Given alarming fiscal imperatives, states and interests in all advanced industrial democracies have struggled over health care policy. I explore the interface between state autonomy in health care policy and the political mobilization of provider interests, especially physicians. Evidence from Germany, Japan, Canada, and Great Britain suggests that, longitudinally, policy makers everywhere have tried to increase state autonomy in health care, and this has generally triumphed over even effectively mobilized providers. The countries that have most successfully restrained the growth of health care expenditureswhile still providing ready access to relatively high-quality careare those where states have most actively restrained both demand- and supply-side system interests in policy making. In each country, states have increasingly articulated their own greater capacities in health care policy, pushed to do so by the imperatives, especially fiscal, embedded in the policy domain.