Guarantees of free medical care are important constitutional guarantees that provide material benefits and the most specific type of public debt to the citizen. It is shown that in modern Russia, implemented a version of the strategy of providing state guarantees of free medical care, based on a combination of resource reduction and attempts to improve the efficiency of their use. There is no paradigm of transformation and development of the industry, which has a strategic focus and covers all levels and components of the national health system. The authors believe that due to the traditional conservatism of the health care system, it is difficult, but possible, to solve this problem by the internal forces of the industry. To do this, it is necessary to create conditions in which the circle of strategic decision-makers in health care will be separated from the circle of persons developing and implementing tactical tools.