FROM MANAGED COMPETITION TO MANAGED COOPERATION - THEORY AND LESSONS FROM THE BRITISH-EXPERIENCE

The United Kingdom led the world in transforming the largest single he alth care system from a publicly administered service to a set of inte rlocking contracts. Policy lessons that can be adapted by employers, n ations, and other large payers are identified. These lessons are drawn from the improvements that the British made over the design of manage d competition, the mistakes and problems they experienced, the underly ing trends toward privatization and class discrimination, and the limi tations to competition that have led the British toward managed cooper ation in collaborative purchasing for the health needs of communities. Yet market reform and the rhetoric of efficiency have justified the s hrinking of health services, the shift of costs to household budgets, and the use of public moneys to support private services and investors at greater expense by moving properties and services off the public l edger. In these ways, managed competition can Americanize health care and pose fundamental questions about what policy goals are really bein g pursued.