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HMOs have been so successful that they now occupy a dominant position in the market for health care in the United States. Approximately forty-five million Americans are uninsured. Of the remainder, about half are enrolled in some type of HMO. Most others receive some sort of managed care plan. Less than 10 per cent of Americans still have classic fee-for-service private health insurance (down from more than 70 per cent in the late ’80s). So even though many people equate HMOs with private health care, these sorts of corporations exist only because of the failure of private markets to supply appropriate health care. HMOs succeed precisely because they are more efficient than insurance markets. There should be no illusions about the character of these organizations—they are giant bureaucracies. The largest of them, Kaiser Permanente, employs over eleven thousand physicians and has more than six million subscribers in the state of California alone. This makes Kaiser larger than most of the government-run health care systems in Canada. And while the Canadian system is extremely decentralized, Kaiser Permanente is a single, vertically integrated corporation.
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Joseph Heath (The Efficient Society: Why Canada Is As Close To Utopia As It Gets)