One of our biggest, most enduring questions, for those of us who care about health policy and politics, is understanding how health reform changes come about. Does incremental change add up to something significant? What conditions have to be in place for big reforms to occur? And when do seemingly small changes ignite big reform? Andrew Kelly's article, “Boutique to Booming: Medicare Managed Care and the Private Path to Policy Change,” describes an important example of the latter within the Medicare program. He unravels the circumstances that made Medicare susceptible to a dramatic increase in enrollment in private plans under Medicare Advantage—from 3 percent to 30 percent over a twenty-five-year period. He describes how as enrollment and spending increased, Medicare's politics were remade by the political empowerment of the managed care industry and the creation of a new subconstituency of beneficiaries.

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