Almost daily reports about the growing crisis in the U.S. health care system hit the airwaves. The litany of problems becoming all too familiar:

• High costs
• Uneven quality
• Inadequate access
• Disparities in treatment and outcomes

The Blue Sky Initiative was established in 2003 to examine and analyze the problems facing the health system from a different perspective, defining the nature of the problem–and therefore the solutions–in a new and broader mindset. We agree the problems of cost, quality, access and disparities in health care are important issues; however, we contend they are symptoms of larger underlying and more fundamental systemic problems with the organization and financing of the medical care system, and with the overall health system infrastructure.

Discussion on health reform has been limited to the medical care system, ignoring social, environmental, behavioral and other factors that influence health, but are generally not under the purview of medical care. To achieve meaningful health reform, significant and fundamental changes need to be made in the organization, financing and governance within medical care services as well as traditional public health services; population health services; and civic, business, and nonprofit activities–these latter areas together having a greater impact on producing health than does medical care. Each of these sectors needs to have incentives aligned to promote health; be connected to facilitate appropriate information exchange; be part of a defined accountability structure so that their respective health effects are recognized by participants across the sectors; and be integrated so that resource allocations and policy decisions can be coordinated and the overall health system can operate more effectively, efficiently, and equitably for all Americans.

The Blue Sky Initiative aims to broaden the health reform discussion and promote a transformative reform strategy that:

• Acknowledges that science and experience have given us the opportunity to direct the health system to promote health itself; therefore, the first objective of health reform should be to optimize the health of the entire population and not just to provide more or even improved medical care.
• Explicitly incorporates what we now know about the multiple determinants of health, including those that fall outside of the purview of medical care; therefore, the second objective of health reform should be to create a health system that acknowledges, balances, and strategically targets the upstream determinants that influence the health of individuals and populations.
• Fully exploits recent understanding of the "upstream" determinants of health, including the role of risk factors, protective measures, and health promotion early in an individual´s life; therefore, the third objective of health reform should be to build prevention and health promotion into the structure of our health system to improve health over the lifespan, with a particular focus on the earliest years.