This essay examines the role of business health care purchasers in keeping market solutions at the center of the health system. One might assume that employers would have a clear ideological preference for market solutions, but big business managers are ambivalent about market interventions at both the firm and public policy levels. Although currently enthusiastic about market–oriented managed care, large employers have been periodically disappointed by firm–level market experiments during the past two decades. They viewed with skepticism the Republican proposal to apply private–sector market cures to the public Medicare and Medicaid, fearing that the proposals would accelerate cost–shifting to private business payers. Big business objections have been muted, however, by the organizational weakness so vividly illustrated during the national health reform debate.

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