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Until the second quarter of the 20th century, medical treatment had little positive effect on when, or even whether, sick people recovered. With the discovery of ways to reverse the biochemical deficiencies that caused some diseases and the development of antibacterial drugs, it became possible to cure sick people. These early successes and the therapeutic optimism they engendered stimulated the biomedical research community to develop a host of more powerful agents to treat heart disease, cancer, neurological disorders, and other ailments. These increasing opportunities for productive intervention as well as a fundamental restructuring of the market away from nonprofit health care providers to for-profit entities and the expansion of the pharmaceutical, medical device, and insurance industries that saw opportunities to make money providing medical services, together with increasing expectations by the public, have led to spending an accelerating amount of money on medical services, reaching $2.6 trillion and nearly one-fifth of the United States' entire gross domestic product in 2011 (Fig. 1-1).

Figure 1-1.

(A) Total annual expenditures for medical services in the United States between 1960 and 2010. (B) Expenditures for medical services as a percentage of the gross domestic product. (Source: Statistical Abstract of the United States, 2011. Washington, DC: US Department of Commerce, pp. 99.)

This situation has led to continuous calls for reform from a wide spectrum of stakeholders, from business leaders who saw their costs skyrocketing, to labor leaders who saw health insurance costs putting downward pressure on wages, to advocates for the growing number of uninsured people who were simply priced out of the system, to political decision makers who saw out-of-control costs of providing medical care through government programs such as Medicare and Medicaid, jeopardizing other important government services.

Because of the fact that medical care touches everyone's life in one way or another and because of the high stakes—financial and otherwise—for the individuals and organizations that provide these services, reforming the health care system has been a controversial and politically charged issue.

After over a year of increasingly partisan debate, in March 2010 the Democrats in Congress passed the Patient Protection and Affordable Care Act without a single Republican vote. On March 23, 2010, President Barack Obama signed the bill into law.

While this law has many provisions, including requiring people to have or purchase health insurance and imposing many regulations on the health insurance industry, it also recognizes that the current medical system is unsustainable financially and includes several provisions designed to get the costs of the medical system under control. (Indeed, one of the main facts driving the debate was the observation, from an ongoing research project at Dartmouth University, the Dartmouth Atlas of Health Care,* that 30% of the nation's medical spending would be unnecessary if all regions of the United States the provided services at the ...

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