Despite a stinging recession accompanied by rising unemployment, healthcare continues to increase the bite it takes from the US economy. Although healthcare reform is the highest domestic priority of the administration, there are many challenges in finding a strategy that will bring together a fragmented system that has been sustained by massive outlays of both private and public dollars. Medicaid is a jointly funded (federal–state) means-tested programme that provides healthcare cover for approximately 61 million beneficiaries, roughly half of whom are children of low-income families. A number of strategies have been advanced in an effort to control the growth of public and private spending in healthcare. The UK's National Institute for Health and Clinical Excellence sets standards and reviews technologies and procedures for use within the healthcare system. In the US there is a widespread perception that the public will never accept economic analyses as a component of healthcare evaluation.