The numbers are mind-boggling.

Health care spending will reach $1.9 trillion this year, averaging more than $6,000 per person. Though the United States spends more on care than any other nation, nearly 45 million Americans, including more than a half-million Hoosiers, are uninsured.

Since 2000, the cost of health insurance has risen 59 percent while wages have gone up only 12 percent. This trend is clearly unsustainable.

That's why we asked CEOs and physicians from Indianapolis -- all major players in the health care field -- to diagnose how to lower the cost and increase coverage, without compromising quality.

The existence of racial and ethnic disparities in care is the most striking and unacceptable characteristic of the current U.S. health system. Racial and ethnic minorities receive a lower quality of health care in this country and have poorer health outcomes even after adjusting for differences in income, age, insurance status and severity of illness.

Research shows that these disparities are strikingly consistent across a wide range of disease conditions and health services. For example, minorities are less likely to receive appropriate cardiac medications or bypass surgery after a diagnosis of heart disease. Racial differences also exist in the receipt of appropriate cancer screening tests, sophisticated treatments for HIV infection, pediatric care, diabetes care and many surgical procedures.

The consequences of these disparities are severe for both affected individuals and society. Delayed diagnosis or inadequate care can lead to costly and avoidable complications. For the individual, these disparities may result in higher morbidity, greater disability and diminished personal productivity. These findings mean higher health care costs for both the public and private sectors, which lead to higher taxes and insurance premiums for many, increased corporate expenses and reduced industry competitiveness.
Although the exact relationships remain unclear, we know many factors associated with these disparities. Some are access-related such as lack of a primary care provider, difficulties with transportation and inadequate insurance.

Cultural differences may affect patient preferences, be in conflict with health practitioner beliefs and thus cause higher patient refusal rates. Language barriers or literacy limitations may hinder access to health information or impair navigation of complex health systems.
Though the overwhelming majority of health care providers are not overtly biased, subconscious prejudice and stereotyping may contribute to differences in care.

In recent years, the Department of Health and Human Services has successfully implemented a number of generic and disease-specific initiatives to reduce minority health disparities. As a result, we're improving the care of minority patients with diabetes, hypertension, HIV infection and cancer screening.

But we still have a long way to go. First we must improve reporting methods and obtain more complete data to better understand the causes of disparities. We must raise awareness of them in both the general population as well as among health professionals. Cultural competency must become a routine part of training. Public and private health plans should offer incentives to providers to practice evidence-based medicine for all patients, regardless of backgrounds.

We also must increase the proportion of underrepresented minorities in the health professions. Minority health care providers are more likely to practice in minority and medically underserved neighborhoods, which can improve access. These are good reasons to reduce the barriers to education for young minority students interested in pursuing careers as health care professionals.

We must support scholarship and loan programs targeted for minority students, such as the Lulu and George Rawls Award of Excellence established through the Wishard Foundation. We can eliminate this gap in health care, but only through a multi-level approach involving both public and private efforts and resources that includes education.

The continued rise in health care costs is not sustainable. At this rate, costs will double in less than a decade. But we're doing many things right now to make health benefits more affordable.

• Data show that 7 percent of our members account for 63 percent of the total health care costs we pay. That is the nature of insurance. What this means is that we can reach the greatest potential for savings by focusing on a relatively small group of patients and better managing their conditions and care.

In our Care Counselor program, for example, a case manager coordinates support for members with multiple chronic diseases. A study of the program found that it saved $4 for every $1 spent while improving health and achieving high customer satisfaction.
So we not only improve the health of our members most in need; we also reduce the costs of caring for them -- helping hold down premiums for members.

• Innovative consumer-driven health plans are helping hold down the rise in health care costs. Lumenos, a WellPoint company, is a pioneer and market leader in this field. A typical CDHP includes traditional coverage with a high deductible and a member health account funded by the member and/or employer. The higher deductible means lower premiums, and the health account provides tax-free savings to cover expenses within the deductible. The final ingredient is information that consumers can use to choose the best options for health care dollars.

An independent study by McKinsey and Co. found that Americans covered by consumer-driven health plans were 50 percent more likely to ask about the cost of health care options. They were also 30 percent more likely to get an annual check-up, 25 percent more likely to engage in healthy behaviors and 20 percent more likely to follow treatment regimens for chronic conditions.

• Lack of health insurance coverage actually contributes to rising health premiums. People without insurance are more likely to put off going to the doctor until their condition has become serious and costly to treat -- and those costs are borne by all.

A third of the uninsured in America may be able to afford coverage, but they don't know it's available, don't know how to get it or don't think they need it. We're marketing health plans that provide value to this group. For example, our Tonik plans, currently offered in California and Colorado, are aimed at young people ages 19 to 29. Typical premiums are as low as $64 a month.

To reach the uninsured who have low incomes but are not eligible for government programs, we're also developing more affordable products for individuals and small businesses, such as our Blue Access Economy Plan. In 2004, WellPoint provided new individual policies to an estimated 375,000 people who had previously been uninsured.

• WellPoint serves about 29 million members nationwide, and we process 600 million medical and pharmacy claims a year. While strictly protecting the privacy of each patient, we can turn extensive data into useful information to improve health care and reduce costs.
Health care professionals can analyze this information about outcomes to identify the most effective treatments, and information about prices and quality measures that consumers can use to make choices about their health care and coverage.

These steps are part of WellPoint's larger vision to transform health care. By helping consumers make informed choices, and by developing innovative solutions that anticipate their needs, we can help make possible even better care at lower cost.

As patients -- and as citizens and business leaders -- we Americans tend to approach health care in an episodic fashion. We think about it when we need to, and then only with reference to the immediate problem at hand, be it our own high blood pressure or our company's insurance burden.

However, if we really want the best of health as individuals -- and if we want a fairer, more cost-effective, higher-quality health-care system as citizens -- then we would do better to stop looking for quick fixes and consider instead an integrated set of remedies. Here are five:

• Let the consumer be the driver. No one should think of health care as mostly free, or paid by others -- the mind-set that our current system of employer-based health insurance encourages. Putting individual patients in charge of how health-care dollars are spent would improve personal responsibility for health, elevate the neglected factors of "value" and "quality" in health-care choices, and reduce the cost-shifting within the system that currently makes it nearly impossible to figure out what a health-care product or service is really worth.

Congress has already taken a major step in this direction by authorizing Health Savings Accounts as part of the Medicare Modernization Act. HSAs create the means for individuals (usually with their employers' help) to set aside money for routine medical expenses. Linked to HSAs, high-deductible insurance plans continue to provide the all-important safety net, but at a much lower cost than traditional health insurance. Best of all, HSAs belong to the individual and are portable, from job to job and eventually into retirement.

• Organize health care around the patient. If you have ever undergone unnecessary medical tests, been caught between two doctors who seemed unable to communicate with each other or watched a health problem get worse as you were shunted around "the system," then you know that current health-care delivery often falls far short of the patient-centered ideal.

Organizing health care around the patient would not mean indulging patients' whims. On the contrary, it would begin with the idea that individuals bear primary responsibility for their own health. Doctors and other providers would place far more emphasis on teaching us how to prevent illness in the first place. Before and after illness strikes, rewards would go to providers who guide patients toward high-quality outcomes rather than to those who excel at protecting themselves from liability. A consumer-driven payment system would create the basic incentives for patient-centered care, leaving it to the patients themselves to pick the winning delivery models.

• Bring health care into the Information Age. No sector in the U.S. economy has failed so utterly as health care to reap the benefits of information sharing and productivity made possible by the computer. It is long past time to create networks for the flow of patient information to reduce medical errors, cut administrative waste and permit better integration of care.

The federal government is working to establish standards for recording, sharing and protecting patient information with the goal of bringing Medicare, Medicaid and the Veterans Administration's systems into the digital age. Regional initiatives such as the Indiana Health Information Exchange are also driving transformation, and the prospects of reaching a critical mass of networked patient information are good.

• Fix malpractice law. Over the last decade, liability costs in medicine have risen far faster than the costs of health care itself, imposing a net expense of about $80 billion per year on the U.S. system that benefits no one so much as the attorneys involved. Alternative means of protecting patients from malpractice have been proposed across the political spectrum -- and we should enact some large-scale experiments quickly.

• Assure universal access. Every American must have access to basic, affordable health insurance. This is not code language for socialized medicine. Indeed, the most straightforward way to offer universal access may be to replace the current tax exclusion for employer-based benefits with a refundable tax credit, available to all, for the purchase of private health coverage. The credit could be supplemented by governments and employers with additional financial aid for those in need.

Any of these remedies would improve our health-care delivery and payment system. Together, they might truly transform it.

In June, the national moratorium on construction of specialty hospitals expired. This moratorium sought to stop the construction of specialty facilities like orthopedic and heart hospitals. It was supported by the American Hospital Association and opposed by the American Medical Association.

A bill is pending in Congress now to renew the moratorium. A permanent ban on specialty hospitals is included in the proposed budget reconciliation bill adopted by the Senate and currently before the House-Senate conference committee.

In Indiana, a bill was introduced but failed to pass in the last legislature to ban full-service hospital construction not authorized by local officials in counties where there was a county hospital. In its absence, some Indiana counties have passed either outright bans or local certificate-of-need ordinances.

Eventually, a comprehensive federal statute likely will pre-empt all local and state ordinances and statutes. But in the meantime, what is this all about?

At the very least, it's a complicated mix of local control over who delivers health care in a community, and the cost of, need for and quality of that health care. It's readily apparent that the patient is not the first person mentioned when such matters are debated.

The most important issue is the quality of service and health care provided to patients in a given geographic area, regardless of what the county boundary happens to be. Elected officials and health care providers need to cooperate in implementing a common vision of the best quality health care possible in their respective areas.

The real reason health care costs are increasing has little to do with hospital construction. What we should be talking about is how to improve the general health of our state rather than arguing about whether or not to locate a specific facility in a specific place.
As part of Clarian's mission of education, research and clinical care, it is our responsibility to reach out to local communities to help improve the health care provided where need exists.

Of course, this issue won't go away, and the day will not come when everybody agrees to collaborate. In the meantime, we will continue to try to live out our mission with the guidance and support of the communities we serve.

Evans is president and CEO of Clarian Health Partners in Indianapolis.

Every Thursday afternoon I am immersed in situations that powerfully represent the American health care system's greatest failure. On that day of the week I volunteer my physician services to Horizon House, where Indiana University Medical Group staffs a clinic for a Downtown homeless population.

Horizon House is a remarkable story in itself, a day shelter that somehow scrapes together the resources to serve the homeless, including social work, case management, mental health, medical, legal, occupational rehabilitation services and some of the basic infrastructure for decent living in our city -- showers, lockers, telephones and a day room for socialization.

Medical and mental health services are largely rendered at Horizon House without compensation. Virtually all of the Neighbors (people served by Horizon House) walk in the door for the first time not only homeless but also without insurance. Their health problems are myriad and complex, including mental health disorders, respiratory infections, rashes, injuries attributable to living on the street and sleeping under bridges and the interpersonal violence that pervades their hard-scrabble lives.

Typically, they also have various chronic conditions such as hypertension, asthma, and diabetes -- conditions that are out of control for the lack of appropriate primary care services available on a sustained basis. The patchwork of care accessible to them in emergency rooms, shelters and free clinics is simply inadequate to the requirements of their chronic conditions for care plans, sustainable supplies of medicines, continuity of care, regular monitoring and management that responds to changing circumstances.

Any serious look at the quality and effectiveness of their care would rate it as inadequate, not because the clinicians they see are stupid or ill-prepared, but because the care they receive is ill-timed, uncoordinated, intermittent and severely resource-constrained. I do my best on Thursday afternoon, but my best is not adequate to the need.

There are many reasons why the American health care system can and should be criticized. In our fragmented, segmented, crazy-quilt approach to providing medical care for everyone, world-class medicine and medical ghettos co-exist, cheek by jowl. The former is driven by medical science, innovation and centers of excellence. The latter is fueled by poverty, lack of basic health insurance and the absence of the political will to enfranchise everyone.

Medical neglect, especially as it affects more than 43 million U.S. citizens who lack insurance, costs us all dearly when the cumulative burdens of chronic conditions finally take their toll, leading to disability, emergency hospitalizations and institutionalizations -- all at public expense.

High cost and low quality are the usual grounds for faulting the U.S. health care system. Improving the cost-effectiveness, coordination and quality of care for those with insurance will be important to our health care system's performance but, from a total population perspective, making substantial progress in reducing the social costs of poor health and securing major improvements in quality of medical care await the advent of universal health insurance.

Inui, M.D., is president and CEO of Regenstief Institute and associate dean of health care research for Indiana University School of Medicine.