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February 2, 2000

Quality of Health Care and the HMO Marketplace—Reply

Author Affiliations

Phil B.FontanarosaMD, Deputy EditorIndividualAuthorStephen J.LurieMD, PhD, Fishbein FellowIndividualAuthor

JAMA. 2000;283(5):602-605. doi:10.1001/jama.283.5.601

In Reply: Dr Coulter views yesterday's market failures as prelude to tomorrow's successes. Last year the number of uninsured people increased by another million, Medicare HMOs ejected hundreds of thousands of patients, and HMOs announced 10% premium increases. How long should we wait for the market to work?

The competitive free medical market that Coulter mentions is more an insurance executive's fantasy than patient-experienced reality. Employers, not patients, choose health plans. Only 20% of small firms offer more than 1 health plan; even among large firms, less than a third offer more than 2 plans.1 The choices patients really want—of physician and treatment options—are usurped by profit-driven insurers.