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ordinating or overseeing health care to which consumers could complain. Patients received medical care through a decentralized and fragmented delivery system. Furthermore, no governmental authority oversaw medicine. Patients could complain of egregious conduct to state licensing boards, but these boards had limited powers. Typically, licensing boards exercised their power only to revoke or suspend the licenses of doctors who had been convicted of criminal offenses or were impaired by alcohol or drug use.68 Courts provided a forum for patients injured by medical malpractice, but this was a very limited and costly form of consumer voice.69 MANAGED CARE Managed care changes the interplay of exit and voice. MCOs reduce exit options.70 They restrict patients to providers in the network, or offer patients financial incentives to use preferred providers. Even when available, exit often has limited value. Switching physicians within a plan may not produce new clinical choices because MCOs influence the medical practice of all physicians through financial incentives and rules. Ownership of MCOs is also becoming concentrated. When a few oligopolies dominate the market, they become complacent about the risk of losing market share and less responsive to consumer switching.71 Albert Hirschman characterizes their behavior as “lazy monopoly�.72 Such firms may prefer to lose difficult customers rather than improve performance. MCOs may prefer to lose patients with high-cost illnesses because it will increase their profit. In that case, dissatisfied customers may find equally unresponsive competitors when they exit. In fact, most employees have very little choice among health plans. In 1996, fifty two percent of mid-sized firms offered employees only one health plan and only twenty four percent offered