In the early 1990s, America began to realize it faced a crisis in health care spending and equitable and adequate health care for all. The Academy organized a four-day conference exploring this subject. Topics included the history of the role of physicians and academic hospitals in caring for the poor; trends in the ability of poor and medically underinsured individuals to obtain medical care; what medical education can do to improve care for the poor; the impact of health care reform on the poor; and recent trends in health care, with an emphasis on implications for teaching hospitals in caring for poor patients. The final day was devoted to identifying problems and potential solutions, and making recommendations for reform. The edited report was distributed to U.S. medical school deans; government and nongovernment officials working on national health care reform; and health care leaders in California, the focus of much of the conference.