The Patient Safety Consortium included a group of 26 diverse hospitals in or near California. In 2001 and 2002, many consortium hospitals were surveyed using the Patient Safety Climate in Healthcare Organizations (PSCHO) tool to present quantitative measures of hospital safety climate and qualitative reports on safety practices over 2 years. Investigators engaged in discussions with consortium hospitals to elicit reports about their patient safety activities. Overall quantitative measures of safety climate remained approximately the same over the 2 years, although in some specific survey areas climate appeared to improve. Hospitals reported a range and mix of patient safety activities. While considered an essential enabler of safety, cultural change takes time. Significant hospital efforts appear to be underway, and attention to a number of lessons from past patient safety efforts may benefit future undertakings.

Dissatisfaction with the financing of U.S. health care is widespread. The system is inefficient, inequitable, and increasingly perceived to be unaffordable. Because only incremental reform is deemed politically feasible, inordinate attention is devoted to treating the institutional symptoms rather than diagnosing systemic problems that require major surgery. As an alternative, we propose a voucher system for universal health care, an efficient, fair, and relatively simple approach that might elicit broad support. We recognize that change is not imminent, but such a proposal can stimulate discussion and provide a readily available model when the political climate becomes hospitable for endorsing meaningful reform.

The key features of the voucher system are the following:

• Universality
• Free Choice of Health Plan
• Freedom to Purchase Additional Services
• Funding by an Earmarked Value-Added Tax
• Reliance on a Private Delivery System
• End of Employer-Based Insurance
• Elimination of Medicaid and Other Means-Tested Programs
• Phasing Out of Medicare
• Administration by a Federal Health Board
• Establishment of an independent Institute for Technology and Outcomes Assessment