Discussions of the economics of health care usually start with the observation that health care spending has risen from 5 to 11 per cent of the gross national product over the past two decades. Despite spending more of its gross national product on health care than any other country, the United States is 15th in male life expectancy, 7th in female life expectancy, and 13th in infant mortality.1,2 Although these are generally relevant facts if one is thinking about health care as a social problem, such conditions have long existed and are not the source of today's acute pressures to . . .