Establishing the Medicare Program in 1965 led to greater access to care for millions of Americans. Yet, until the mid-1980s Medicare spent minimal efforts measuring or improving quality. Since that time, the Health Care Financing Administration (HCFA), later called CMS, has led many efforts to measure, publicly report, and work with providers to improve care. In 2005, policymakers seek to build incentives for improved quality into the payment system. This policy is critical for encouraging improvement and rewarding investment. Future efforts need to look beyond individual provider settings to encouraging improvement for patients receiving care in multiple settings, and at home.