clinical information to provide the right care with an emphasis on health and disease prevention. Payment and information systems would stimulate and support a patient-centered care system that is coordinated, accessible, and safe.

With a focus on prevention and improving outcomes for chronic disease, the nation could achieve substantial improvements in population health with policies that align incentives with the provision of right care and prudent use of resources, provide clinicians with information system tools and decision support, and build and expand public health programs. We should aim for healthier, more productive lives through prevention of disease, earlier intervention, and effective management of chronic conditions, including people with multiple comorbidities. In addition, more effective and humane care for people with late-stage diseases could address the huge variations in care.

By setting targets and implementing policies that meet and raise benchmarks of top performance, we have the opportunity to save lives, improve the quality of life and care experience, lower safety risks to patients, and prevent the onset of disease and complications. As illustrated by key indicators from the Commission's National Scorecard on U.S. Health System Performance, improving average performance to targets or benchmarks set by current top performers by 2020 would achieve substantial gains in population health and patient experiences (Exhibit ES-5).