Fact: As a nation, medical care expenditures represent 10.6% of the gross national product. The portion of the nation's medical care dollar coming from federal sources declined slightly (42.6% to 41.4%) between 1981 and 1984, but this share is more than 15 percentage points above the comparable figure from the years prior to 1965 (Anderson, 1985).

As these numbers illustrate, paying for health care is a very expensive proposition in the United States, consuming a higher proportion of our nation's resources than is true for most developed nations. While we have strongly resisted any move to a government-run system of health care delivery, the above numbers also show clearly that the federal government pays for a substantial share of all health care in this country.

Three major themes have dominated the health policy agenda during recent years: access to health care, cost containment, and quality of care. The fates of these issues have waxed and waned over the years as changes in health care delivery, federal budgetary politics, and shifting public opinion have altered the environment over time. In the 1960s, access was the key issue, as Democratic administrations used government programs to make health care more readily available to all Americans. As inflation levels soared in the 1970s, cost containment was forced onto the agenda, resulting in a series of attempts to reduce federal expenditures on hospital care. Finally, by the mid-1980s, cost containment pressures were modifying slightly; we have recently witnessed a return to access issues and the emergence of quality as a new political issue.