1 See Uwe E., Reinhardt, West Germany's Health-Care and Health-Insurance System: Combining Universal Access with Cost Control, in U.S. Bipartisan Comm'n on Comprehensive Health Care (The Pepper Commission), A Call for Action, 3, 7–9 (Supp. 1990);Google Scholar John K., Iglehart, Germany's Health Care System, 324 New Eng. J. Med. 503, 503 (1991)Google Scholar (first of two parts).

2 Reinhardt, supra note 1, at 7; Iglehart, supra note 1, at 503, 504; see also Craig R., Whitney, Paying/or Health the German Way, N.Y. Times, Jan. 23, 1993, at 1, 4.Google Scholar

3 See Reinhardt, supra note 1, at 10-11; Iglehart, supra note 1, at 504. The private carriers in Germany are also subject to considerable federal regulations — among them a government-imposed fee schedule for physicians.

4 Suzanne W., Letsch, National Health Care Spending in 1991, Health Aff., Spring 1993, at 94, 101.Google Scholar

5 Jeremy W., Hurst, Reforming Health Care in Seven European Nations, Health Aff., Fall 1991, at 9Google Scholar (reporting results of a study of recent reforms to the health care systems of seven Organization for Economic Cooperation and Development [OECD] countries: Belgium, France, Germany, Ireland, the Netherlands, Spain, and the United Kingdom).

6 See Reinhardt, supra note 1, at 10. See also Iglehart, supra note 1, at 507 (“Some 6.3 million Germans — affluent people and many childless couples — purchase comprehensive private insurance.“). In Canada, “[pjrivate insurance may cover additional services but duplication of the public coverage is proscribed.” Steffie, Woolhandler & David U., Himmelstein, The Deteriorating Administrative Efficiency of the U.S. Health Care System, 324 New Eng. J. Med. 1253, 1253 (1991).Google Scholar

7 See Hurst, supra note 5, at 12; Eugene Vayda & Raisa B. Deber, The Canadian Health Care System: A Developmental Overview, in Canadian Health Care and the Stat. 125-26 (1992).

8 Hurst, supra note 5, at 13-14.

9 Id. at 10.

10 General Accounting Office, Health Care Spending Control: The Experience of France, Germany and Japa. 32 (1991).

11 Hurst, supra note 5, at 10.

12 See Willard G., Manning et al., Health Insurance and the Demand for Medical Care, Am. Econ. Rev. 251 (1987)Google Scholar (reporting results of the Rand Health Insurance Experiment).

13 See Dale A., Rublee, Medical Technology In Canada, Germany, and the United States, Health Aff., Fall 1989, at 178, 180Google Scholar (“American physicians, with a universe of modern technology at their fingertips, are the envy of the world's physicians.“)

14 See Stuart H., Altman & Marc A., Rodwin, Halfway Competitive Markets and Ineffective Regulation: The American Health Care System, 13Google Scholar J. Health Pol., Pol'y & L. 323, 334 (1988). For a discussion of state efforts to control costs, see George J. Annas Et al., American Health LAW 219 (1990).

15 See Arnold S., Relman & Uwe E., Reinhardt, Debating For-Profit Health Care and the Ethics of Physicians, Health Aff., Summer 1986, at 5, 12.Google Scholar For a general discussion of physician entrepreneurship, see Committee on Implications of For-Profit Enterprise in Health Care, Institute of Medicine, Physicians and Entrepreneurism in Health Care, in For-Profit Enterprise in Health Care 151-70 (Bradford H. Gray ed., 1986).

16 Rosemary Stevens, in Sickness and in Wealth: A History of the American Hospital in the Twentieth Century 359-61 (1989).

17 As already noted, some states in the United States control certain segments of their health sector through formal planning—for example, through Certificates-of-Need for hospital beds or hospital-based, high-tech equipment. See supra Section II.B. These strictures, however, have generally been of limited effectiveness. Where hospitals have been prohibited from acquiring certain high-tech equipment, for example, physicians have been able to acquire and operate it in close proximity to the hospital without regulatory control.

18 As Table 2 suggests, perhaps that particular donkey is just too weak to carry much of a cost-containment load.

19 PPOs are networks of fee-for-service providers that have agreed to grant large, third-party payers price discounts in return for insurance contracts that steer the insured toward these “preferred“ providers through specially tailored forms of cost sharing. See Annas Et al., supra note 14, at 775.

20 See, e.g., Julie, Kosterlitz, Managing Medicaid, 24Google Scholar NAT'L L.J. 1111 (1992) (describing how HMOs have lower per capita health care costs than does Medicaid in Ohio).

21 Edmund F., Haislmaier, Why Global Budgets and Price Controls Will Not Curb Health Costs, Heritage Found. Rep., Mar. 8, 1993,Google Scholar available in Lexis, Nexis Library, Omni File.

22 See George D., Pillari, Those Pliable Occupancy Rates, Mod. Healthcare, May 20, 1991,Google Scholar at 26, 27 (listing 1990's median occupancy rate for 5600 U.S. hospitals at 48.85%).

23 Kevin, Grumbach & Philip, Lee, How Many Physicians Can We Afford, 265 Jam. 2369, 2369 (1991).Google Scholar

24 See Erik, Eckholm, Those Who Pay Health Costs Think About Drawing Lines, N.Y. Times, Mar. 28, 1993, § 4, at 1.Google Scholar

25 Congressional Budget Office, Projection of National Health Expenditures 1 (1992); see also Dana, Priest, Health Care Price Caps Considered, Wash. Post, Feb. 14, 1993,Google Scholar at Al.

26 Glenn, Kessler, Bitter Medicine: Reform Is Coming—And This Could Be Painful, Newsday, Apr. 11, 1993, at 11.Google Scholar

27 BNA, Number of Uninsured Persons Increased to 36.6 Million in 1991, Daily Labor Rep., Jan. 12, 1993, available in Lexis, Nexis Library, Omni file (reporting results of the Employee Benefit Research Institute Study).

28 M. Susan, Marquis & Stephen H., Long, Uninsured Children and Xational Health Reform, 268 Jam. 3473, 3473 (1992).Google Scholar

29 BNA, supra note 27; see also David U., Himmelstein et al., The Vanishing Health Care Safety Net: New Data on Uninsured Americans, 22 Int'l J. Health Svcs. 381, 387 (1992).Google Scholar

30 See, e.g., Susan, Dentzer, Health Care Gridlock, U.S. News & World Rep., Jan. 20, 1992, at 22;Google Scholar Lynn, Wagner, Health Economist Trashes Reform Plans of Both Bush and Clinton, Mod. Healthcare, Oct. 12, 1992, at 10.Google Scholar

31 See Raisa B., Deber, Canadian Medicare: Can It Work in the United States? Will It Survive in Canada?, 19 Am. J. L. & Med. 75, 79 (1993).Google Scholar For a discussion about Canada's funding drugs for low-income families, see supra Section H.A.

32 See U.S. Bipartisan Comm'n on Comprehensive Health Care (The Pepper Commission), A Call for Action 34-35 (1990).

33 For example, “[o]ne obstetrician … said she doesn't inform pregnant Medicaid patients that they are entitled to a pain killing epidural while in labor [because] Medicaid reimbursements to anesthesiologists are so low, they balk at taking her patients.” Kinsey, Wilson, Nobody Likes the R-Word: Rationing of Care Is Unpopular, But It's Happening Just the Same, Newsday, Apr. 22, 1993, at 23.Google Scholar

34 See, e.g., Richard E., Brown, From Advocacy to Allocation: The Evolving American Health Care System, 316 New Eng. J. Med. 169 (1987).Google Scholar

35 See, e.g., David, Kirkpatrick, Practicing Medicine Above and Below the 49th Parallel; One Physician's Experience: The Fiction, The Facts, 151 Arch. Intern. Med. 2150, 2152 (1991).Google Scholar

36 Robert J., Blendon, Views on Health Care: Public Opinion in Three Nations, Health Aff., Spring 1989, at 151, 156.Google Scholar

37 Id.

38 In this regard, see the fascinating analysis of this facet of British health care in Henry J. Aaron & William B. Schwartz, The Painful Prescription: Rationing Hospital Care (1984).

39 For a discussion of the “career” of a medical technology innovation, see John B., McKinlay, From “Promising Report” to “Standard Procedure“: Seven Stages in the Career of a Medical Innovation, 59 Milbank Mem. Fund Q. 374 (1981).Google Scholar

40 For example, Germany's health care spending limit is tied to the growth of workers’ salaries and wages. See John K., Iglehart, Germany's Health Care System, 324 New Eng. J. Med. 1750,Google Scholar 1751 (1991) (second of two parts).

41 For a description of this aspect of the Clinton proposal, see Uwe E., Reinhardt, Commentary: Politics and the Health Care System, 327 New Eng. J. Med. 809, 811 (1992).Google Scholar The American College of Physicians's proposal was first outlined in American College of Physicians, Universal Insurance For American Health Care, 117 Ann. Intern. Med. 511 (1992).

42 Konzertierte Aktion, or the Concerted Action Conference, is a group that recommends the annual aggregate increases in providers’ fees and suppliers’ prices. Iglehart, supra note 40, at 1752.

43 See, e.g., Alain C., Enthoven, Commentary: Measuring The Candidates On Health Care, 327 New Eng. J. Med. 807 (1992).Google Scholar For a discussion of one of Enthoven's proposal, see John B., Judis, Whose Managed Competition?, New Republic, Mar. 29, 1993, at 22–23.Google Scholar For a critical review of the concept of managed competition, see Uwe E., Reinhardt, Comment on the Jackson Hole Initiatives for a Twenty-First Century American Health Care System, Health Econ., Apr. 1993, at 7.Google Scholar

44 See Alain C., Enthoven, The History and Principles of Managed Competition, Health Aff., Supp. 1993, at 24, 29.Google Scholar

45 Alan L., Hillman et al., Safeguarding Quality in Managed Competition, Health Aff., Supp. 1993, at 110Google Scholar (discussing strategies for implementing a system of quality assurance under managed competition).