We in the United States have historically been unwilling to make the difficult choices necessary to achieve an equitable and affordable health care system. There has been an unrealistic expectation that all Americans could be afforded access to needed medical care without any requirement that they pay their fair share of the costs. Government and other large purchasers have increasingly reduced their own costs through price discounts rather than through far more difficult measures to reduce system costs. To accommodate these conflicting forces, a byzantine structure of cross-subsidies and cost-shifts has evolved. This structure is now collapsing under the weight of unrelenting growth in overall health costs. As the inequities and costs of our system have been felt by a growing number of Americans, we have witnessed an emerging consensus that major reform is needed.