begin a dangerous domino effect, in which premiums will increase, more employers will drop coverage, and the nation's uninsured population will swell as a result. Estimates of the costs involved have ranged from pennies per month to dire predictions that premiums will rise by as much as 23 percent a year, causing millions to lose coverage. Such wide variation is a result of differences in the interpretation of mandates and of assumptions that flow from those interpretations. 16 But most of these estimates have been produced by parties that have a financial interest in the outcome. To sort out myth from reality, independent and credible analyses of the costs of various quality assurance mechanisms are needed. Reliable analyses would help determine if and when cost-quality trade-offs truly exist.
There is little doubt that medical care in the United States ranks among the highest quality care in the world and that choice, information, and fair appeals mechanisms are core ingredients of health care quality. But quality care is often unavailable to Americans who lack health insurance, and changes in the health care system threaten to jeopardize quality even for the insured. The commission has drawn the attention of policymakers and the public to the intertwined issues of quality, access, and affordability. Efforts to control health care spending are crucial, but the drive to save dollars should not be at the expense of patient care. The path to quality health care for all Americans will have many bumps along the way, but it must be pursued with vigor.