In the United States, any reformer who tries to build a model for comprehensive, universal health care must reckon with the core ethos of this society, which revolves around market competition. The chapters that follow explain how we can blend that ethos with some structural elements of a single-payer system to provide universal coverage at a price we can afford. In general, this means taking some—but not all—of the profit out of health care. It means imbuing health care with more of a social consciousness than it has today. And it means government intervention to ensure that the market works.

There can be no real market for health care unless the government sets the rules for one. This is well understood—although rarely enforced—in the antitrust field. If insurance companies, hospital systems, or physician groups are allowed to keep growing, they will raise prices in markets where they acquire monopoly or near-monopoly power. Similarly, if there are no restraints on how many new cardiac surgery programs or imaging facilities can be introduced in a region, supply-induced care will raise the amount of health care spending.

If it were possible, however, to construct a limited form of free enterprise, strictly regulated by the government, and if everyone had insurance, competition could lead to lower costs and higher quality. This was the central insight of Alain Enthoven and the other advocates of managed competition, and it led to Bill and Hillary Clinton’s bold but flawed attempt to achieve universal coverage. What if there were another way to negotiate the same passage, avoiding the Clintons’ mistakes and engaging health care reform on today’s terms?

The central premise of this book is that a different form of managed competition could succeed if it changed the equation in two ways: First, all primary-care physicians would have to join groups of a certain size that would be financially accounta¬ble for all professional services. And second, competition among these physician groups, rather than among insurance companies, would create the health care market. By incorporating a strong yet flexible regulatory framework that delegated power to regional authorities, this approach could prevent the federal government from gaining too much control over health care.

Naysayers will object that such radical reforms could never be adopted, given the determined opposition of the insurance and drug industries and the small-business lobby. Perhaps they’re right. But forces are building up to support fundamental change. Employers are getting mad, and they’re not going to take it much longer. Unless the ever-growing cost of health care is contained, many large companies might just drop coverage. And if enough voters eventually conclude that their choice is between lack of health care access and a government-run system, they might choose the latter. At that point, an approach like the one described here could suddenly look very appealing to those who’d prefer not to have decisions about their health care made in Washington.