The "managed care backlash" arguably topped the list of media and policy co
ncerns in 1998. Yet, against the background of the highly charged environme
nt in which the future of our health care system continues to be debated, t
here is a dearth of concrete, "objective" faces on the nature of the change
s, the reasons for them, and their meaning. An analysis of five important t
hemes that emerged from a review of the recent literature on health system
change concludes that an inherent tension exists between the interest in ra
pidly driving down health care costs through organizational change and the
long time frames that are required to make fundamental changes in structure
, process, and orientation. Unfortunately, in an environment in which purch
asers are driven to seek cost savings and the political will supports a plu
ralistic and mixed public/private system, the health system may chart an al
ternative course, with the result that purchasers may rely increasingly on
individual cost sharing and continue to cut back the amount of coverage the
y are willing to offer. The real challenge for public policy makers is to c
onfront the issues directly, avoiding political incentives to adopt easy an
d fast solutions for these complex matters.