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The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care, to also substantially change the organization and delivery of care. The FRESH-Thinking Project (www.FRESH-Thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists and others representing diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1) Replace the current fee-for-service payment system with a payment system that encourages and rewards innovations in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2) Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3) Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4) Develop health information technology infrastructure with national standards of interoperability to promote data exchange. 5) Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree upon methods to make available to researchers de-identified information from this database on clinical interventions, patient outcomes, and costs. 6) Identify revenue sources, including capping the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of covering all Americans. 7) Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance coverage could obtain a standard benefits package through these exchanges. 8) Create a Health Coverage Board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.