Current ideas about the role of the state include an enthusiasm for mechanisms of “indirect” or “third-party” governance. The health care arena, in which models of indirect governance have a long history, is an important test bed for these ideas. Classically, the arena was marked by trust-based, principal-agent relationships established to overcome information gaps. Over time (and to different degrees across nations),emphasis shifted to contractual relationships assuming relatively well-informed actors and then to performance monitoring and information sharing within complex and loosely coupled networks. In this latest stage,there is a risk that some important features of democratic leadership, and of decision making in the health care arena, will be eclipsed. Accountability mechanisms must clearly locate responsibility for actions and must allow for the exercise of professional judgment.