THE BARRIERS TO CHANGE are as formidable as they are familiar. They are systemic, mostly of our own making, and have long blocked serious attempts to bring about needed change. In fact, we have become so used to them we act as if they are normal. But when you pile the barriers all in one place it is easy to see just how imposing a roadblock they make. When we talk about “quality,” this is the context from 30,000 feet above the roadway:

• The system is unequal. Racial and ethnic minorities tend to receive lower-quality health care than whites do, even when insurance, income, age and medical conditions are comparable.
• The system isn’t fair or equitable. More than 44 million people go without any health insurance coverage at all—and then some providers charge the uninsured more than they charge anyone else.
• The system isn’t safe. Remember when the Institute of Medicine estimated that as many as 98,000 patients a year die from medical errors? Recent studies (1) suggest the actual number of fatalities is so much higher that medical mistakes may now rank as the third leading cause of death, next to heart disease and cancer.
• The system isn’t trusted. Public confidence in the leaders of health care institutions has fallen drastically in the past generation—from nearly 80 percent in 1966 to less than 30 percent in 2004.(2) A majority of Americans now say they are afraid something bad will happen to them if they have to be admitted to the hospital. In a national poll,(3) more than 55 percent said they worried about getting the wrong treatment or a serious infection. And 62 percent say they believe the health care system will get worse in coming years.(4)