The U.S. health care delivery system is in need of overhaul. Care is fragmented, unsafe, and inefficient. Achieving higher levels of performance requires organizational capacity, including information technology (IT) and specialized expertise, not present in most settings. Organizational capacity is fortified through the benefits of larger scale and clinical integration. The evolution of new organizational structures will open up opportunities to redesign payment programs and invest capital toward building high-performing systems. A comprehensive policy agenda is needed to encourage growth in organizational capacity, including national priorities and goals, performance measurement and reporting, payment reform, community leadership, IT, and public education.