Implicit in "who shall live?" however, is "who shall decide?" and, one step further along, "who shall lead?" With insurance coverage declining, the health care sector absorbing an increasing share of the economy, and the need to make policy decision--both public and private--about the organization, financing, and delivery of health care, as well as about how to influence the contours of the environmental, social, and behavioral attributes that affect health, it is equally important to explore who will take charge and under what conditions. (p.181)

. . . In Paul Starr's (1982. The Social Transformation of American Medicine. New York: Basic Books.) classic account, building on Eliot Freidson's (1970. Profession of Medicine: A Study of the Sociology of Applied Knowledge. New York: Dodd, Mead.) earlier work and what Robert Alford (1975. Health Care Politics: Ideological and Interest Group Barriers in Reform. Chicago: University of Chicago Press. ) previously characterized as physicians' "professional monopoly," the authority that organized medicine had established tied to scientific legitimacy "spills over its clinical boundaries into areas of moral and political action." James Morone (1990. The Democratic Wish: Popular Participation and the Limits of American Democracy. New Have, CT: Yale University Press. p. 254) sums up nicely the simple health care leadership paradigm of much of modern U.S. history: "A single pattern dominated American health care politics for most of the twentieth century: public power was ceded to the medical profession. Health care providers acted as trustees of health care policy. Legislation that they opposed was defeated; programs that were legislated were placed in their hands." The American Medical Association (AMA), which carried physician interests forward on the national stage, was unique among interest groups in laying claim to every institutional and financial resource that grants such organizations their political sway (Peterson, Mark A. 2001. From Trust to Political Power: Interest Groups, Public Choice, and Health Care. Journal of Health Politics, Policy and Law 26(5):1145-1163). The fragmented institutional arrangements or American government and other attributes of national and state politics afforded the opportunity to translate the well-organized professional monopoly into a policy monopoly (Peterson, Mark A. 1993. Political Influence in the 1990s: From Iron Triangles to Policy Networks. Journal of Health Politics, Policy and Law 18(2):395-438.; Marmor Theodore R. The Politics of Medicare. 2d ed. 2000. New York: Aldine de Gruyter.). Who shall lead? The docs. At that time. (p. 182)

As the twenty-first century began, leadership of health care policy making and politics was no longer the singular purview of organized medicine, or even a contentious arena of medicine, insurance, business, labor, and some institutional reflection of consumers or the public. Within each of these sphere of interest, internal conflict and contradictions fragmented even further the representation and projection of interests associated with physicians, insurers, employers, unions, and advocates for reform . . . Government at all levels was at once called upon to lead--on insurance coverage, cost control, quality assurance, and patient protections-- and told to leave these matters to the market. Fragmented governing institutions layered in a complex arena of federalism confronted a densely populated realm of interests in which sectoral differences were pronounced and intrasectoral contention often even more manifest. This is the new and current status quo; In this context we once again ask the question, who shall lead? The answer is now not as simple . . . (pp.185-6)