The modern JAMA has been working toward comprehensive American health system reform since 1987, emphasizing cost control, access for all, and promotion of quality.1 One of us (P.M.E.) has been developing market-based health system thinking for more than 25 years.2 The concept of managed care is hardly new. The Kaiser plans began in the American West in the 1930s.3 The massive reform that has occurred in the 1990s has been phenomenal and largely unpredicted, although much of it has been called for by many authors.4-6 Many patients, providers, and purchasers alike consider the system to be in turmoil, some even in chaos. But movement is profound and irreversible, at least in the short run.
As we go forward, we believe that physicians should be more involved and influential in determining where the American health system is going. It is unrealistic to expect to return to unmanaged,
Ellwood PM, Lundberg GD. Managed CareA Work in Progress. JAMA. 1996;276(13):1083-1086. doi:10.1001/jama.1996.03540130081034