In a country as prosperous and promising as ours, it is alarming that the sickest Americans are paying more for care and getting less for their money. Yet that is the result of a recent analysis by the Commonwealth Fund. The U.S. healthcare system is in a great state of flux - spending as a whole is beginning to trend downward while out-of-pocket costs for consumers are going up. Those consumers are not only patients; they are employers, governments and communities.