The fundamental problems that beset the U.S. health care system--cost, quality, and access--differ in scope and intensity in inner cities. Current trends in health care are system-wide but are more difficult to accommodate in inner cities because of scarce resources and stresses to the health care system. In this position paper, the American College of Physicians seeks to highlight directions and innovations in public policy for inner-city health care with renewed determination that health care problems in the United States must be solved, especially in cities, where they are most extreme. Many persons in inner cities experience an urban health penalty because of the concentration of economic decline, job loss, and major health problems. Because the problems originate in a complex interaction of socioeconomic factors, behavior, environment, and disease that is related to race and ethnicity, multifaceted approaches that extend beyond the medical model are needed to improve health status. The College argues for tackling health problems of the inner city in the context of a comprehensive urban policy that addresses the root causes of poverty. In addition, this position paper contains more specific recommendations to improve health care delivery to inner cities. The College calls for a comprehensive urban partnership initiative to address all aspects of the urban penalty--social, economic, and health-related--and recommends solutions through public and private collaborations that can be adapted to the circumstances of each community. In addition, policy recommendations address health care coverage, providers, public health initiatives, community involvement, and short-term improvements to such existing programs as Medicaid.