We begin by examining the growth in spending in the United States health care system. Next, we define five priority areas of delivery system reform, and identify cost saving opportunities in these areas. Third, we highlight models of delivery system reform that are currently in practice across the country, with particular attention to their effect on health care cost and quality. The fourth section details the ACA's delivery system reform provisions and the status of their implementation. The report concludes with an analysis of the Administration's progress and offers recommendations for steps moving forward. The salient fact underlying this report is that the drivers of unnecessary and excess cost in the U.S. health care system result from systemic causes. Public insurance programs, private insurance coverage, military and veterans' care, even corporate self-insurance, all are seeing dramatic and continuing cost increases. The problem is system-wide, and the solution must be too. If these issues are not addressed, policymakers will face increasingly unpleasant and difficult threats to the insurance coverage, both private and public, of millions of Americans. Gail Wilensky, who oversaw Medicare and Medicaid under President George H.W. Bush, said, "If we don't redesign what we are doing, we can't just cut unit reimbursement and think we are somehow going to get a better system." The ACA offers solutions that do not cut benefits or increase premiums, but instead reform systems of health care delivery to improve health outcomes and cost efficiency. The key challenge facing the United States is how quickly, thoroughly, and efficiently the reform of our health care delivery system can be implemented.